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- Referral to an infectious diseases specialist or sexual health physician with experience in HIV is recommended
for all people with a significant exposure to HIV
- GPs may be the first point of contact for people with symptoms of acute HIV infection
- Regular HIV testing should be considered as a routine aspect of healthcare for people at risk of HIV exposure
- Rates of HIV infection are increasing in New Zealand, especially among men who have sex with other men
- Preventing risky behaviour is the key to reducing HIV infection, however once a potential exposure has occurred,
post exposure prophylaxis can be considered in some cases
New cases of HIV are increasing in New Zealand
In 2008 more people were diagnosed with HIV than in any other year since surveillance records began in the 1980s. This
reflects a pattern of increasing numbers of notified cases since 2000. During 2008 a total of 184 people were newly diagnosed
by antibody testing. A further 43 people, most of whom had previously had their HIV infection diagnosed overseas, were
identified as the result of having their first viral load testing in New Zealand.
Half of the cases were men infected by having sex with other men (MSM), a third were men or women infected through heterosexual
contact and the remaining cases were through injecting drug use, blood transfusion (overseas), mother to child transmission
or unknown risk behaviours.1
HIV infection is most commonly diagnosed in European men aged 30–49 years. Among MSM with HIV, Māori and Pacific
men are represented at around the same rate as in the general population.1 However it has been suggested that
Māori and Pacific men may get tested later than European men.
HIV infection by heterosexual transmission is often acquired overseas. Women from “Other” ethnicities have
a proportionally higher rate of diagnosis than any other ethnicity, followed by men from “Other” ethnicities.
Rates of infection among Māori, Pacific and Asian people were proportionally higher (even more so for women) compared
to European people.1
A similar pattern is emerging in 2009. So far (January to June) 78 people have been diagnosed with HIV and a further
19 identified, after having their first viral load testing in New Zealand. Just under half of the total number were MSM.2
There is concern that the increasing infection figures reflects complacency about the continuing risk of becoming infected
with HIV. Preventing risky behaviour is the key to reducing HIV infection. As well as educating individuals there is a
need to try to reduce the likelihood of acquiring HIV once a potential exposure has occurred. One possible approach is
to offer post exposure prophylaxis with the aim of reducing the risk of acquiring the infection and preventing further
transmission to others.
Managing non-occupational exposure incidents
Scenario: A patient presents to general practice on Monday, after engaging in risky behaviour over the weekend that
puts him/her at risk of HIV infection. What do you do?
First establish what happened
Take a detailed history of the incident e.g. what sexual activity took place, whether it was consensual, details of
injecting drug use.
It is preferable to use medical terminology when discussing sexual practices and sexual health, however it is important
that the patient understands the terminology used. Conversely, the clinician should ask for clarification of any colloquial
terminology they are unfamiliar with. A non-judgemental attitude will help to ensure that any risky behaviours are fully
See BPJ 20 (April 2009), Let’s
talk about sex.
If possible, find out any details that are known about the person who is the source of potential HIV exposure. If the
patient does not know the source’s HIV status and contact details are available, establish whether the patient or
practice will attempt contact.
Check clinical history
- Has the patient had any previous HIV tests?
- Does the patient have any current or previous STIs?
- Check hepatitis B and hepatitis C status – recent tests or immunisation
- Consider taking a psychiatric, drug and alcohol history
Further information on Hepatitis B and Hepatitis C is available from: Hepatitis B:
treatments now available for primary care bpacNZ, Aug 2018 and Hepatitis C: you can't treat it if you don't test for it bpacNZ, Aug 2017
Assess risk of HIV transmission
The risk of HIV transmission is determined by:3
- Method of exposure
- Risk that the source is HIV positive
- Co-factors associated with increased risk of transmission from the source to the exposed person
Method of exposure. The risk of HIV transmission with sexual contact is difficult to quantify as there
are many additional factors that influence risk such as concurrent STIs or other genital conditions, cervical or anal
dysplasia and circumcision status.4 The highest risk behaviour is receptive anal intercourse without a condom
with a person known to be HIV positive (Table 1). Oral intercourse poses the lowest risk but HIV may very rarely be transmitted
by this method of exposure, particularly when there is a breach in oral mucosal integrity.4
Source status. If possible, the source should be contacted to establish their HIV status. If they do
not know their status, request that they be tested.
