Human immunodeficiency infection (HIV) and acquired immunodeficiency syndrome (AIDS)

Human immunodeficiency virus (HIV) infection is caused by HIV type 1 or 2. There are multiple subtypes of HIV-1 (which can also be referred to as clades). Viruses that are a combination of these subtypes may also be encountered and are referred to as circulating recombinant forms (CRFs).

The period from exposure to primary HIV infection syndrome (seroconversion illness) is usually two to six weeks. The period from exposure to development of detectable anti-HIV antibodies is usually less than one month and may be much shorter, but may be up to three months. This will vary with the type of test performed. Given the tests used in WA pathology laboratories, an HIV test should be positive within six weeks of exposure. The presence of the virus itself can be detected earlier.

This table shows the risk of transmission associated with a variety of HIV exposures. Please note that the estimated risk of transmission per exposure event presented in the table has been determined on the basis of a HIV positive individual who is not on antiretroviral treatment.

HIV disease is characterised by depletion and/or dysfunction of cells in the immune system. A person affected by the HIV disease process is likely to exhibit a range of symptoms related to immune deficiency.

Up to 80 per cent of people who are infected with HIV will experience a glandular fever-like illness within six weeks of infection. This often occurs at the time when HIV antibodies appear, and is called a seroconversion illness or primary HIV infection syndrome. However, some patients may have a HIV-negative result with standard testing for up to three weeks after the onset of symptoms (which is why a second follow-up test may be required). Subsequently, there is a period of months to years during which the person with HIV infection is well, even though there is a progressive depletion of CD4+ T lymphocytes and a progressive increase in HIV viral replication (known in HIV RNA testing as ‘viral load’). Eventually, immune function becomes compromised to the stage whereby opportunistic infections and/or cancers develop. This stage is known as acquired immunodeficiency syndrome (AIDS). The most common cancers are Kaposi's sarcoma and lymphoma. A wide range of pathogens may cause disease in AIDS. Most are viruses such as cytomegalovirus and other herpes viruses, fungi such as Pneumocystis jiroveci, Cryptococcus neoformans and Candida sp.or mycobacteria.

HIV infection may also affect immune system cells in the nervous system and cause neurological diseases. The most common neurological disease is chronic encephalitis, which may result in a sub-cortical dementia associated with other neurological abnormalities, usually referred to as HIV-associated neurocognitive disorder (HAND).

HIV infection is a progressive condition, which can result in AIDS and death in the majority of infected people if the infection is not treated with antiretroviral therapy. Combination antiretroviral therapy is highly effective in arresting the progression of HIV infection and suppressing viral replication. Patients on antiretroviral therapy can enjoy a normal life expectancy but must remain on treatment.

HIV infection should be considered in patients with risk factors, and/or a consistent clinical illness.

Primary HIV infection syndrome

Primary HIV infection syndrome (seroconversion illness) presents a rare opportunity to identify HIV infection, which otherwise may remain unidentified for years. Primary HIV infection syndrome usually occurs within two to six weeks after HIV exposure and may include:

• fever
• malaise
• anorexia
• myalgia
• headache
• sore throat
• lymphadenopathy
• generalised maculo erythematous rash
• night sweats
• severe lethargy
• nausea
• arthralgia
• photophobia
• diarrhoea
• thrombocytopenia
• mouth ulceration
• rash

Neurological manifestations including meningoencephalitis and peripheral neuritis may also be observed.

The acute illness may be accompanied by neutropenia, lymphadenopathy, thrombocytopenia, and mildly elevated erythrocyte sedimentation rate (ESR) or serum transaminase levels.

Clinical evidence shows that early initiation of antiretroviral therapy is associated with better health outcomes for the patient. Referral to a specialist in HIV medicine as soon as possible after diagnosis is essential to provide the patient with an opportunity to commence antiretroviral therapy as soon as possible after infection.

(See list of contacts in contacts for specialist advice on STIs and HIV).

