The NSW HIV control guideline outlines the procedures, requirements and responsibilities for those involved in routine HIV surveillance and public health follow up activities. It applies to Health Protection NSW (HPNSW), NSW laboratories conducting confirmatory HIV testing, clinicians involved in diagnosing or managing people newly diagnosed with HIV, and Public Health Units (PHUs).
This document does not provide guidance or advice for the clinical management of a person living with HIV. For guidance in matters related to the clinical management of a person newly diagnosed with HIV refer to the following:
High
Routine
Health Protection NSW (HPNSW) Responsibilities
Laboratory Responsibilities
Diagnosing Clinician Responsibilities
Managing Clinician Responsibilities
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Human immunodeficiency virus (HIV) is an RNA virus and member of the Retroviridae family, subfamily Lentiviridae, and genus Lentivirus. HIV primarily targets CD4+ T-helper lymphocytes, leading to severe immune suppression and increased vulnerability to various secondary infections and cancers.
There are two identified types of HIV which differ in transmissibility, disease progression and treatment response:
Dual infection with both HIV-1 and HIV-2 can occur.
Humans.
Viral load plays a critical role in determining the likelihood of HIV transmission, with higher levels significantly increasing transmission risk.1 Globally HIV is primarily spread through unprotected sexual contact, the sharing of contaminated injecting equipment, particularly among people who inject drugs, and from mother to child during pregnancy, childbirth or breastfeeding. The impact of these transmission pathways differ across regions of the world, and have shifted over time due to changes in behaviour, targeted public health initiatives and improved access to ART and pre-exposure prophylaxis (PrEP).
Despite these advances, sexual transmission remains the predominant mode of HIV acquisition globally including in Australia. Given the complexity and variability of individual circumstances, assessing the risk of HIV transmission or acquisition should be tailored to each person and evaluated on a case-by-case basis.
More details about transmission risk are available in the ASHM National Post-Exposure Prophylaxis for HIV guidelines.
Following transmission of HIV the onset of symptoms associated with acute seroconversion illness can occur within 2 - 4 weeks and 40 to 90 percent will experience symptoms. Symptoms of seroconversion may resemble an influenza like illness and are manifestations of the body's initial immune response to the virus.
After HIV acquisition, it generally takes two to three weeks for detectable levels of HIV antigen to appear in blood. Modern HIV antigen and antibody combination screening assays that are negative after six weeks generally exclude HIV infection, but current testing guidelines still recommend a test 12 weeks post-exposure.
Infectiousness is determined by viral load and is lifelong if untreated. People living with HIV who are able to maintain a viral load <200 copies/mL (undetectable), most commonly through ART, have no risk of transmitting HIV to their sexual partners.2-7 Similarly, there is no risk of transmitting HIV to an unborn infant if the mother has an undetectable viral load prior to, and during, pregnancy.6,8
Without ART, HIV viral load is generally detectable in blood and viral load varies depending on the stage of infection, with high viral loads associated with higher risk of HIV transmission. As viral load testing methods have improved over time, what constitutes as an 'undetectable' viral load has changed. Based on available evidence, many high-income countries (including Australia) consider a viral load of < 200 copies per mL of blood to be 'undetectable' and therefore pose no transmission risk.4
Furthermore, based on recent evidence the WHO now considers viral loads of <1000 copies per mL of blood to pose a near zero HIV transmission risk.4,9 This category has been defined as 'suppressed' viral load.9 These categories are summarised below:
HIV infection progresses through three distinct phases if left untreated. The rate of progression varies widely, from a few months to decades. In Australia, most individuals diagnosed with HIV begin ART as soon as possible, preventing disease progression.
Acute HIV infection:
Acute HIV infection encompasses both asymptomatic and symptomatic phases occurring shortly after HIV transmission. This stage is marked by rapid viral replication, high HIV RNA levels, widespread infection of CD4+ T cells and a transient drop in CD4 count. Seroconversion, the development of detectable antibodies against HIV antigens, typically follows.
In 60-90% of people, a brief seroconversion illness resembling influenza may occur, lasting around 14 days.10-12 Common clinical features include fever, rash, pharyngitis, lymphadenopathy and splenomegaly.
