The early stages of an HIV infection present many challenges in clinical decision making. In the previous section, we covered how objective measures can vary based on the timing of infection. Using subjective measures in the clinical setting is even more challenging, if not impossible, to accurately diagnose acute retroviral syndrome (ARS).

Only half of new HIV infections are estimated to cause symptoms between 2-4 weeks after acquisition. Among those who reported symptoms, only fever and fatigue occurred in most cases. Other less commonly reported symptoms include myalgia, rash, headache, sore throat, cervical adenopathy, joint aches, night sweats, and diarrhea. ₍₃₎  This leads to a very broad differential diagnosis. Taken altogether, symptoms of ARS are both unreliable and extremely nonspecific; and thus, should not be used in isolation to make clinical decisions.

Furthermore, after this short period of time when symptoms occur, patients can go on for years without any new complaints. In fact, despite collective efforts to perform more routine testing, it is estimated that about 13% of people living with HIV/AIDS (PLWHA) are unaware of their diagnosis and account for over a third of new infections. ₍₄₎

How, then, can we improve our clinical gestalt for a condition that presents so ambiguously and has such an enormous impact on the lives of individuals and communities?

The answer to this question is complex, but it relies on several key points.

• An environment and approach that fosters patient comfort and trust is necessary to start relevant conversations
• Thorough and accurate sexual and substance use histories must be obtained
• A firm understanding of HIV tests must be developed and they should be utilized judiciously.

We will cover techniques and frameworks to help you improve these skills in the coming sections.