Primary HIV infection may be followed by:

• chronic lethargy
• depression
• irritability

Non-specific viraemic manifestations include:

• mucosal ulceration
• desquamation of skin
• exacerbation of seborrhoea
• recurrence of Herpes simplex virus (HSV).

STI Atlas (external site)

Laboratory investigations of HIV infection include tests for three different purposes:

• tests to diagnose HIV infection and if positive to monitor the amount of virus present (i.e. viral load)
• tests to assess for immune deficiency (e.g. CD4 + T cell count)
• tests for opportunistic infections and malignancies arising from HIV-induced immunodeficiency.

Only tests for diagnosing HIV infection and immune deficiency are considered here.

Please also see Education, Preventing and Counselling below for information regarding Pre- test discussion – informed consent for HIV testing and Post-test discussion – conveying HIV test results.

Tests for diagnosing HIV infection

An HIV diagnosis in Australia is based on detecting antibodies to HIV in a blood sample. Combination HIV antibody/antigen testing is initially undertaken as a screening test for HIV, detecting the presence of either antigen or antibody. Positive screening tests must be confirmed by a diagnostic assay such as a Western Blot assay. If the requesting clinician is uncertain as to how soon after infection a given test will yield a positive result, a window period of two to six weeks should be used (see below).

HIV testing can also be performed using rapid point-of-care testing which provides results within 30 minutes. Point-of-care tests have a longer window period than laboratory-based assays. Any positive point-of-care test must be followed up with definitive diagnostic testing using laboratory-based assays. Point-of-care tests may be useful in high risk populations such as men who have sex with men, populations that are difficult to reach, and individuals who might otherwise not access HIV testing or return for their results. Point-of-care tests are not recommended for use in populations or settings with very low HIV prevalence.

Window period

There is a period after infection, when the screening test will not detect either antibody or antigen because they are yet to be produced or are present at a level that cannot be detected. This is called the window period. The time after infection at which antibody is identified is a function of the individual's response to HIV and the type of test used, but it is usually in the order of two to six weeks. Although HIV testing may be negative, the person is usually highly infectious.

• A negative screening test for HIV excludes HIV infection provided that the last potential HIV exposure was at least 12 weeks before the test. If not, the test must be repeated at an appropriate time.
• Some reactive EIA results are not due to HIV infection. Therefore, all repeatedly reactive results must have confirmatory tests performed such as an HIV Western Blot test and/or a nucleic acid or p24 antigen test if acute HIV infection is suspected.
• If the Western Blot test is positive, then HIV infection is highly likely. It is recommended that the HIV antibody tests be repeated on a second blood specimen from the patient to confirm the diagnosis of HIV infection.
• Tests for detection of HIV proviral DNA are available but are only used in special circumstances, for example when there is uncertainty about the diagnosis of primary HIV infection or for the assessment of the babies of HIV-infected women. This should be discussed with a specialist in HIV medicine or infectious diseases (see list of contacts in contacts for specialist advice on STIs and HIV). 

Tests for monitoring HIV infection

• The degree of HIV replication can be assessed by assaying the amount of HIV RNA in plasma. This is often referred to as the viral load. Viral load (RNA) testing is used to monitor the infection after a diagnosis is made.

Tests of immune function

HIV infection causes a decline in the number of several types of lymphocyte, particularly CD4+ T lymphocytes. These are essential cells in the body's immune system. As they decline, the opportunistic infections and malignancies that are characteristic of HIV-induced immunodeficiency become more frequent.

The CD4+ T cell count is the main laboratory test indicator of the degree of immune deficiency produced by HIV infection:

• Normal: Over 500 CD4+ T cells/µL of blood.
• Early immune deficiency: 350-500 CD4+ T cells/µL of blood. Clinical signs and symptoms are few.
• Intermediate immune deficiency: 200-350 CD4+ T cells/µL of blood. Increasing signs and symptoms, especially infections of skin and mucosa.
• Advanced immune deficiency: <200 CD4+ T cells/µL of blood. Frequent clinical manifestations of immune deficiency.