The risk of HIV transmission is highest during the acute infection phase, making early recognition and diagnosis of HIV important to support timely treatment and reduce onwards transmission risk.
Chronic HIV infection:
Following acute infection, HIV enters a prolonged asymptomatic stage. Key features include:
During this phase, individuals may remain asymptomatic or present with non-specific symptoms such as:
As CD4+ counts decline, susceptibility to opportunistic infections increases, signalling progression toward advanced HIV disease.
Acquired immunodeficiency syndrome (AIDS)
AIDS represents the most advanced stage of HIV infection, resulting from untreated chronic HIV and progressive depletion of CD4+T cells.
The World Health Organisation (WHO) defines advanced HIV disease as any of the following:
It is possible for a person to progress to advanced HIV infection without experiencing prominent HIV related symptoms. In the absence of ART, AIDS is associated with a markedly increased risk of severe opportunistic infections and HIV associated malignancies often leading to significant morbidity and mortality. People with ART related immune reconstitution after being diagnosed with an AIDS defining illness should no longer be considered to have AIDS.
Detailed statistics for HIV epidemiology are provided by UNAIDS for global trends, the Kirby Institute for Australian data the NSW Health HIV Data Reports for NSW specific information.
Globally, in 2024, it was estimated that 40.8 million people were living with HIV and approximately 44.1 million people died from AIDS-related illnesses since the epidemic began in the 1980s.13
In Australia, HIV prevalence remains comparatively low at 0.14% of the general population, with concentrated epidemics observed in specific subpopulations. HIV notifications have declined since 2014 as a result of treatment and behaviour change. Public health measures related to the COVID-19 pandemic likely contributed to the further decrease between 2019-2022.14
HIV risk is shaped by behavioural, biological, and structural factors. While anyone can acquire HIV under the particular exposure circumstances, the following groups are considered at elevated risk:
More details about these priority groups and other intersectional areas of focus are described in the NSW HIV Strategy 2021-2025 and the Ninth National HIV Strategy 2024-2030.
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Successful HIV prevention relies on the availability, accessibility and inclusivity of diverse prevention methods, particularly for Aboriginal and Torres Strait islander peoples and other culturally and linguistically diverse communities. Use of a combination of prevention strategies is more effective than relying on a single method in isolation. Comprehensive HIV prevention requires a multi-faceted approach. Key prevention activities include:
These strategies are comprehensively described in the NSW HIV Strategy 2021-2025 and Ninth National HIV Strategy 2024-2030.They include:
PrEPHIV PrEP is a highly effective strategy for preventing HIV for people who are HIV-negative but at increased risk. It involves taking an oral medication, typically a combination of tenofovir and emtricitabine, either daily or on demand, which significantly reduces the chance of HIV transmission through sexual contact or injecting drug use. In Australia, PrEP is available through the Pharmaceutical Benefits Scheme (PBS) and can be prescribed by general practitioners and nurse practitioners.
For more details and clinical considerations see the Australian STI Management Guidelines and National PrEP Guidelines.PEPHIV PEP is an emergency medical treatment aimed at preventing HIV infection after a potential exposure. It consists of a 28-day course of ART and must be initiated as soon as possible and within 72 hours of the exposure to ensure maximum effectiveness. While PEP can significantly reduce the risk of HIV transmission, it is not a replacement for ongoing HIV prevention strategies such as safer sex practices or PrEP.Clinicians are responsible for clinical assessment and prescribing PEP. The ASHM guidelines provide comprehensive recommendations on risk assessment, medication protocols, and follow up care. Please refer to the ASHM PEP Guidelines.
HIV is a scheduled medical condition listed in categories 2, 3 and 5 of the NSW Public Health Act 2010. Laboratories are required to report confirmatory western blot and nucleic acid results to NSW Health. Medical practitioners must provide information about the medical condition and other risk factors, upon request by HPNSW.