If the source is unable to be contacted or they refuse to disclose their status, the risk that they are HIV positive
is based on seroprevalence (Table 2).
The United Nations AIDS organisation has information on worldwide prevalence
of HIV and AIDS.
Co-factors that increase risk of transmission3
- High viral plasma load in source – a person is most infectious when they first contract the virus and when they
have AIDS related symptoms
- STI in either the source or exposed person, especially genital ulcer disease and symptomatic gonococcal infections
- Breach in genital mucosal integrity e.g. trauma or genital tract infection
- Breach in oral mucosal integrity (in relation to oral sex)
- Exposed male is uncircumcised (inner mucosa of foreskin is more susceptible to infection and tears)
|Table 1: Risk of HIV transmission with non-occupational exposure (Adapted from ASHM3)
|Type of exposure with HIV+ source
||Estimated risk of HIV transmission per encounter
|Receptive anal intercourse without a condom
|Use of contaminated drug injecting equipment
|Insertive anal intercourse without a condom
|Insertive or receptive vaginal intercourse without a condom
|Bites, other trauma
|Table 2: Estimated seroprevalence of HIV in New Zealand
||HIV prevalence (estimated)5
|MSM in Auckland
||5 – 10%
|MSM in other cities
||2 – 5%
|Injecting drug users in New Zealand
|Commercial female sex workers in New Zealand
||0.1 – 1%
|Immigrants from developing
5 – 40%
1 – 5%
|Heterosexual men and women in New Zealand
Management and referral
The role of the GP is to establish whether there has been significant risk of exposure to HIV. If this is the case,
the patient should be referred immediately to an infectious diseases or sexual health physician with HIV experience. HIV
testing and follow-up care takes place within this setting.
Non-occupational post exposure prophylaxis
Antiretroviral drugs may be prescribed for people who have had a significant risk of HIV exposure, to reduce the possibility
of acquiring the infection. Non-occupational post exposure prophylaxis (NPEP) ideally should be started within a few hours
of the exposure and no more than 72 hours later, as it is very unlikely to be effective after this time.
The use of NPEP is still controversial as there is currently limited evidence that it reduces the transmission of HIV
and concern that it may encourage risky behaviour. It is also very costly ($1000 – $1500 per month) and adherence
may be an issue due to the length of treatment required (28 days) and potentially serious adverse effects of the drugs.6
NPEP is currently not funded in New Zealand. PHARMAC has assessed an application for this indication and it is currently
being considered alongside other funding priorities. Post exposure prophylaxis is funded by special authority for occupational
exposure (e.g. needle stick injuries) and in some cases of sexual assault (usually covered by ACC).
If NPEP is being considered, the patient should be referred urgently to an infectious diseases consultant. PHARMAC has
published a list of named specialists that have been approved to prescribe antiretrovirals in New Zealand.
See the Pharmaceutical Schedule Update, 1 January 2009, Page 4. Also available online at
Indications for NPEP
NPEP may be considered if the source is known to be HIV positive or the source status is unknown, but they are from
a high-risk population, which includes:4
- Men who have sex with other men
- Men who have sex with both men and women
- Injecting drug users
- People from a country where HIV is prevalent
- Commercial sex workers
- People who have a sexual partner belonging to any of these groups
And there has been:
- Receptive or insertive anal or vaginal intercourse
- Shared drug injecting equipment
A clinician considering prescribing NPEP would usually calculate the risk of infection, based on the type of exposure
and the risk of infection in the source (see Tables 1 and 2). In general, NPEP is considered if the transmission risk
is greater than 1 in 15000.3
Examples of risk calculation–
- Receptive anal intercourse with MSM source of unknown HIV status in Auckland:
Unprotected receptive anal intercourse (1/120) x MSM in Auckland (10%) = 1/1200
- Sharing of drug injecting equipment with an HIV positive source:
Use of contaminated injecting equipment (1/150) x HIV positive source (100%) = 1/150
- Insertive vaginal intercourse with a sex worker of unknown HIV status:
Insertive unprotected vaginal intercourse (1/1000) x female sex worker in New Zealand (1%) = 1/100000
For NPEP, a two or three drug regimen is prescribed for a course of 28 days.