Assessing HIV risk factors

Assess risk factors for HIV, and consider testing in patients either with a glandular fever-like illness, or with unusual or persistent infections for which there is no adequate alternative explanation. Presence of any of the following lifestyle clues, epidemiological clues or clinical clues indicates that HIV testing should be offered.

Lifestyle clues	Unprotected sex Male-to-male sex injecting drug use Use of unsterile tattooing and body piercing equipment Unprotected sex with a person who has migrated from or recently travelled to a country with a high prevalence of HIV Overseas travel to or work in a country with a high prevalence of HIV, particularly where interaction with local health providers has been reported  Multiple sex partners/recent or frequent partner change History of STI.
Epidemiological clues	All antenatal women Migration from high prevalence country
Clinical clues	Presence of another STI Seroconversion illness (e.g. fever, myalgia, rash) Atypical or severe prolonged infections without other apparent cause (e.g. oral candidiasis, oral hairy leukoplakia, severe persistent genital herpes) Tuberculosis.

Investigating other STIs and blood-borne viruses

All patients with HIV infection should have investigations to exclude other STIs and blood-borne viruses.

• The presence of HIV indicates a risk of other infections due to shared risk factors.
• The presence of STIs can increase the risk of HIV transmission and acquisition.
• Patients with HIV should also be tested for other STIs and BBVs.

The treatment for HIV can be complex, although with newer antiretroviral treatments there has been a significant improvement in simpler therapeutic regimens which can consist of a single tablet daily. Specialist advice must be sought, and the person referred to the appropriate service provider (see contacts for specialist advice on STIs and HIV). 

• Advances in HIV treatment mean that most people who live with HIV take daily oral medication to ensure their HIV viral load is at an undetectable level, arresting the HIV viral replication cycle and protecting their immune system. This means that HIV is widely regarded as a chronic but manageable condition whereby HIV positive people can have a normal life expectancy. 
• Early identification of HIV infection can lead to early treatment uptake which may slow the decline of immune system function. Early diagnosis and treatment initiation can reduce HIV viral load, which reduces the risk of onwards HIV transmission. This is also referred to as Treatment as Prevention (TasP).
• Clinical evidence has demonstrated that patients who have sustained a HIV viral load of below 40 copies per millilitre (referred to as ‘undetectable’ based on current test sensitivity) for more than six months have a negligible risk of onwards sexual transmission. Discussions about HIV viral load and risk of onwards transmission should take place between the HIV specialist and patient, with condom use promoted as a safer sex strategy.
• In the absence of antiretroviral therapy, HIV infection usually progresses from no apparent illness to AIDS and death over a median of ten years. However, the pace of disease progression is variable. Almost all people who are infected with HIV will eventually have symptoms related to the infection without antiretroviral therapy. 
• The use of antiretroviral therapy is a specialised and rapidly changing field of medicine. A patient should initially be referred to HIV specialist services for treatment. General practitioners are encouraged to participate in the shared care of patients with HIV and can be authorised to prescribe HIV medicines. See page on WA HIV s100 community prescribers
• People with HIV may have complex needs, so may need to access a support network that will assist in maintaining good physical and mental health.
• Planning HIV care requires the identification of patients who need:
  
  • immediate medical care
  • antiretroviral therapy
  • management of coinfections
  • management of comorbidities. 
• Hepatitis A and B vaccination should be considered for people who are seronegative for these infections. Pneumococcal vaccine and influenza vaccine should also be considered (refer to the NHMRC's Immunisation Handbook (external site).

