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Emergency Residents Miss Opportunities to Diagnose Early HIV Infection

DETROIT — In up to two-thirds of cases, acute infection with human immunodeficiency virus presents as a mononucleosis-like illness. Yet, a survey of emergency medicine residents suggested they would rarely screen for acute retroviral syndrome (ARVS), missing opportunities for early diagnosis and treatment.

Study authors, who presented recently at IDWeek 2014 in Philadelphia, note that 20% of people unknowingly infected with HIV are responsible for more than 50% of new infections annually, adding, “A high index of suspicion is needed to screen for ARVS as there are no unique characteristics that distinguish it from other viral illnesses.”

Researchers from Detroit Receiving Hospital/Wayne State University in Detroit and colleagues sought to determine how often emergency medical residents consider ARVS in the differential diagnosis of general viral symptoms when patients present with fatigue, fever, muscle or joint aches, and sore throat. Symptoms usually appear within 7-14 days of infection, according to background in the article.

Results of an electronic survey of more than 700 emergency medical residents from more than 100 resident programs across the country were presented. The survey included case-based questionnaires: One in which the patient’s sexual orientation was identified as homosexual and another with no information on sexual orientation.

The survey’s four sections included treatment options for the scenario, knowledge of ARVS symptoms, likelihood of ordering a rapid HIV test, and recommendations following a negative result.

A link to one of the two versions of the survey – identified or unidentified sexual orientation – was randomly sent to all U.S. based EM residency training program directors with a request to forward it to the program’s residents. More than 700 responses were received from 101 out of 158 EM programs that received the link.

Overall, fewer than 27% of the emergency residents responding said they would order a rapid HIV test for the patient described as having fever, sore throat and swollen lymph nodes or hypoxia, cough and dyspnea. Yet the likelihood of ordering an HIV tests quadrupled with patients who identified as homosexual compared to those who did not identify their sexual orientation – 56.4% vs 14.6%.

Regardless of sexual orientation, however, more than half of the respondents said they would order the test if the patient had rash, weight loss and diarrhea.

The residents also were highly likely to order the tests in patients who identified themselves as sexual assault victims, female prostitutes and intravenous drug users.

Interestingly, 85% of the residents were able to correctly recognize the symptoms of AVRS, and 76% of respondents recognized a repeat HIV test was needed following an initial negative rapid test.

The authors note that the “residents do not consider ARVS in their differential diagnosis in patients with symptoms of viral illness, particularly in the absence of a high risk qualifier. This deficit in knowledge application may have significant negative public health consequences in the fight against HIV transmission."