What are the symptoms of Human Immunodeficiency Virus (HIV)?

HIV Symptoms

HIV infection presents with distinct symptom patterns across three clinical phases: acute infection (2-4 weeks post-exposure), asymptomatic period (years), and advanced disease/AIDS (when CD4 count drops below 200 cells/mm³).

Acute HIV Infection (Acute Retroviral Syndrome)

Acute retroviral syndrome occurs in the first few weeks after HIV infection, before antibody tests become positive, and is characterized by a constellation of symptoms that should prompt immediate nucleic acid testing. 1

The most predictive symptoms include:

• Fever (most common and highly predictive) 1, 2
• Myalgia (muscle aches) 2
• Malaise and fatigue 1
• Lymphadenopathy (swollen lymph nodes) 1
• Skin rash 1
• Sore throat 1
• Headache 1
• Arthralgia (joint pain) 1
• Night sweats 1
• Diarrhea 1
• Unintentional weight loss 1

A validated symptom score assigns 11 points for fever, 8 points for myalgia, and 4 points for weight loss; a total score ≥11 is 72% sensitive and 96% specific for acute HIV infection. 2

Asymptomatic Period

Most HIV-infected persons remain asymptomatic for years (averaging 8 years) after initial infection, though the virus is actively replicating and gradually destroying the immune system. 3, 4 During this phase, patients typically have no symptoms but are infectious to others. 1

Early Symptomatic HIV (CD4 Count 200-500 cells/mm³)

As CD4 counts begin to decline below 500 cells/mm³, certain opportunistic conditions emerge with increasing frequency:

Dermatologic Manifestations

• Seborrheic dermatitis (one of the earliest and most persistent markers, increasing in severity with disease progression) 5
• Fungal infections including tinea and onychomycosis (appear early but become more diffuse and treatment-resistant as disease advances) 5
• Psoriasis (may present with increased severity) 5
• Recurrent herpes simplex 3
• Herpes zoster (shingles) 3

Oral Manifestations

• Oral candidiasis (thrush) 3
• Oral hairy leukoplakia 3

Hematologic

• Immune thrombocytopenia (ITP, often presents early in clinical course) 3

Advanced HIV/AIDS (CD4 Count <200 cells/mm³)

When CD4 counts fall below 200 cells/mm³, the risk of life-threatening opportunistic infections and AIDS-defining conditions increases dramatically. 3 These symptoms require urgent medical evaluation and immediate referral: 1, 6

Constitutional Symptoms (Critical Warning Signs)

• Unexplained fever (particularly lasting ≥2 weeks) 1, 6
• Significant weight loss (≥5% in 3 months or ≥10% over 6 months) 1, 6
• Night sweats 1, 6
• Persistent fatigue 1

Respiratory Symptoms

• Shortness of breath/dyspnea 1, 6
• Persistent cough 1, 6
• Chest pain 1

Gastrointestinal Symptoms

• Chronic diarrhea (unexplained, lasting ≥2 weeks) 1, 6
• Nausea and abdominal pain 1
• Difficulty swallowing (dysphagia/odynophagia, suggesting esophageal candidiasis) 3

Neurologic/Psychiatric Symptoms

• Persistent severe headaches 1
• Memory loss and difficulty concentrating 1
• Depression, apathy, anxiety 1
• Lower extremity paresthesias, pain, or numbness 1
• Seizures 1
• Gait abnormalities 1

Dermatologic (Advanced Disease)

• Kaposi sarcoma (purple/brown skin lesions) 1, 5, 3
• Molluscum contagiosum 1
• Severe folliculitis 1
• Eosinophilic folliculitis (HIV-specific papular dermatosis) 5
• Prurigo nodularis 5
• Proximal subungual onychomycosis (PSO, a useful marker particularly in AIDS patients, spreading rapidly from proximal nail margin) 5

Oral Manifestations (Advanced)

• Oral candidiasis (marked increase with advanced disease) 5, 3
• Oral hairy leukoplakia 1
• Kaposi sarcoma (oral) 1, 5
• Aphthous ulcers 1
• Gingivitis and periodontal disease 1

Ophthalmologic

• Vision changes or loss 1
• Retinal exudates or cotton wool spots 1

Other Physical Findings

• Generalized or localized lymphadenopathy 1
• Hepatomegaly or splenomegaly 1
• Evidence of wasting or lipodystrophy 1

Critical Clinical Pearls

Any HIV-infected patient presenting with fever, significant weight loss, dyspnea, or persistent cough requires urgent medical evaluation, as these symptoms suggest advanced disease with high risk for life-threatening opportunistic infections. 1, 6 These patients need immediate CD4 count measurement, HIV viral load testing, chest radiograph, and consideration for urgent antiretroviral therapy initiation. 1, 6

Cutaneous anergy (inability to mount delayed-type hypersensitivity responses) increases with declining CD4 counts, with approximately 80% of patients showing anergy when CD4 counts fall below 50 cells/mm³. 5

The presence of oral candidiasis, unexplained fever, unexplained weight loss, or CD4+ lymphocyte count below 200 cells/mm³ indicates at least 25-50% risk of developing AIDS within the next 3 years. 7

Common Pitfall to Avoid

Do not wait for antibody testing to diagnose acute HIV infection—if acute retroviral syndrome is suspected based on symptoms (especially fever, myalgia, rash, and lymphadenopathy within weeks of high-risk exposure), order HIV nucleic acid testing immediately, as antibody tests will be negative during this critical window period. 1 Early diagnosis during acute infection allows for immediate antiretroviral therapy, which can delay disease progression and reduce transmission risk. 1