Pregnancy

Australian categorisation system for prescribing medicines in pregnancy (external site)

Related links

• HIV and AIDS (Healthy WA)

Immunisation

People living with HIV should be offered HAV and HBV vaccination, if not immune. See Guidelines for the Provision of Hepatitis A and B Vaccine to Adults in Western Australia at Risk of Acquiring these Infections by Sexual Transmission (PDF 248KB).

Prophylaxis for HIV 

There are two types of prevention approaches for HIV based on the prophylactic use of antiretroviral drugs.

• Pre-exposure prophylaxis (PrEP)  for ongoing exposure to HIV, and 
• Post exposure prophylaxis (PEP) for recent exposure (within 72 hours) to HIV. 

Pre-exposure prophylaxis

PrEP is a once-daily pill (combination of two antiretroviral medicines tenofovir and emtricitabine) used by HIV negative people at medium to high risk of HIV exposure. PrEP may be a prevention option for: sexually active gay and bisexual men, trans and gender diverse people, heterosexual people with a HIV-positive partner who does not have an undetectable viral load, and people who inject drugs.

It is important that before considering whether PrEP is an appropriate prevention option for a patient, that relevant testing and a full medical history is documented. Contraindications and precautions relating to PrEP include:

• Acute HIV-1 infection
• New onset or worsening renal impairment
• HBV infection, particularly chronic HBV (patients with HBV should be referred to a specialist, see contacts for specialist advice on STIs and HIV)
• Decreases in bone mineral density 
• Redistribution/accumulation of body fat
• Pregnancy
• Nursing mothers.

Patients need to take a daily dose of PrEP for 7 days before high levels of protection are achieved for both vaginal and rectal exposure to HIV.

Daily vs on-demand PrEP

Daily PrEP is the commonly prescribed regimen as per the National PrEP Guidelines (external site); however on-demand PrEP can also be prescribed in certain situations.

Daily PrEP must be the preferred regimen when there is ongoing risk of acquiring HIV over long periods of time.

On-demand PrEP as an alternative regimen can also be effective when exposure happens only for relatively short periods of time (e.g. during travel), or around single events of HIV exposure. It may also be considered for people who have adverse events with previous use of daily PrEP. On-demand PrEP is only recommended for men-who-have-sex-with-men (MSM) and transgender women.

Pre-exposure Prophylaxis (PrEP) for HIV prevention has been listed on Australia’s Pharmaceutical Benefits Scheme as an s85 medication, thereby allowing any medical practitioner, and endorsed nurse practitioners, to be able to prescribe PrEP to an eligible Australian resident who holds a current Medicare card.

Although PrEP can now be prescribed by any medical practitioner or endorsed nurse practitioner, a list of WA Department of Health trained PrEP Prescribers can be accessed here WA PrEP Prescribers (external site)

Clinicians interested in prescribing PrEP can access PrEP training on ASHM's online learning module 'Prescribing PrEP in Australia' (external site).

A new PrEP Decision Making Tool (PDF 134KB) has been developed for WA primary care providers to assist with prescribing PrEP and ongoing patient management.

For more information about PrEP see the National PrEP Guidelines (external site).

Post-exposure prophylaxis 

Post-exposure prophylaxis (PEP) can be for non-occupational and occupational exposure to HIV.
Non-occupational post exposure prophylaxis (NPEP) is a course of antiretroviral drugs (e.g. Truvada® [300 mg Tenofovir and 200 mg Emtricitabine] once daily for 28 days) that should be commenced as soon as possible (and definitely within 72 hours), following exposure to HIV in community settings. NPEP may help reduce the risk of HIV transmission after unsafe sex, sharing of injecting equipment, or when it is known or likely that there has been a high risk of exposure. However, NPEP is no longer routinely recommended for nonoccupational exposure when the HIV-positive source is on antiretroviral treatment and has an undetectable viral load.

