1. 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 1 1

2. 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

3. Detection of HIV 0 1 2 3 4 5 6 7 8 9 10 Symptoms p24 Antigen HIV RNA
HIV EIA*
Western blot
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

4. 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

5. 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

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

7. 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

8. 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 ;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% %
seatle 8.6% %
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

9. 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

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

11. Results

12. 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, %
61 / 1, % 28 4
20% 7%
Jail
172 / 1, % 0%
STD Clinics
236 / 27, % 9 4%
MTU
31 / 2, %
1 false+
------
Total
640 / 41, % 41 6%
This includes all of LA AHI cases, 1 AHF case (1/7/08), 1 LAGLC case (1/16/08) 12 12 12

13. 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

14. 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

15. 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

16. 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

17. 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

18. 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

19. 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

20. 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

21. 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

22. 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.

23. 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

24. 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)