STD Co-infection Among Acute HIV Patients in Los Angeles County Michael W. Chien, Ali Stirland, Apurva Uniyal, Peter R. Kerndt STD Program, Los Angeles County Dept. of Public Health mchien@ph.lacounty.gov 1 1

HIV Viremia and Antibody Response HIV RNA (plasma) HIV Antibody 11 22 10 20 30 40 50 60 70 80 90 100 Acute HIV Infection (Window Period) Days

Detection of HIV 0 1 2 3 4 5 6 7 8 9 10 Symptoms p24 Antigen HIV RNA HIV EIA* Western blot 0 1 2 3 4 5 6 7 8 9 10 The presence of HIV can be detected using tests that detect HIV directly in the blood, as early as 1-2 weeks after infection. Antibody tests take one to five weeks longer. The big question is: do people show up for HIV tests during the first few weeks after infection? If not, the question of when different tests detect HIV would be moot. BUT IF THEY DO, we could be missing a lot of HIV infections depending on which test is used. Although Western blot is considered by many to be the “standard” confirmatory test, it turns positive considerably later than many of the accurate screening tests. Weeks Since Infection *3rd generation, IgG & IgM *2nd generation EIA IgG *1st generation EIA IgG After Fiebig et al, AIDS 2003; 17(13):1871-9

Pooled NAAT Screening for Early HIV Infection A B C D E F G H I J 100 Individual specimens (HIV antibody negative) 10 Pools of 10 A B C D E F G H I J 1 Screening Pool

HIV Testing EIA non-reactive Pooled NAAT Neg. Pos. HIV Negative Vironostika® HIV1 antibody test Roche Amplicor® Monitor HIV-1 or GenProbe Aptima assay Pooled NAAT Neg. Pos. LA County uses 1st generation EIA antibody test Detectable 4 ½ to 5 ½ weeks or more after infection Nucleic Acid Amplification Test (NAAT) Identifies virus before antibody is produced HIV-1 RNA detectable as early as 6-11 days after exposure HIV Negative Presumptive AHI 5

Objective To examine the prevalence of STDs among a cohort of acutely infected HIV patients in Los Angeles County

Cohen, Pilcher, UNC Center for AIDS Research Background STDs in HIV-positive individuals increases the risk of HIV transmission HIV RNA in Semen (Log10 copies/ml) Acute Infection 3 wks STD Episode AIDS Cohen, Pilcher, UNC Center for AIDS Research

Background II In acute HIV infection, individuals are highly infectious Studies have suggested over 40% of new infections may be caused by persons with primary HIV infection Treatment of STD in HIV co-infected may reduce HIV transmission After people become aware they are HIV-positive, the prevalence of high-risk sexual behavior is reduced substantially – reduced number of partners and sero-sorting * HIV-pos Aware vs. HIV-pos Unaware Meta-analysis of high-risk sexual behavior in persons aware and unaware they are infected with HIV in the U.S. Marks G, et al. JAIDS. 2005;39:446 Great opportunity – bring same standards of care as blood bank Frustrating How many pts come back after window period? NAAT – may help resolve tricky results like WB neg or indet IRB approval X3 19 mths of planning Belinda towns, AHO, AMD, NM, SPHI Detailed Training will be given at each site & hand holding after 1st & 2nd generation EIAs test for IgG - detectable 5 wks or more 3rd generation EIAs test for IgG & IgM - detectable 3-4 wks or more Rapid tests detect infection after 3-4 wks Vironostika EIA (estimate 7-10% increased yield) SF 10.5% inc rate 3.9% +ve EIA LA 7.1% 0.8% seatle 8.6% 2.3% SF and LA found that the addition of HIV RNA screening to routine HIV antibody screening in STD clinics increased the diagnostic yield for HIV infection* NAAT appears to be more sensitive than conventional tests in identifying acute infection; nonetheless, NAAT has not been approved by the FDA as a diagnostic test for HIV 8 8

Study Population 13 Public Health Department STD clinics Mobile Testing Unit (MTU) 2 community STD clinics, majority of clients are MSM (sites A&B) Jail Unit for MSM and transgenders 9 9

Data Collection STD/HIV Intake form Public Health Laboratory testing database STD surveillance database

Results

Pooled Testing - Acute HIV Detection Studies Los Angeles, 02/06 – 01/08 Site EIA +/Total EIA (%) NAAT pos. EIA neg. (n) % increased HIV infection detected (%) Site A Site B 140 / 7,830 1.8% 61 / 1,793 3.4% 28 4 20% 7% Jail 172 / 1,595 10.8% 0% STD Clinics 236 / 27,861 0.8% 9 4% MTU ---------- 31 / 2,708 1.1% ---------------- ------- 1 false+ -------- ------ Total 640 / 41,787 1.5% 41 6% This includes all of LA AHI cases, 1 AHF case (1/7/08), 1 LAGLC case (1/16/08) 12 12 12