To be effective, initiation of NPEP needs to occur within 72 hours, the earlier the better. All patients assessed as requiring NPEP during business hours should be referred to a s100 HIV prescriber (see list of WA HIV s100 community prescribers) or a sexual health clinic (see contacts for specialist advice on STIs and HIV). In geographical areas where these options are not available, or in cases that require attention outside of business hours, people should present to their nearest hospital Emergency Department. Patients who identify themselves as having had a high risk exposure to HIV may also call the 'WA PEP' line (1300 767 161).

For more information about NPEP, including how to assess risk, find out about availability, refer patients and provide follow-up care, see the Department of Health’s operational directive Protocol for non-occupational post-exposure prophylaxis (NPEP) to prevent HIV in Western Australia (external site). For further information please refer to the Australian National Guidelines on Non-Occupational and Occupational exposure to HIV (external site).

For management of occupational exposure to HIV, see the Department of Health’s operational directive Management of Occupational Exposure to Blood and Body Fluids in the Healthcare Setting (OD 0641/15) (external site).

See a business card sized leaflet (PDF 866KB) explaining the difference between PrEP and PEP, which can be given to patients who may be at high risk of HIV. Free copies of this leaflet can be ordered from the WA Health Online Publication Ordering System (external site)

Treatment as Prevention (TasP)

Early identification of HIV infection can lead to early treatment uptake. Early diagnosis and treatment initiation can reduce HIV viral load, which reduces the risk of onwards HIV transmission. This is also referred to as Treatment as Prevention (TasP)

Pre-test discussion – informed consent for HIV testing

The purpose of pre-test discussion is to obtain informed consent and should address:

• confidentiality
• the reason for the tests
• identifying risk activities
• understanding of the requirement for statutory notification and contact tracing
• awareness of the disease process and efficacy of treatment
• awareness of modes of transmission and prevention.

Post-test discussion – communicating HIV test results

A positive HIV test result must be discussed with the patient in person.

A negative diagnosis provides an opportunity to reinforce the pre-test discussion and focus on prevention.

HIV is a notifiable disease under the WA Public Health Act 2016 and should be reported to the Department of Health as soon as possible (ideally within 72 hours) after a confirmed diagnosis. To notify a case of HIV please complete the HIV notification form available at WA STI/BBV or HIV Notification or a hardcopy form can be obtained from your local population/public health unit (see contacts for specialist advice on STIs and HIV).

'What it means to have HIV': This video resource provides important information regarding living with HIV, and can be used to assist patients recently diagnosed with HIV, to understand and manage their condition.

When discussing a new HIV diagnosis with a patient, the following would ideally be included within your discussion with the patient:

• Inform your patient about the confidentiality of the test results and explain the legal requirements for completing the notification form, with an emphasis on confidentiality of all information.
• If the patient is willing, discuss contact tracing/partner notification (see Contact tracing).
• Explain to your patient that whilst there is no cure for HIV yet, that HIV is a manageable condition with daily treatment. This treatment is in the form of daily oral tablets, which works to control HIV, and prevent the virus progressing into AIDS. HIV and AIDS are not the same. 
• People living with HIV can lead long and healthy lives, with a similar life expectancy to a person who does not have HIV. They can still have relationships, have sex, and have children if they choose. 
• Outline to the patient they will be referred onto a HIV specialist (if the diagnosing practitioner is not experienced in HIV medicine, they should avoid technical discussions regarding disease progression or treatment options) and that a nurse from that clinic will be in touch (if an appointment has not already been made) to make an appointment for them (see contacts for specialist advice on STIs and HIV).
• While they are waiting for their specialist appointment, discuss with your patient:
  
  • strategies to prevent onward transmission, emphasising the need to practice safer sex (with condoms) and not share injecting equipment
  • that they do not have to tell people that they have HIV, however they must ensure they take the appropriate precautions in preventing onwards HIV transmission, as there are laws in place that criminalise HIV transmission when precautions are not taken
  • some occupations may require disclosure, and this should be discussed with the specialist.
• A new diagnosis for many people can be a traumatic experience, so it may be advisable to refer to a support organisation for counselling or other forms of social assistance such as the WA AIDS Council (see contacts for specialist advice on STIs and HIV). People with HIV should be counselled by a person able to discuss the medical, psychological and social implications of HIV infection. Appropriate social support and psychological resources should be available, either on site or through referral, to assist the patient in coping with emotional distress.
• Avoid overloading the patient with excessive information and arrange for further counselling at a later time if needed. Provide patient with a fact sheet (Healthy WA).