The commonly recommended drug regimen for NPEP is zidovudine + lamivudine (Combivir) plus either efavirenz (Stocrin)
or lopinavir + ritonavir (Kaletra). Clinicians may select a different drug combination, depending on specific patient
factors related to the treatment history of the source patient (if known), or the risk of adverse effects.4
If the patient is being referred immediately to specialist care, HIV testing will not be required by the GP. Otherwise,
an HIV test (HIV antibody) should be requested immediately, and testing will need to be repeated regularly (see follow
up below) as it can take up to six months for infection to be detected.7
Assess pregnancy risk and consider the emergency contraceptive pill if required.
Test for Hepatitis B, Hepatitis C and STIs (chlamydia, gonorrhoea, syphilis, depending on exposure history).
- HIV repeat testing at four to six weeks, three months and six months after exposure4
- Provide support when discussing HIV test results
- STI repeat testing at four to six weeks and three months as appropriate
- Hepatitis C repeat testing (if indicated) at four to six weeks, three months and six months after exposure4
- Offer Hepatitis B vaccination if infection has been ruled out.
- Discuss precautions e.g. use condoms, avoid sharing blood-contaminated fomites (razors, toothbrushes) until final
negative test at six months4
- Reinforce safer sex messages
If the patient is receiving NPEP, they will require ongoing assessment for adverse effects as well as LFT, CBC and electrolyte
monitoring. Responsibility for this should be established with the prescribing physician.
Identifying acute HIV infection
Scenario: A patient presents to general practice with persistent flu-like symptoms. After taking a history it is discovered
that the patient has recently engaged in risky sexual behaviour. Is this cause for concern?
Symptoms of acute HIV infection
When an HIV infected person first has an immune response to the virus infected cells, cytokines are released by the
body’s immune system, causing flu-like symptoms.8 This is known as acute or primary HIV infection or
seroconversion illness.7 It usually occurs four to six weeks after initial infection. It is estimated that
around 30 to 60% of people infected with HIV have these signs and symptoms.7,8
The symptoms of acute HIV infection are non-specific and can be easily missed, but history of risky behaviour is the
key to diagnosis. Although there is some doubt that early treatment of HIV is beneficial, early diagnosis provides an
opportunity to decrease the risk of transmission to other people. A person with HIV is very infectious during this period.
This may also be the only occasion when an HIV infected person visits their doctor, before advanced immunosuppression
occurs many years later.7
Suspicion may be raised if a patient presents with flu-like symptoms (Table 3) out of flu season and the fever has lasted
longer than three days.
Taking clinical judgement into consideration, patients presenting with flu-like symptoms should be asked about their
history of risky sexual behaviour or injecting drug use.8
|Table 3: Key signs and symptoms of acute HIV infection (adapted from Anderson, 20038)
||Fever for three or more days (90% cases)
|Lethargy and malaise
|Myalgia and arthralagia
|Lymphadenopathy (40 – 70% cases)
||Headache (especially retro-orbital, worsening on lateral eye movements)
|Signs of meningism with stiff neck on passive flexion
||Rash (particularly maculopapular on thorax and arms)
|Desquamation reactions of the hands and feet
|Sore throat (sometimes candidal)
Managing acute HIV infection
If an acute HIV infection is suspected based on patient history, HIV tests should be requested. HIV antibodies can be
negative for up to six months after the start of the illness, so retesting may be required.8 Some literature
recommends that negative results are repeated in seven days,7 however modern tests are rarely falsely negative.
Anyone with a positive HIV test should be referred to an infectious disease or sexual health physician with HIV experience.
The physical symptoms can be treated symptomatically e.g. with analgesics. Hospital admission may be required if symptoms
are severe or if rehydration is required, however most patients can be managed at home. Symptoms usually resolve spontaneously
within two to three weeks.7
Psychological support is imperative. The patient may be referred to counselling or a peer support group. The New Zealand
AIDS Foundation offers a network of patient support (see contact details at end of article).
HIV testing for at-risk people
Scenario: A patient who may be at risk of exposure to HIV presents to general practice for a routine visit. Should
they be offered an HIV test?
