STAT Steve Beagle UNC CHAVI Field Coordinator University of North Carolina at Chapel Hill

Acknowledgements North Carolina D.I.S. and all Public Health Colleagues and Clients Evelyn Foust, Peter Leone, Todd VanHoy, and Rhonda Ashby (HIV/STD Prevention and Care) JoAnn Kuruc - STAT Program, University of North Carolina (UNC)

What is STAT? Acronym for “Screening and Tracing of Active Transmission” (Acute HIV) Collaboration between UNC and the NC HIV/STD Prevention and Care Branch (Field Services Unit) Statewide program that has enormous public health impact

Acute HIV The STAT Program

Public Health Impact? Most infectious period of HIV infection Early linkage to care HIV education to help prevent downstream transmissions Rapid partner contact and tracing, counseling and testing Research: medical evaluations, treatment interventions and vaccine studies

History of STAT Pilot project in 2001: 8,155 Specimens pooled Two [2] “two month” testing periods (May-June and August-September) Identified five antibody negative, HIV RNA positive samples (four were positive for acute HIV infection and one was a false positive) November 2002: STAT Program Implemented Statewide (SLPH/Field Services/UNC)

STAT Program Testing sites: >110 publicly funded sites across NC Laboratory detection of incident HIV infection Routine HIV Antibody (Ab or EIA) testing HIV-1 QL RNA screening of all Ab (-) specimens Rapid notification of RNA (+) Ab (-) individuals by the NC DHHS STAT DIS Rapid partner notification and testing Systematic data collection on social/sexual networks Ongoing monitoring of transmission patterns by the UNC/NC DHHS STAT Team

STAT Program Classification System STAT Acutes Community Acutes Community Recents

STAT Acutes One of the following test result combinations from the North Carolina State Laboratory of Public Health (NCSLPH) EIA (-), RNA (+) EIA (+), RNA (+), WB (-) EIA (+), RNA (+), WB (I) (“I”= indeterminate)

Community Acutes HIV test results usually the same as with STAT acutes Can test EIA (+) WB (+) with documentation of a negative HIV antibody test within the past 30 days. Cases are discovered by PMDs, hospitals and Field Services HIV testing is usually performed in labs other than SLPH (i.e. LabCorp, Quest)

Community Recent EIA/WB(+) with a documented EIA(-) test within the previous 6 months Our focus: Community recents with … An EIA(-) test ≤ 3 months of the EIA/WB+ result An STD (diagnosed and treated) ≤ 1 month of the first HIV positive test Symptoms consistent with an acute retroviral syndrome (ARS) ≤ 1 month of the first HIV positive test Consider last exposure and any circumstances that would clearly suggest transmission 3 months prior to an +EIA/WB

Acute Retroviral Syndrome or ARS Often overlooked by patients and/or physicians Frequently misdiagnosed as: Flu or viral syndrome Meningitis Rash Rocky Mountain Spotted Fever

ARS (continued) 5. Urinary Tract Infection Sore throat/pharyngitis Upper Respiratory Infection “Viral Syndrome” “Viral illness” Herpes Mononucleosis (mono)

STAT Acutes How are they identified ? ? The NCSLPH detects a positive pool. The pool is deconstructed to identify the positive sample – John Barnhart (ESSU) notified. John notifies Rhonda Ashby, who then notifies the appropriate regional supervisor Regional supervisor assigns the case to a STAT D.I.S. in their region STAT D.I.S. begins investigation, locates and interviews the “possible” acutely HIV infected individual within 72 hours of the testing result

STAT Index Case Protocol STAT Case Possible acute HIV Infection STAT Notification Confirmatory Test HIV Antibody and RNA Testing • DIS Interview Referral to Care Contact < 72 hrs Contact < 8 weeks Contact > 8 weeks STAT Post - Exposure Protocol Contact Protocol Routine Partner Notification Ab + or ( ) RNA + Confirmed Acute HIV + Repeat Testing Weeks 4 & 12 False RNA Positive STAT Index Case Protocol

Post test counseling and field blood What happens once a person is identified and suspected of having acute HIV infection? STAT DIS locates Index Post test counseling and field blood “It is likely that you are infected with HIV” DIS conducts a detailed patient interview Discuss acute HIV’s impact on personal and public health Elicit partner information Discuss importance of medical evaluation Assess for recent viral symptoms, illnesses and STDs

? Anything else “Health Information Release” form Allows evaluation of STAT and HIV incidence in NC Allows DIS to schedule the appointment at UNC or with other ID specialist and to discuss the patient with the STAT and medical team “Blood Storage” consent: Allows specimens to be used in research Medical Evaluation Arrange medical evaluation (UNC or local provider) Provide transportation to UNC or other ID specialist for a free medical exam with a doctor who specializes in Acute HIV infection Care options and (if available) study opportunities are addressed during the ID visit

…and the STAT patient’s partners? Partners exposed < 72 hours prior STAT DIS calls Dr. Leone to discuss “You may have been exposed to HIV” Draw field blood - flag for individual RNA testing Cluster interview

…and the STAT patient’s partners? Partner exposure >72 hours and <8 weeks “You may have been exposed to HIV” Obtain field blood – flag for RNA testing Cluster interview

…and the STAT patient’s partners? Partners exposed >8 weeks Routine partner notification within 14 days after WB confirmation of the STAT acute Cluster interview

Courtesy of Dr. Lisa Hightow-Weidman 21 W 23 H 30’s W 30’s W 30’s W 21 W 26 W 27 W 30’s W 30’s W 15 male partners 30’s W 27 W 30’s W 20+ Partners 25 B 9 Partners: E-mail addresses/screen names only, Age race Chronic HIV Acute HIV 30’s W HIV and/or Syphilis negative Syphilis 29 W Not tested/ Unknown HIV status HIV/Syphilis coinfection 31 B Crystal Meth Use Gay.com Manhunt 30 W AOL Courtesy of Dr. Lisa Hightow-Weidman College Student Non-Internet sex partner 26

Duke-UNC Acute HIV Infection Research Consortium Research opportunities for patients with Acute and Recent HIV Infection: “Treatment of Acute HIV Infection with Once Daily Atripla” (24 month treatment study which supplies Atripla) “Longitudinal Assessment of Acute/Recent HIV Infection” (Adds to limited scientific knowledge currently available regarding acute/recent infection) 27

Duke-UNC Acute HIV Infection Research Consortium 3) “CHAVI 001: Acute HIV-1 Infection Prospective Cohort Study” Acquire information to develop an HIV vaccine The most relevant information may come from people with acute HIV infection and their partners 28