History and exam
Key diagnostic factors
common
increased risk of maternal HIV infection
Needle-sharing with injection drug use and percutaneous needle-stick injury carry risks of HIV infection rates of 63 to 240/10,000 exposures and 30/10,000 exposures to an infected source, respectively.[43][47][77]
Unprotected receptive anal intercourse leads to an infection rate of 1/70 exposures to an infected source with ejaculation and 1/154 without.[46] Unprotected, receptive penile-vaginal intercourse without barrier contraception carries a risk of 1 infection/333 exposures in low-income countries and 1 infection/1250 exposures in high-income countries.[45]
Recent sexually transmitted infection (STI) and vaginitis, particularly HSV-2, bacterial vaginosis, and gonorrhea, are associated with an increased risk of HIV acquisition.[48][49][50][51]
increased risk of perinatal HIV transmission
High maternal viral load is associated with an increased risk of perinatal HIV transmission. Elevated HIV RNA at delivery is independently associated with risk of transmission.[21] The absence of prenatal antiretroviral therapy (ART) is associated with an increased risk of perinatal HIV transmission. Maternal prenatal ART is independently associated with reduced risk of transmission.[21]
Without a suppressed viral load on antiretroviral therapy, breast milk contains high levels of the HIV virus and transmission can occur at any point during lactation.[1][34][35][36][37] High maternal viral load (in plasma and in breast milk), breast milk immunologic factors, maternal breast pathology (such as mastitis, cracked or bleeding nipples, abscesses), and low maternal CD4 count are associated with increased risk of transmission through breast-feeding. Infant gastrointestinal pathology, such as candidiasis, may disrupt mucosal integrity and aid viral transmission.[38][39][40][41][42]
Other diagnostic factors
uncommon
oral candidiasis
Suggestive of advanced HIV infection.
increasing dyspnea
Suggestive of advanced HIV infection.
weight loss
Suggestive of advanced HIV infection.
fever
Occurs in the acute seroconversion phase of the virus.
malaise
Occurs in the acute seroconversion phase of the virus.
lymphadenopathy
Occurs in the acute seroconversion phase of the virus.
maculopapular blanching rash
Occurs in the acute seroconversion phase of the virus.
Risk factors
strong
needle-sharing with injection drug use
unprotected receptive penile-vaginal intercourse
Causes 1 infection/333 exposures to an infected source in low-income countries and 1 infection/1250 exposures to an infected source in high-income countries.[45]
unprotected receptive anal intercourse
Causes 1 infection/154 exposures to an infected source without ejaculation and 1 infection/70 exposures to an infected source with ejaculation.[46]
percutaneous needle stick
Causes 30 infections/10,000 exposures to an infected source.[47]
sexually transmitted infections (STIs) and bacterial vaginosis
There is evidence that nonulcerative STIs increase the risk of HIV transmission.[48] Multiple studies have demonstrated the association between recent acquisition of an STI and transmission of HIV. After controlling for demographic and behavioral risk factors, the population attributable risk was 50.4% for sero-prevalent HSV-2, 5.3% for gonorrhea, and 17.2% for bacterial vaginosis.[49][50][51]
high maternal viral load (perinatal transmission)
High maternal viral load is associated with an increased risk of perinatal HIV transmission. Elevated HIV RNA at delivery is independently associated with risk of transmission.[21]
absence of prenatal maternal antiretroviral therapy (perinatal transmission)
The lack of prenatal maternal antiretroviral therapy is independently associated with risk of transmission.[21]
breast-feeding in mothers without viral suppression (perinatal transmission)
Without a suppressed viral load on antiretroviral therapy, breast milk contains high levels of the HIV virus and transmission can occur at any point during lactation.[1][34][35][36][37] High maternal viral load (in plasma and in breast milk), breast milk immunologic factors, maternal breast pathology (such as mastitis, cracked or bleeding nipples, abscesses), and low maternal CD4 count are associated with increased risk of transmission through breast-feeding. Infant gastrointestinal pathology, such as candidiasis, may disrupt mucosal integrity and aid viral transmission.[38][39][40][41][42]
violence against women and girls
Women who are victims of intimate partner violence have been shown to be at greater risk of HIV/STI infection compared with women with no history of intimate partner violence.[52][53][54] A history of sexual or physical abuse during childhood or adulthood is also associated with an increased risk of HIV infection.
weak
multiple sexual partners
low maternal CD4 count (perinatal transmission)
May accompany advanced maternal HIV disease and therefore a high plasma viral load.
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