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The Rational Clinical Examination |

Does This Adult Patient Have Early HIV Infection?  The Rational Clinical Examination Systematic Review

Evan Wood, MD, PhD, FRCPC1,2; Thomas Kerr, PhD1,2; Greg Rowell, MSc, MISt3; Julio S. G. Montaner, MD, FRCPC, FCCP1,2; Peter Phillips, MD, FRCPC, FCCP1,2; P. Todd Korthuis, MD, MPH4,5; David L. Simel, MD, MHS6,7
[+] Author Affiliations
1British Columbia Centre for Excellence in HIV/AIDS, St Paul’s Hospital, Vancouver, British Columbia, Canada
2Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
3Clinical Policy Office, Fraser Health Authority, Vancouver, British Columbia, Canada
4Department of Medicine, Oregon Health and Science University, Portland
5Department of Public Health–Preventive Medicine, Oregon Health and Science University, Portland
6Durham Veterans Affairs Medical Center, Durham, North Carolina
7Duke University Medical Center, Durham, North Carolina
JAMA. 2014;312(3):278-285. doi:10.1001/jama.2014.5954.
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Importance  Timely identification of human immunodeficiency virus (HIV) infection in adults can contribute to reduced mortality and likelihood of further HIV transmission. During the first 6 months after infection, known as early HIV infection, patients often report a well-described constellation of symptoms and signs. However, the literature examining utility of the clinical examination in identifying early infection has not been systematically assessed.

Objective  To assess the accuracy of symptoms and signs in identifying early HIV infection among adults.

Data Sources  We searched MEDLINE and EMBASE (1981-May, 2014) for articles investigating symptoms and signs of early HIV infection in adults and searched reference lists of retrieved articles.

Study Selection  We retained original studies that compared symptoms and signs among patients with early HIV infection in comparison to HIV-negative individuals.

Data Extraction and Synthesis  Data were extracted and used to calculate sensitivity, specificity, and likelihood ratios (LRs), and meta-analysis was used to calculate summary LRs.

Results  Of 1356 studies, 16 studies included data that were eligible for meta-analysis and included a total of 24 745 patients and 1253 cases of early HIV infection. Symptoms that increased the likelihood of early HIV infection the most included genital ulcers (LR, 5.4; 95% CI, 2.5-12), weight loss (LR, 4.7; 95% CI, 2.1-7.2), vomiting (LR, 4.6; 95% CI, 2.5-8.0), and swollen lymph nodes (LR, 4.6; 95% CI, 1.3-8.0). No symptoms had an LR that was 0.5 or lower, but the absence of recent fever (LR, 0.74; 95% CI, 0.64-0.84) slightly decreased the likelihood of early HIV infection. The presence of lymphadenopathy on physical examination was the most useful sign (LR, 3.1; 95% CI, 1.0-5.2). No sign had an LR of 0.5 or less, but the absence of lymphadenopathy slightly decreased the likelihood of early HIV infection (LR, 0.70, 95% CI, 0.49-0.92). Using data from studies that considered combinations of findings (range of possible findings, 4-17), the summary LR for individuals with 0 findings was 0.47 (95% CI, 0.38-0.58).

Conclusions and Relevance  The limited utility of the clinical examination to detect or rule out early HIV infection highlights the importance of routine testing for HIV infection among adults.

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