Human Immunodeficiency Virus Infection A026

Current RMA Instruments

Changes from previous Instruments

ICD Coding

• ICD-9-CM Codes: 042, 795.71, V08
• ICD-10-AM Codes: B20, B21, B22, B23, B24, Z21

Brief description

This SOP covers the spectrum of HIV infection, from asymptomatic infection to full blown AIDS.

Confirming the diagnosis

The diagnosis is based on blood testing (serology/immunoassay or testing for HIV RNA).  A variety of tests can be performed but combination HIV antigen and antibody tests together with a HIV-1/HIV-2 differentiation immunoassay is the current preferred approach.

The relevant medical specialist is an infectious diseases physician.

Additional diagnoses covered by SOP

• AIDS (acquired immunodeficiency syndrome)
• HIV 1 infection
• HIV 2 infection

Clinical onset

 A significant proportion of patients with HIV infection will be initially asymptomatic.  Some develop non-specific symptoms such as fever, sore throat, rash, myalgia/arthralgia, diarrhoea, and headache at the time of acute infection.  First evidence of the infection may be from a screening blood test.

Clinical worsening

With currently available antiretroviral medications the condition can be well controlled in most patients.  Untreated, the condition will progress through an asymptomatic phase to a symptomatic phase to AIDS and eventually death.