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Acute HIV in North Carolina STD Clinics The North Carolina STAT Project Peter A. Leone, MD Associate Professor of Medicine University of North Carolina.

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Presentation on theme: "Acute HIV in North Carolina STD Clinics The North Carolina STAT Project Peter A. Leone, MD Associate Professor of Medicine University of North Carolina."— Presentation transcript:

1 Acute HIV in North Carolina STD Clinics The North Carolina STAT Project Peter A. Leone, MD Associate Professor of Medicine University of North Carolina Medical Director, NC HIV/STD Prevention and Care, NCDHHS

2 Acute HIV The window period between: - Appearance of HIV in blood - Host Antibody response Seroconversion defined as “confirmed” by + WB Time period (4-8 weeks) may narrow with newer generation ELISAs

3 Couthino et al., Bulletin of Mathematical Biology 2001

4 Diagnostic Testing Timeline 0 1 2 3 4 5 6 7 8 9 10 Symptoms p24 Antigen HIV RNA HIV ELISA Weeks Since Infection Recombinant peptide ELISA Viral lysate ELISA Fiebig et al, AIDS 2003;17(13):1871-9

5 Rationale for Acute HIV Diagnosis Most Infectious period and Dx often missed Individual Perspective –Improve prognosis with acute treatment???? –Early entry into care Public Health –Recognized previously missed infections –Avoid transmission to partners with risk reduction 10-100 fold increased transmission risk x 4-6 months May be responsible for 30-50% of all transmission of HIV - Identify Transmission networks for intervention

6 Pitfalls in AHI Diagnosis rarely pursued/rare event Majority of patients may be asymptomatic Signs and symptoms non-specific –few clues Laboratory testing must be directed Linkage to surveillance and PCRS in real time Kahn JO, Walker BD, N Engl J Med1998;339: 33-39.

7 The North Carolina STAT Project

8 NC Approach to detection of AHI Screening of all HIV Ab negative or WB indeterminate Blood from public clinics for HIV RNA ( ~120,000 tests/year) Review of all community cases - Ab neg., HIV RNA + - Ab.+ with Hx neg. HIV Ab within 3 mo - Ab + but with recent acute symptoms

9 Our approach to Screening for AHI Specimen pooling Advantages Reduced cost No change in specificity Universal screening Disadvantages Requires large testing volume Trade off in sensitivity Logistics Time to locating patient

10 90 individual specimens 9 intermediate pools (10 specimens) 1 master pool (90 specimens) Pooling and resolution testing

11 NC STAT All Testing Sites Nov.1, 2002- May 1,2005 Number screened: 287,760 Number of Ab+: 1,379 Number of AHI: 58 AHI represents ~4.0% of all HIV infected

12 Testing Site Type #Tests Ab+ AHI (%) Total AHI (%) HIV CTS 18,299 400 12 (2.9) 21% STD 117,804 526 27 (4.9) 48% FP 47,476 28 -- -- Prenatal/OB 47,598 39 2 (4.9) 3% Prison/Jail 7,158 57 4 (6.6) 7% Other 37,073 320 13(3.9) 22% Distribution of

13 Demographic Comparisons

14 NC STD Clinic AHI Reason for Visit STD related visit Yes 22% (6) No 78% (21) STD Dx Yes 44% (12) * No 56% (15) * 6/12 STD with GC

15 AHI and Symptoms 49-89% symptomatic (Schacker TW, et al., AIM 1996 125:257-64) Symptoms Schacker Kinloch-de Loes NCSTD Fever93%87% 48% Fatigue9326 37 Pharyngitis 7048 30 Headache 5539 26 Rash 15 GI Symptoms 37

16 AHI with Retroviral Symptoms STD Sites FactorTotal (N=27) Any symptoms at any time Any symptoms at testing Any symptoms after testing STD or symptoms at testing No. % 20 74% 11 40.7 11 40.7 21 77.8

17 Specific Symptoms at Time of Testing in STD Clinics Symptoms Total (%) Fever Fatigue GI Symptoms Pharyngitis Headache Rash Lymphadenopathy 6 (22%) 5 (18) 3 (11) 1 (4)

18 Why Pursue AHI in STD Clinic Populations Entry point for high risk individuals High % of AHI in public health setting Overlap of incubation periods of classic STIs and HIV Already drawing blood for syphilis Opt out approach for HIV testing

19 Incorporating AHI Screening in STD clinics: 1.Screen all 2.Rapid Test “Plus” -Rapid HIV tests can be offered with symptom screen Problem: Which symptoms (fever?) over what time period (2-4 wks)? Symptoms at best will detect 40% - Targeted screening based on risk ( i.e. MSM, anal/vaginal sex in past 2 weeks,etc ) based on site prevalence or type 3. Bottom line- rapid testing and AHI screening are not mutually exclusive -Need for further research to define symptom screen and develop predictive models for AHI screening

20 Women with AHI 5/16 AHI women were pregnant at the time of testing. All were initiated on ART, received AZT at delivery, as did their infants. None of the infants were infected. During this same frame, there were 6 HIV+ infants born in NC. 3/6 infants were born to women who retrospectively were found to have seroconverted after having undergone routine HIV testing earlier in pregnancy. This supports the use of a repeat testing strategy in pregnant women.

21 Pregnancy Conclusion STAT was effective in identifying 5 AHI pregnant women, resulting in prompt initiation of ART and, ultimately, preventing transmission of HIV to these at risk infants. Three of the 6 women who delivered HIV-infected infants during this same period seroconverted after undergoing HIV testing early in pregnancy. The strategy of AHI screening or repeat HIV testing is most likely highly cost effective due to the high risk and rate of vertical transmission in acutely infected pregnant women. A formal cost effectiveness analysis is in progress. Despite our overall low numbers of perinatal transmission, NC’s universal enhanced screening strategy has had an impact on the residual transmission of MTCT in our state.

22 Recommendations The residual cases of perinatal transmission may be reduced further if the following strategy were to be implemented domestically: Universal HIV testing of all pregnant women early in pregnancy. For all Ab(-) women, reflex testing with HIV RNA. For women who do have reflex RNA testing and are negative, repeat HIV Ab testing in the third trimester. All women who were Ab(-) RNA (-) early in pregnancy and did not have repeat testing in the third trimester, rapid testing with reflex HIV RNA at the time of delivery should be performed. All Ab(+) or Ab(-)RNA(+) pregnant women should be initiated on ART as soon as possible.

23 Acknowledgements NC DHHS Evelyn Foust J. Todd McPherson Lou Turner Leslie Wolf Todd Vanhoy Rhonda Ashby Del Williams Steve Beagle North Carolina DIS NIMH, NIDDK, HPTN, UNC Fogarty Center, UNC STD CRC, UNC CFAR UNC-Chapel Hill Christopher Pilcher Susan A. Fiscus Joseph J. Eron, Jr JoAnn Kuruc Myron S. Cohen Kris Patterson William C. Miller Trang Q. Nguyen Sandi McCoy

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