Minimum data required at time of notification:
Laboratories are required to notify HPNSW within 24 hours of a diagnosis as per the NSW disease reporting requirements, providing the information below:
If the diagnosing clinician cannot be contacted, the matter should be referred to HPNSW. HPNSW may then refer to the case to Sexual Health Info Link (SHIL) to support appropriate patient follow up and ensure linkage into appropriate care pathways.
If a clinician involved in the care of the patient requests a copy of the full HIV laboratory report, the laboratory should provide the report directly to that clinician or HPNSW upon request.
Minimum data required during routine follow up activities
It is recommended in the HIV management guide for clinical care that HIV drug resistance testing is undertaken at the time of all new HIV diagnoses, to both guide choice of treatment for the individual and contribute to surveillance of population level drug resistance rates. Select HIV reference laboratories perform HIV drug resistance testing by sequencing segments of the pol gene of the HIV virus and analysing the sequences with the HIV drug resistance database.
HIV reference laboratories that perform HIV drug resistance testing are required to report the following to HPNSW:
Diagnosing Clinician
If the diagnosing clinician is unable to manage the patient, a referral to HIV specialist care (HSP) is required to ensure continuity of treatment and public health follow up. For newly diagnosed patients, HPNSW requires confirmation of specialist referral details (if relevant) and reason for HIV testing. It may not be necessary to complete the entire HIV notification form.
For patients with known diagnosis made outside of NSW, HPNSW may contact the requesting clinician to obtain details of the patient's previous diagnosis (i.e. location and date of diagnosis) if it has not previously been notified to NSW.
Managing Clinician
For newly diagnosed patients, the managing clinician should liaise with the diagnosing clinician to confirm that contact tracing has been initiated and appropriately documented. The HIV notification form must be returned within 14 days of receiving it from HPNSW. Additionally, managing clinicians are required to complete the HIV enhanced surveillance (six-month follow up) form within 14 days of receiving it from HPNSW. This follow up ensures comprehensive data collection and supports long-term monitoring of HIV cases.
Death Notification
Death of a person living with HIV (PLHIV) is reported to the National HIV Register. HPNSW is also notified through submission of the Notification form in line with standard reporting protocols.
HPNSW uses laboratory notification forms to determine whether urgent public health actions are needed. To support timely response:
HIV notification forms completed by clinicians should be entered as soon as possible to ensure accurate surveillance and timely reporting.
HPNSW is responsible for reporting all HIV cases diagnosed in NSW to the National HIV Registry, which is maintained by the Kirby Institute at the University of NSW Sydney, on behalf of the Department of Health, Disability and Ageing.
In instances where a case involves diagnosis or ongoing management across state borders, HPNSW actively communicates with relevant interstate public health departments to collect and verify necessary data. This collaboration is essential to maintain consistent and accurate reporting across jurisdictions, prevent duplication, and support coordinated public health responses.
All external communications are conducted in accordance with privacy legislation, ensuring that information is deidentified and shared only when required for public health action. HPNSW also maintains thorough documentation of these communications and conducts regular reviews to uphold reporting standards and strengthen cross-border coordination.
National case definitions are regularly reviewed. The current versions can be found via the following links:
National laboratory case definitions are regularly reviewed, and the current version can be found via the following link: HIV laboratory case definition.
In addition, detailed information regarding the HIV testing process and special considerations are outlined in the ASHM National HIV testing Policy V1.5, and best practice for laboratories is outlined in Requirements for laboratory testing for human immunodeficiency virus (HIV) and hepatitis C virus (HCV) Fourth Edition 2023.
The diagnosis of HIV is primarily made through laboratory testing that detects markers of HIV infection in blood. In the first 10 days after infection, no markers are typically detectable. After this period, viral nucleic acid (RNA or proviral DNA) may be identified using nucleic acid tests (NAT), which are useful for detecting acute infection. Around 2–3 weeks post-infection, HIV p24 antigen becomes detectable, and by 4 weeks, antibodies to HIV are usually present, depending on the type of test used.