Pooled Testing - Acute HIV Detection Studies Los Angeles, 02/06– 01/08 HIV NAAT testing led to: 6% increase in HIV detection 20% increase (Site A) 7% increase (Site B) 1 in 1000 1 in 275 (Site A) 1 in 433 (Site B) 13

Patients with Acute HIV Infection (AHI) VL (cp/ml) at time of initial HIV-1 Ab negative test: 6 <100,000 (lowest 1,502;1,827 to >500,000 in 9 days) 10 >100,000 19 >500,000 6 w/ invalid quantitative assay 1 <75 (false positive) 25/41 (61%) patients presented with symptoms 10 AHI symptoms only (flu-like &/or rash &/or fever) 4 AHI and STD symptoms 10 STD symptoms 1 cervical lymphadenopathy N=41 Update this slide to include VL data from 14

Gender of Cases and Sex Partners Gender of AHI cases 39 male 1 transgender M to F 1 female male female 28 11 2 Gender of sex partner 27 (66%) MSM only 11 (27%) MSMW/W 2 (5%) MSW only 1 (2%) WSM Update this slide N=41

Number of Sex Partners 3 months prior to diagnosis N=41, range=1 to 72 partners *6 with no information on gender of sex partner

Anal Intercourse & Condom Use 3 months prior to diagnosis 38 (93%) reported anal intercourse 29 insertive & receptive (incl. 2 who reported vaginal sex) 5 receptive only (incl. 1 who reported vaginal sex) 4 insertive only N=41 11 (30%) never used condoms for anal intercourse 5 (13%) always use condoms 21 (57%) sometimes / mostly N=37

Sex Partner Risks 30 (73%) reported having ever met anonymous sex partners: 14 internet 9 bar/clubs 6 bathhouse/sex club 5 (12%) reported sex with IDU in the year prior to diagnosis 8 (20%) reported sex with HIV positive partner(s) in the year prior to diagnosis N=41 19 met anonymous in past 3 months, 26 in past year

Drug Use 1 year prior to diagnosis 20 (56%) used one or more drugs 15 (41%) methamphetamines 9 used meth with at least 1 other drug (ecstasy, nitrates, viagra, ketamine, poppers) 5 viagra All used in combination with at least one other drug (meth, ecstasy, nitrates, ketamine, cocaine, marijuana) 4 marijuana 3 alcohol only 3 nitrates only N=41

AHI and STD Co-infection 39 / 41 AHI were tested for at least one STD 37 Males (24 MSM, 11 MSMW, 2 MSW) 39 tested for CT/GC 37 tested for syphilis 18/39 (46%) co-infected on lab tests 4/37 (11%) early syphilis 7/39 (18%) CT 14/39 (36%) GC 6 co-infected with more than 1 STD 3 CT/GC 2 early syphilis/GC 1 early syphilis/CT/GC Result: From February 2006 through October 2007, 34 persons with acute HIV were identified; 32 were tested for at least one other STD. Of these, 29 were MSM; two were MSW; and one was a M-to-F transgender who had sex with men. All 32 acute HIV cases were tested for CT and GC; 30 patients were additionally tested for syphilis. Overall, 18 (56.3%) acute HIV patients were co-infected with at least one other STD: 7 (21.9%) had CT, 14 (43.8%) had GC and 5* (17%) had syphilis. Of these, 2 had CT only; 7 GC only; 2 syphilis only; 3 CT/GC; 1* syphilis/GC; and 2 with syphilis/CT/GC. (* Corrected since abstract submitted) 37 Males (24 MSM, 11 MSMW, 2 MSW) 1 Female (WSM) 1 Transgender M to F 2 also had genital warts 20

STD Prevalence *MSM visiting 12 LAC STD Clinics in 2006 Sas program phl_query_030708 *MSM visiting 12 LAC STD Clinics in 2006 **All visits to 12 LAC STD Clinics in 2006

Conclusion STD co-infection in the acute stage of HIV infection is common. Increased likelihood of AHI among MSMs w/ Diagnosis of an STD Recent high risk sexual exposures (eg. anonymous parters, sex with IDU, sex with HIV positive partner) Other risk history, including methamphetamine use, viagra use and meeting of partners from the internet Individuals with acute HIV and an STD co-infection provide a target for intervention to reduce HIV transmission.

Recommendations Any MSM presenting for evaluation of an STD with a negative HIV Ab. test should be tested for acute HIV infection. Any individuals with acute HIV should be tested for other STD’s. Retest for syphilis, longer window period on syphilis than for HIV naat

Acknowledgements Los Angeles County Department Of Public Health Sexually Transmitted Disease Program Staeci Morita Lashawnda Royal KaiJen Chen Public Health Laboratory Lee Borenstein Debbie Emlein Los Angeles Gay and Lesbian Center (LAGLC) Robert Bolan Quentin O’Brien AIDS Healthcare Foundation Whitney Engeran New York State Diagnostic HIV Laboratory Judith Wethers Monica Parker Tim Sullivan Kathy Gumbel Centers for Disease Control and Prevention Pragna Patel (Project Officer)