1. NSW State Reference Laboratory for HIV Cunningham PH 1,3, McNally LP 1, Finlayson R 2, Cornwall J 1, Evans S 1, Carrera A 1, Kelleher AD 1,3, Cooper DA 1,3 1. St Vincent’s Hospital Sydney 2. Taylor Square Private Clinic, Darlinghurst Sydney 3. University of New South Wales Sydney Australia Enhanced surveillance of acute HIV infection in inner Sydney

2. Diagnoses of HIV infection and AIDS 1 in Australia 1. AIDS diagnoses adjusted for reporting delays. Source: State and Territory health authorities Australian HIV Surveillance report January 2007 NCHECR UNSW Australia

3. The HIV epidemic in Australia 193 children 1,878 female (78% heterosexual) 24,069 male (81% homosexual) Total 26,267 31 December 2006 Australian HIV Surveillance report January 2007 NCHECR UNSW Australia HIV infection 26,267 AIDS 10,125 Deaths 6,723 19,544 living with HIV

4. Newly diagnosed HIV infection in Australia, including diagnoses of newly acquired HIV infection, by year Source: State and Territory health authorities Australian HIV Surveillance report January 2007 NCHECR UNSW Australia

5. HIV infection, 2002 - 2006, by HIV exposure category Source: State and Territory health authorities Newly diagnosed HIV infection

6. Detection of Acute Infections during HIV Testing in North Carolina Christopher D. Pilcher, M.D., Susan A. Fiscus, Ph.D., Trang Q. Nguyen, M.P.H., Evelyn Foust, M.P.H., Leslie Wolf, Ph.D., Del Williams, Ph.D., Rhonda Ashby, B.S., Judy Owen O'Dowd, B.S., J. Todd McPherson, M.S., Brandt Stalzer, B.S., Lisa Hightow, M.D., William C. Miller, M.D., Ph.D., Joseph J. Eron, Jr., M.D., Myron S. Cohen, M.D., and Peter A. Leone, M.D.

7. Rationale St Vincent’s Hospital reference laboratory diagnoses 60-70% of NSW cases of HIV (30-40% Australia) – sentinel surveillance role St Vincent’s Hospital reference laboratory diagnoses 60-70% of NSW cases of HIV (30-40% Australia) – sentinel surveillance role 75% of newly identified cases of HIV are from high HIV case load primary care sites – 86% acute cases have clinical suspicion of AHI 75% of newly identified cases of HIV are from high HIV case load primary care sites – 86% acute cases have clinical suspicion of AHI Reports of incremental detection of acute HIV cases with routine use of 4 th generation HIV-1/2 Ab/Ag combo EIA – 3-5 days earlierReports of incremental detection of acute HIV cases with routine use of 4 th generation HIV-1/2 Ab/Ag combo EIA – 3-5 days earlier Enhanced surveillance strategy is focused on detection of AHI and monitoring rates of recent HIV infectionEnhanced surveillance strategy is focused on detection of AHI and monitoring rates of recent HIV infection Proactive application of direct detection tests for HIV by antigen only EIA and/or NAT applied in cases with clinical indication of AHI Proactive application of direct detection tests for HIV by antigen only EIA and/or NAT applied in cases with clinical indication of AHI Pooled HIV RNA testing of high risk 4 th generation seronegative samples may further improve yield of nascent AHIPooled HIV RNA testing of high risk 4 th generation seronegative samples may further improve yield of nascent AHI Potential applications for surveillance, early clinical intervention and possible prevention of secondary HIV transmission Potential applications for surveillance, early clinical intervention and possible prevention of secondary HIV transmission

8. DNA NAT RNA NAT p24 Ag EIA 3rd gen EIA 1st gen EIA Incidence EIA 1wk 2wk 3wk 6wk 2mo 6mo 1yr 2yr 3yr +8yr acuteestablishedlate

9. HIV-1/2 Ab/Ag combo EIA improves yield of AHI Australian experience Australian experience Comparatively low HIV incidence (1.2) and prevalence (74) per 100,000 population HIV Ab/Ag combo EIAs introduced widely in Australia since 2003 Study of 4 laboratories (high and lower prevalence) in first 12 months since the introduction of HIV Ab/Ag combo screening yielded 27 cases of AHI Since 2005 – St Vincents Hospital has detected a further 17 HIV- 1 Ag only cases with combo EIA n=17HIV p24 Ag (pg/mL)HIV RNA copy/mL (log10) Median1,49413,000,000 (6.11) Maximum17,55016,800,000 (7.22) Minimum17271,100 (4.85) Abbott HIV-1/2 Ab/Ag Combo CEIA BioRad HIV-1 p24 Ag only EIA Roche COBAS HIV MONITOR/ COBAS AmpliPrep TaqMan