HIV antibody/antigen (4th generation) combination tests are the standard initial screening tool for HIV used by most laboratories in Australia due to the low cost, high sensitivity, and rapid turnaround time. The test detects both HIV-1 antigen and antibodies to HIV-1/2 generally within 3 - 4 weeks from infection. Any reactive result on the initial screening test must be repeated, and if the repeat is also reactive the sample is referred to a reference laboratory for confirmatory testing to determine whether the reactivity is true positive or a false positive result.
Western blot immunoassay is the most common confirmatory HIV test. Western blot detects antibodies in the blood (serum) that bind to various HIV proteins. These antibodies typically appear in a predictable sequence as infection progresses, and the resulting banding patterns on the blot can help identify the stage of infection. However, this means indeterminate results can also occur and are characterised by the presence of some HIV-related bands but not enough to meet the criteria for a positive result. There are several causes for indeterminate results such as early seroconversion and recent PrEP or PEP use. In these instances, the western blot can be repeated after 2-4 weeks or a confirmatory molecular test can be used.
Qualitative RNA PCR is now the preferred molecular confirmatory test for people over 18 months of age, offering a definitive yes or no result by detecting the presence or absence of HIV RNA in a blood sample. These tests are particularly valuable in identifying early HIV infections especially during the acute phase when antibody tests may not yield positive results. Their high sensitivity makes them especially useful in diagnosing HIV in individuals with recent high-risk exposure, or those with indeterminant antibody tests.
HIV proviral DNA PCR is now primarily reserved for specific clinical scenarios. Proviral DNA tests are commonly used for the assessment of HIV status in infants born to HIV-positive mothers, where maternal antibodies can interfere with standard serological tests. Given the complexity of the assay and its limited scope of application, proviral DNA testing should be guided by a specialist in HIV medicine or infectious diseases.
Genotypic antiretroviral resistance testing detects viral mutations that reduce the effectiveness of ART. Typically performed through genotypic analysis, it identifies mutations in the reverse transcriptase, protease, or integrase genes that confer resistance to specific antiretroviral drugs. Resistance testing is recommended when a person enters care and whenever treatment failure occurs. These results guide clinicians in selecting effective regimens preventing further resistance and supporting sustained viral suppression by tailoring therapy to the individuals' resistance profile.
CD4+ T cell count is used to assess the degree of immune suppression caused by HIV:
CD4+ T cell counts should be interpreted in conjunction with clinical status and viral load when assessing the stage of HIV infection for surveillance purposes. These tests are no longer routinely performed for patients who are clinically stable and maintain an undetectable viral load. Testing CD4+ T cell count is now primarily limited to initial assessment before starting ART, and in specific clinical scenarios such as evaluating the need for opportunistic infection prophylaxis or investigating unexplained immunologic decline.
Viral load testing is used to monitor HIV infection after diagnosis. It measures the amount of HIV RNA in plasma providing a direct assessment of viral replication. This is a key indicator of treatment effectiveness. A sustained undetectable viral load is the primary goal of ART as this is associated with improved health outcomes and reductions in HIV transmission risk.
Point of care or rapid tests (POCT) that detect HIV specific antibodies are effective screening tools designed to expand access to HIV diagnosis particularly in community based, outreach and low resource settings. These tests are typically immunoassays that identify the presence of antibodies produced in response to HIV infection. They commonly use finger prick blood or oral fluid collected by a trained clinician and provide results within 20 minutes allowing same visit counselling, provisional diagnosis and referral for further care. Rapid HIV tests are highly sensitive (99.5%) and specific (99%) when performed correctly but may be less sensitive than laboratory tests in acute infection. All POCT reactive tests must be confirmed using a validated confirmatory testing algorithm before a definitive diagnosis is made.
HIV self-tests offer individuals a private, convenient and reliable way to screen for antibodies to HIV. They are single use finger prick blood tests that integrate a lancet, blood collection system and test strip into one device. They are designed to minimising user error and simplifying the testing process. Results are available in 15-20 minutes. While highly accurate for screening all reactive results must be confirmed by further testing by a trained healthcare professional. HIV self-testing supports earlier diagnosis, reduces barriers to testing, and increases testing uptake among populations who may not access conventional health care.15
As of November 2025 there are two HIV self-tests approved for use in Australia, the Atomo self-test and the Panbio HIV self-test. HIV self-test results are not captured by the NSW HIV surveillance system.