At follow-up:

• stress confidentiality
• confirm the patient's understanding of the infection
• if the patient is ready to deal with more information, provide further details of the infection and how to prevent its transmission
• continue to educate about the prevention of onward transmission. 
• provide continued support
• provide information about other sources of information and support, such as the WA AIDS Council (see contacts for specialist advice on STIs and HIV).

Emotional distress is a normal response when first being informed of a positive HIV test result. Patients face several major adaptive challenges:

• accepting living with a chronic disease
• coping with possible stigmatising and discriminating behaviours from others
• developing strategies for maintaining physical and emotional health
• initiating changes in behaviours to prevent HIV transmission.

People with HIV should be counselled by a person able to discuss the medical, psychological and social implications of HIV infection. Appropriate social support and psychological resources should be available, either on site or through referral, to assist the patient in coping with emotional distress

Counselling for these patients should embrace:

• contact tracing or management of sexual partners
• patients' rights and responsibilities
• family and community support resources
• the need for continued counselling and support

Work

Patients living with HIV who are health care workers may perform exposure prone procedures (EPPs) if they comply with the Australian National Guidelines for the Management of Healthcare Workers Living with Blood Borne Viruses and Healthcare Workers who Perform Exposure Prone Procedures at Risk of Exposure to Blood Borne Viruses (external site).

Prophylaxis for HIV 

For people at high risk of HIV infection there are two types of prophylaxis for HIV:

• Pre-exposure prophylaxis (PrEP)  if there is ongoing exposure to HIV, and 
• Post exposure prophylaxis (PEP) if there is recent exposure (within 72 hours) to HIV. 

See Education, counselling and prevention in the previous section for more details on PrEP and PEP. 

Contact tracing for HIV

Every possible effort for thorough contact tracing should be undertaken in all cases of HIV (see also Contact tracing).

Contacts include not only sex partners but also anyone who has shared needles or other injecting equipment with the index case.

Contact tracing for HIV enables early diagnosis and treatment of possible HIV infection and associated illness, and offers the opportunity to encourage risk-reducing and protective behaviours. Contact tracing is a means of concentrating risk-reduction efforts on people at high risk of contracting or transmitting HIV infection.
Contact tracing is undertaken by nurses employed by public health units. GPs and primary health care providers can provide invaluable information to public health nurses to facilitate identification and testing of partners.

• Because HIV can potentially lead to serious health implications and historically has been a highly stigmatised infection, managing sexual partners carries with it a special need for sensitivity and care.
• Particularly with HIV those responsible for contact tracing should have a clear understanding of local community sensitivities.
• People with HIV infection should be advised of any risk they pose to uninfected sexual partners, and of the need to practice safe sex.
• Contacts of HIV-infected patients should be traced, and offered testing and counselling.
• A person who has HIV infection or is at risk of HIV infection must not make any blood, semen or organ/tissue donations.

Special considerations

Several publications have been produced by Australian, State and Territory governments, other agencies and community groups, to assist health care providers and patients in preventive education and in managing HIV infection. These are available from the Department of Health and various other agencies (see contacts for specialist advice on STIs and HIV and contacts for patients – where to go).

• Determining how far back to trace contacts can be difficult.
  
