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On behalf of the H-TEAM initiative Targeted screening and immediate start of treatment for acute HIV infection decreases time between HIV diagnosis and viral suppression among MSM at a Sexual Health Clinic in Amsterdam M. Dijkstra, M.S. van Rooijen, M.M. Hillebregt, A.I. van Sighem, C. Smit, A. Hogewoning, T. Heijman, E. Hoornenborg, M. Prins, J.M. Prins, M.F. Schim van der Loeff, G.J. de Bree On behalf of the H-TEAM initiative

Conflicts of interests None to declare

Beneficial for patients Reduces onward transmission Insight into the potential for “post treatment control” interventions Rapid diagnostic and referral trajectory for acute HIV infection among MSM at the Amsterdam STI clinic Increase # acute HIV diagnoses, start ART within 24 hours Lee Ebiomedicine 2016, Grijsen PLoS Med 2012, Powers Lancet 2011, Ananworanich PLOS One 2012

Objective Evaluation of rapid acute HIV trajectory by comparing the trajectory with routine diagnostics and care, regarding: Acute HIV diagnosis Time from diagnosis to: intake at HIV treatment centre start ART viral suppression

Rapid acute HIV trajectory, August 2015

Rapid acute HIV trajectory, August 2015 Campaign1 GP Routine STI Immediate start of ART Mass-media campaign The Amsterdam Score2 Point-of-care HIV-RNA 1. www.hebikhiv.nl/en 2. Dijkstra BMC Infectious Diseases 2017, Lin JAIDS 2018

Rapid acute HIV trajectory Methods - diagnosis ~22 days2 Routine testing Rapid acute HIV trajectory 2008 Ab If sick Ag/Ab HIV testing strategy 2014 ~17 days2 ~10 days2 Universal Ag/Ab 2015 Universal Ag/Ab Ab Ag/Ab Score1 POC RNA 1. Dijkstra BMC Infectious Diseases 2017, Lin JAIDS 2018 2. Cohen NEJM 2011

Methods – ART initiation Routine care Rapid acute HIV trajectory CD4 <500 2008 ART initiation strategy CD4 <500 Acute HIV 2012 Data linkage between STI clinic and HIV treatment centres 2015 Immediate start Universal start

Results - characteristics 19,728 MSM - 63,278 HIV testing visits 2008-2017 1,013 newly diagnosed with HIV Acute HIV (Fiebig I-II) Recent HIV (Fiebig III-V) Chronic HIV (Fiebig VI) Negative n 20 269 724 62,265 Age (years)* 37 35 34 Days since last clinic visit* 84 148 282 190 *Median

Rapid acute HIV trajectory, 2015-2017 127 26 98 33 HIV positivity rate Trajectory: 7.6% Routine: 0.7% 284 35 Acute HIV positivity rate Trajectory: 4.0% Routine: 0.03% 249 Negative Acute HIV Recent HIV Chronic HIV 10 7 2 230

Results – acute HIV diagnosis 2008 n=768 2014 n=108 4.6% 2015- 2017 n=118 4.2% 2015- 2017 n=19 52.6%

Results – data linkage HIV treatment centres 665 / 1,013 records Acute HIV (Fiebig I-II) Recent HIV (Fiebig III-V) Chronic HIV (Fiebig VI) Viral load at intake (log10 copies/ml)* 6.5 4.9 4.5 CD4 count at intake (cells/mm3)* 440 520 460 CD4 nadir (cells/mm3)* 425 400 360 *Median

Results – days to viral suppression 2008 n=335 14 437 569 2012 n=223 13 99 228 2015-2017 n=72 Median days from HIV diagnosis to: Universal start 9 29 95 2015-2017 n=15 1 1 55 Immediate start

Conclusions Targeted screening resulted in a higher proportion of acute HIV infection than routine screening among MSM at the STI Clinic in Amsterdam Implementation of a rapid acute HIV trajectory, along with changes in treatment guidelines, resulted in a shorter duration between HIV diagnosis and viral suppression

H-TEAM acknowledgements Professor Joep Lange

Acknowledgements www.hteam.nl Linda May Paul Oostvogel Ineke Stolte Marije Groot Bruinderink Nina Schat Peter Reiss Arjan van Bijnen Jan van Bergen Wim Zuilhof Sylvia Bruisten Alje van Dam Udi Davidovich Arjan Hogewoning Michelle Kroone David Kwa Dominique Loomans Annebel Tahey Linda May Paul Oostvogel Ineke Stolte Gerben Rienk Visser Dewi Usmany Henry de Vries Justin Luidens

Variables significantly associated with HIV seroconversion in Amsterdam Cohort Studies Beta coefficient Fever 1.6 Lymphadenopathy 1.5 Oral thrush 1.7 Weight loss 0.9 >5 sexual partners Gonorrhoea Receptive condomless anal intercourse 1.1  Amsterdam score Dijkstra BMC Infectious Diseases 2017, Lin JAIDS 2018

Amsterdam score Cut-off Sens % Spec % AUC Development in Amsterdam Cohort Studies (NL) 1.5 76.3 0.82 Validation in Multicenter AIDS Cohort Study (USA) 56.0 88.5 0.78 Validation in San Diego Early Test Program (USA) 81.0 78.2 0.88 Dijkstra BMC Infectious Diseases 2017, Lin JAIDS 2018