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Management of a HIV notification requires clear communication between HPNSW, the diagnosing clinician and the managing clinician. When the diagnosing clinician is not an S100 provider they cannot provide ongoing HIV management and treatment, so a referral to an S100 provider is required. HPNSW should confirm whether a referral to specialist care was made, either by facilitating the HIV Support Program (HSP) or contacting the diagnosing clinician directly.
Once the patient has been referred, the managing clinicians assumes responsibility for:
PHUs are not usually required to follow up HIV cases and are not involved in routine notification processes. However, PHU involvement may be necessary when further investigation is requested by the patient or clinician, or when HPNSW identifies unusual clustering or an unclear source of infection. In such instances PHUs may assist in determining the epidemiological context and support broader public health responses.
The HSP is a service facilitated by HPNSW to provide expert guidance and referral support to clinicians who may have limited experience in managing HIV. HSP ensures that all healthcare providers involved in the care of NSW residents diagnosed with HIV have access to specialist advice, promoting timely referral to specialist care and facilitating rapid treatment initiation as appropriate.
Local health districts (LHDs) should establish clear referral pathways to an S100 provider for people tested within public services. These pathways should include access to immunology, infectious disease or sexual health to ensure continuity of care and timely HIV specialist intervention. However, HSP is also available to any clinician in a NSW Health facility.
Standard Hours: HSP Coordinators (HIV specialist clinicians) are available during standard business hours (Monday - Friday 0830-1700 hours).
After-Hours Support: For urgent queries outside these hours - specifically Monday - Friday 1700-1900 hours SHIL provides support to assist with HSP requests.
Response Timeframes: Once an HIV diagnosis is confirmed and notified by a reference laboratory, and HSP support is requested, HPNSW must respond and action the request within one business day.
Follow up by the HPNSW HIV surveillance team is conducted in three phases, occurring at two time points:
Diagnosing clinician follow up
If the diagnosing clinician has requested an HSP referral, HPNSW must facilitate linkage with the appropriate HSP coordinator at the preferred time requested by the diagnosing clinician within one business day. HPNSW must also confirm the details of specialist referral with the diagnosing clinician within five business days of notification, regardless of whether an HSP referral was made.
If the diagnosing clinician is also an S100 provider these steps are not required, as all necessary information will be collected during routine surveillance follow up as described below.
Managing clinician follow up
HPNSW conducts routine surveillance for all newly diagnosed HIV cases in NSW, to confirm diagnosis details and collect essential epidemiological data. This is facilitated through the HIV Notification Form, which is distributed to the managing clinician, between 2 weeks and 3 months after the initial notification. Clinicians are required to complete and return the form within 14 days of receipt. Upon return to HPNSW the data is promptly entered into the Notifiable Conditions Information Management System (NCIMS). All data handling must comply with confidentiality and security protocols outlined in PD2025_008.
At six months after a new diagnosis, enhanced surveillance is initiated to obtain additional clinical and epidemiological data for those still in care in NSW. HPNSW distributes the HIV Enhanced Surveillance Form to managing clinicians on a quarterly basis. Clinicians are required to complete and return the form within 14 days of receipt.
Upon return to HPNSW the data is promptly entered into NCIMS. All data handling must comply with confidentiality and security protocols outlined in PD2025_008.
HIV screening during pregnancy should be performed in accordance with local clinical guidelines. In cases where HIV is diagnosed in pregnancy, it is essential that the case be discussed with a clinician experienced in the management of HIV in pregnancy to ensure optimal treatment and outcomes for both the pregnant person and child. For more details see the HIV Management Guideline for Clinical Care.
Any new HIV diagnosis in a child should trigger a review in line with local protocols to examine contributing factors and care pathways. These cases should be managed in consultation with a specialist paediatrician to ensure appropriate care and support.18
Healthcare workers (HCW) living with HIV who perform exposure prone procedures (EPPs) must 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.
Management of cases among HCW is coordinated by the LHD. The policies governing the management of bloodborne virus (BBV) exposures and HCW living with BBVs:
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