  • The incubation period for primary HIV infection is one to twelve weeks, but the seroconversion illness may pass unnoticed or be difficult to recall.
  • Trace back at least 12 weeks before a confirmed primary HIV illness. If an infected contact cannot be found, then a source for the infection has not been located. Therefore, extend the trace-back period. Prior HIV negative serology may be beneficial in establishing the time frame needed for contact tracing. 
  • If the date of primary infection cannot be confirmed, the trace-back period may be years, depending on the patient's history of risk behaviour and clinical presentation.
  • As HIV-2 infection is not endemic in Australia, expert support for contact tracing should be sought if there is a possibility of a patient with HIV-2 having been infected locally.
  • A patient who presents with AIDS will usually have been infected for several years (median – 8 to 10 years).
• Oral sex, with the presence of broken skin, ulcers or cuts has been reported as a possible means of transmitting HIV infection but overall it remains a negligible risk activity.
• If the index case has donated or received blood products, contact the relevant Blood Transfusion Service.

Advise patients of the need for indefinite specialist follow-up and life-long antiretroviral therapy.

Effective HIV management requires access to antiretroviral therapy and monitoring associated with the long term use of these drugs. Shared care arrangements with a general practitioner should be established for all HIV positive patients for the management of non-HIV related health issues. Such an arrangement will most likely include regular monitoring by the specialist, which is communicated to the primary health care provider and vice versa. Ongoing two-way communication between the HIV specialist and primary health care provider is important to ensure that all the patients' health care needs are appropriately met, and that there are no contraindications or concerns in relation to the patient's ongoing antiretroviral therapy.

As discussed previously, patients with HIV should be referred to a HIV specialist or GP specialising in HIV medicine for assessment and for the establishment of a patient management plan.

Special considerations

• Specialist advice should always be sought for treatment and follow-up of HIV-infected patients.
• Review patients three months after exposure to repeat blood tests for syphilis, hepatitis B virus (HBV) and hepatitis C virus (HCV). 
• Discuss with patients their desires or plans for conceiving children. People living with HIV are able to safely conceive and give birth to HIV negative babies. Family planning should be discussed in collaboration with the patient’s HIV specialist.
• Discuss with patients their general well-being and any mental health indications they may have.
• While most people living with HIV conscientiously avoid behaviour which exposes others to the risk of HIV infection, a very small number of individuals continue to place others at risk. The Integrated Case Management Program (ICMP), Department of Health Western Australia, assists individuals to modify their behaviour, through intensive and regular counselling, education and support. This preventive approach is usually successful and only rarely has statutory action, been considered necessary to ensure that a person living with HIV adheres to HIV treatment. For more information see the CMP guidelines.

• Contact tracing is important to prevent further transmission and reinfection (see Contact tracing). 
• Patients who are not on antiretroviral therapy may be considered infectious, with the most infectious periods being before, during and soon after seroconversion, or when CD4+ T cells are very depleted and the viral load increases.
• Patients may continue be infectious throughout their illness, depending on factors such as whether they are on or adhering to antiretroviral therapy, and whether they have any concurrent co-infections including other STIs.
• Always test for other STIs and blood-borne viruses. 
• If a child is diagnosed with HIV, the virus may have been transmitted vertically during pregnancy or delivery. If the mother is HIV-negative, issues of sexual abuse and/or sexual assault should be considered.

Prophylaxis for HIV

For people at high risk of HIV infection there are two types of prophylaxis for HIV:

• Pre-exposure prophylaxis (PrEP)  for ongoing exposure to HIV, and
• Post exposure prophylaxis (PEP) for recent exposure (within 72 hours) to HIV.

See Education, counselling and prevention in the earlier section for more details on PrEP and PEP. 

HIV is a notifiable disease under the WA Public Health Act 2016 and should be reported to the Department of Health as soon as possible (ideally within 72 hours) after a confirmed diagnosis. To notify a case of HIV please complete the HIV notification form available at WA STI/BBV or HIV Notification or a hardcopy form can be obtained from your local population/public health unit (see contacts for specialist advice on STIs and HIV).

Epidemiology of STIs and BBVs in Western Australia