12. Roche COBAS HIV AmpliScreen Enhanced surveillance testing strategy

13. 11,157 Screened HIV-1/2 Ag/Ab combo EIA 538 seropositive (265 (49.3%) newly identified HIV cases) 118/265 (44.5%) Incident HIV infection By STARHS 147/265 (55.5%) Established HIV infection By STARHS 46 acute HIV infections (<3 bands on WB, +p24Ag or HIV DNA 10,573 seronegative 2,922 samples from ‘High Risk’ referral sites (487 pools of 6 member pool) Qualitative HIV-1 RNA 3 Pools Detected (0.1% all samples) 1. CSC3059A 41yo  2. CSC6557A 56yo  3. RM16648 38yo  Results Since 31-Jul-07

14. Incidence EIA results   The Vironostika OTC -LS assay (44.9%) estimated incident infections 5.7% higher than the BED assay (39.2%)   Discordant results (n=29) showed 20 (69%) misidentified as incidents infections by OTC-LS, correctly identified as established by BED (low CD4+ count or reported date of diagnosis >1 year)   5 (17%) samples classified as incident by BED and established by OTC-LS which may highlight the different cutoffs   Although the number of cases of incident using the BED assay is increasing, it does not reach statistical significance (p=0.157; Wilcoxon rank sum – test for trend) Year of Diagnosis2005n=2892006n=2302007n=147 OTC-LSBEDOTC-LSBEDOTC-LSBED Incident HIV infection46.3%37.9%42.3%38.6%46.2%41.2% Established HIV infection53.7%62.1%57.7%61.4%53.8%58.8%

15. 3 cases AHI cases identified by pooled NAT CSC3059A 41yo gay  29-Nov-06 NSU, h/o iUAI, routine STD screen HIV RNA = 240 cpy/mL 10 days later fevers, reflux, dry cough, T=37°C, Dx viral illness 1 day later fatigue, myalgias, gastric reflux ++ T=36.8°C 7-Feb-07 seroconverted by EIA & WB, CD4+ 35%(974), RNA 2800 HIV subtype B CSC6557A 56yo gay  9-Feb-07 insomnia, HIV+ partner, iUAI 7 days ago HIV RNA = 277 cpy/mL 20-Apr-07 HIV RNA >7.0 log 10 CD4+ 35% (580) Described typical PHI illness late March 23-Apr-07 Dx HIV seroconversion related neuropathy HIV subtype B RM16648 38yo gay  21 Jun 07 - Routine HIV screen – no clinical suspicion. HIV RNA = 235 cpy/mL 25-Jul-07 HIV RNA 400 CD4+ 38% (834) WB recent positive

16. 3 rd vs. 4 th generation HIV serology 200520062007Total Newly identified HIV cases 289 (22,532) 230 (11,275) 250 (9,376) 769 (43,183) Total AHI cases 53 (18.3%) 43* (18.6%) 30* (12%) 126 (16.3%) 3 rd generation EIA 35 (66%) 28 (67%) 17 (56.5%) 80 (63.2%) 4 th generation EIA 49 (92%) 42 (97.7%) 27 (90%) 118 (93.2%) HIV-1 p24 Ag only EIA 4 (100%)004 *Note: pooled NAT for 4 th generation negatives commenced 31-July-2006 **

17. Conclusions   Routine application of assays incorporating direct detection of virus including 4 th gen HIV-1/2 Ag/Ab combo improves yield of nascent AHI   STARHS estimates 39-44% of newly identified cases of HIV at St Vincent’s Hospital recent infections   The Vironostika OTC-LS ‘detuned’ assay appears to overestimate the number of incident cases of HIV by ~ 5%   Pooled NAT screening of 4 th generation assay negative samples from in ‘high-risk’ sites further improves yield of AHI   4 th generation HIV-1/2 Ag/Ab combo assays may provide a more routine, timely and cost effective answer than pooled RNA protocols   Testing strategies resulting in increased yield of increases acute and recent HIV infection may highlight opportunities for prevention

19. Acknowledgments NSW State Reference Laboratory for HIV Co-Authors Leon McNally Jane Cornwall Alex Carrera Sara Evans Prof Anthony Kelleher Prof David A Cooper NSW Department of Health US CDC Dr Pragna Patel Referral sites – Primary Infection Working Group Dr Robert Finlayson – Taylor Square Private Clinic, Darlinghurst Dr Robert McFarlane – 407 Doctors, Darlinghurst Dr Mark Bloch – Holdsworth House Medical Practice, Darlinghurst Dr Cassy Workman, Ground Zero Medical Practice, Darlinghurst Dr Ben Hanson – Ben Hanson and Associates, Darlinghurst Dr Ben Anderson – St Leonard’s Medical Centre, St Leonards