There continues to be a stigma associated with HIV testing and many people are reluctant to get checked out. As the
number of HIV cases has been increasing in New Zealand over the past ten years, it is important that people at risk are
regularly tested and safer behaviours are discussed. HIV testing should be normalised and regarded as a standard aspect
of healthcare for those for whom testing is relevant. Advances in treatments means that for many people, HIV can now be
regarded as a long-term illness rather than the death sentence that it once was.
Who should be tested?
HIV testing should be offered and recommended to the following people:7,9
- Sexual partners of people known to be HIV positive
- Men who have disclosed sexual activity with other men
- Female sexual contacts of men who have sex with other men
- Any other person who has a history of unprotected sexual exposure that could result in HIV transmission
- People from a country where there is a high prevalence of HIV
- All people who report sexual contact overseas or have sexual contact with a person from an area of high prevalence
- People seeking assessment for a STI
- Prospective partners in a new sexual relationship
- People with a history of injecting drug use that involves the sharing of needles, syringes, spoons, filters etc
These people should be tested annually or more often if they have a high frequency of risky behaviour.7
N.B. In addition to the scenarios based on risk behaviours above, HIV testing is also recommended for all pregnant women
and all people recently diagnosed with tuberculosis (can be associated with HIV and AIDS).9
How should testing be approached?
Testing should be voluntary and only undertaken with the patient’s knowledge, consent and understanding.9
Make sure the patient understands why they are at risk of HIV and why it is recommended they get tested. If a patient
refuses to be tested, explore the reasons for this choice and ensure that it is not due to incorrect beliefs about the
virus or consequences of testing.7
Discuss and agree upon how the results will be given. Face-to-face provision of results is strongly encouraged. However
recent practice at a number of sexual health clinics has been to discuss giving results by phone at the initial interview,
with the proviso that should any results be of concern the patient will agree to come in the same day for face-to-face
Ensure that language and cultural barriers are addressed and that the patient understands what a positive or negative
result will mean i.e. positive does not mean good news.7
If partners are tested together discuss whether they will disclose the results to each other and how the results will
be acted upon.
If the result is positive, the patient should be referred to an infectious diseases physician or sexual health physician
with HIV experience at the earliest possible time, preferably within 48 hours.7
Have an established recall process if a patient fails to attend an appointment to receive results, particularly if positive.
A negative result may be used as an opportunity to reinforce safer sex messages.
Infectious Disease or Sexual Health physicians at local hospitals are the most appropriate source of information for
The New Zealand AIDS Foundation provides patient information and support through a network of nationwide services:
Phone 0800 80 AIDS (2437)
Thank you to Associate Professor Mark Thomas, Infectious Diseases Specialist, Department of Molecular
Medicine and Pathology, University of Auckland and William Pearce, RN, Dr Edward Coughlan,
Infectious Diseases Specialist & Clinical Director and Dr Alan Pithie, Infectious Diseases Specialist,
Christchurch Sexual Health, for expert guidance in developing this article.
- AIDS Epidemiology Group. HIV and AIDS in New Zealand - 2008. AIDS - New Zealand 2009;March(63).
- AIDS Epidemiology Group. HIV & AIDS in New Zealand - January to June 2009. AIDS - New Zealand 2009;October(64).
- Australasian Society for HIV Medicine Inc (ASHM). Australian guidelines for non-occupational post exposure prophylaxis:
Australian Government Department of Health and Ageing, 2007.
- Landovitz R, Currier J. Postexposure prophylaxis for HIV infection. N Engl J Med 2009;361:1768-75.
- McAllister S, Dickson N, Sharples K, et al. Unlinked anonymous HIV prevalence among New Zealand sexual health clinic
attenders: 2005-2006. Int J STD AIDS 2008;19:752-7.
- Bryant J, Baxter L, Hird S. Non-occupational postexposure prophylaxis for HIV: a systematic review. Health Technology
- British HIV Association, British Association of Sexual Health and HIV, British Infection Society. UK national guidelines
for HIV testing 2008, 2008.
- Anderson J. Recognising acute HIV infection. Aus Fam Phys 2003;32(5):317-21.
- Ministry of Health. Recommendations for HIV testing of adults in healthcare settings - 2008. HIV and AIDS information.
Wellington: Ministry of Health, 2008. Available from: