Primary HIV Infection Education

Ten Years of Screening and Testing for Acute HIV Infection in North Carolina

OBJECTIVE

To describe demographic and behavioral characteristics of persons with acute HIV infection (AHI) over time.

METHODS

We conducted a retrospective assessment of AHI identified through the Screening and Tracing Active Transmission (STAT) program from 2003 to 2012 in North Carolina (NC). AHI was identified using pooled nucleic acid amplification for antibody negative samples and individual HIV-1 RNA for antibody indeterminate samples. The STAT program provides rapid notification and evaluation. We compared STAT-collected demographic and risk characteristics with all persons requesting tests and all non-AHI diagnoses from the NC State Laboratory of Public Health.

RESULTS

The STAT Program identified 236 AHI cases representing 3.4% (95% confidence interval: 3.0% to 3.9%) of all HIV diagnoses. AHI cases were similar to those diagnosed during established HIV. On pretest risk-assessments, AHI cases were predominately black (69.1%), male (80.1%), young (46.8% < 25 years), and men who have sex with men (MSM) (51.7%). Per postdiagnosis interviews, the median age decreased from 35 (interquartile range 25-42) to 27 (interquartile range 22-37) years, and the proportion <25 years increased from 23.8% to 45.2% (trend P = 0.04) between 2003 and 2012. AHI men were more likely to report MSM risk post-diagnosis than on pretest risk-assessments (64%-82.9%; P < 0.0001). Post-diagnosis report of MSM risk in men with AHI increased from 71.4% to 96.2%.

CONCLUSIONS

In NC, 3.4% of individuals diagnosed with HIV infection have AHI. AHI screening provides a real-time source of incidence trends, improves the diagnostic yield of HIV testing, and offers an opportunity to limit onward transmission.

Knowledge and awareness of acute human immunodeficiency virus infection among mobile app-using men who have sex with men: a missed public health opportunity

In a national online survey, we assessed awareness and knowledge of acute human immunodeficiency virus (HIV) infection manifestation among 1748 men who have sex with men (MSM). Only 39% of respondents were aware that acute HIV infection may be accompanied by symptoms. Education and increased access to acute HIV testing may facilitate MSM to appropriately seek acute HIV testing.

Why do men who have sex with men test for HIV infection? Results from a community-based testing program in Seattle

BACKGROUND

The Centers for Disease Control and Prevention recommends at least annual HIV testing for men who have sex with men (MSM), but motivations for testing are not well understood.

METHODS

We evaluated data from MSM testing for HIV at a community-based program in King County, Washington. Correlates of regular testing were examined using generalized estimating equation regression models.

RESULTS

Between February 2004 and June 2011, 7176 MSM attended 12,109 HIV testing visits. When asked reasons for testing, 49% reported that it was time for their regular test, 27% reported unprotected sex, 24% were starting relationships, 21% reported sex with someone new, 21% sought sexually transmitted infection/hepatitis screening, 12% reported sex with an HIV-infected partner, 2% suspected primary HIV infection, and 16% reported other reasons. In multivariable analysis, factors associated with regular testing included having a regular health care provider and the following in the previous year: having only male partners, having 10 or more male partners, inhaled nitrite use, not injecting drugs, and not having unprotected anal intercourse with a partner of unknown/discordant status (P ≤ 0.001 for all). Men reporting regular testing reported shorter intertest intervals than men who did not (median of 233 vs. 322 days, respectively; P < 0.001).

CONCLUSIONS

Regular testing, sexual risk, and new partnerships were important drivers of HIV testing among MSM, and regular testing was associated with increased testing frequency. Promoting regular testing may reduce the time that HIV-infected MSM are unaware of their status, particularly among those who have sex with men and women or inject drugs.

ru2hot?: A public health education campaign for men who have sex with men to increase awareness of symptoms of acute HIV infection

OBJECTIVES

Teach HIV-negative men who have sex with men (MSM) symptoms of acute HIV infection (AHI) and direct them to nucleic acid amplification testing (NAAT) though Public Health--Seattle & King County (PHSKC).

DESIGN

Cross-sectional surveys, retrospective database analysis and chart review.

METHODS

Beginning in June 2009, the ru2hot? campaign described AHI symptoms and NAAT. Two preintervention and two postintervention surveys assessed campaign visibility, symptom knowledge, and healthcare-seeking behaviour. Regression analyses evaluated secular trends in case-finding.

RESULTS

366 MSM completed surveys. In survey 4, 23% of 100 men reported seeing the campaign, and 25% knew 'ru2hot?' referred to AHI. From survey 1 to survey 4, the proportion of subjects who knew ≥2 symptoms or that AHI was a 'flu-like' illness was unchanged (61% vs 57%, p=0.6). However, in survey 4, 13 (72%) of 18 subjects who saw the campaign named fever as a symptom of AHI compared with 19 (35%) of 55 subjects who had not seen the campaign (p=0.005). From 9/2003 to 12/2010, 622 (2.2%) of 27 661 MSM tested HIV-positive, and 111 (18%) were identified by the Public Health--Seattle & King County NAAT programme. In terms of the impact of the campaign on case-finding, diagnosis of EIA-negative/NAAT-positive and OraQuick-negative/EIA-positive cases increased from six in 2004 to 20 in 2010 (p=0.01), but postcampaign numbers were unchanged. 23 (51%) of 45 cases identified before and 8 (44%) of 18 cases identified after the campaign reported symptoms at initial testing (p=0.6).

CONCLUSIONS

Although a quarter of MSM surveyed saw the campaign and knowledge of fever (the symptom of emphasis) was high, case-finding was unchanged. Increasing campaign visibility could have had greater impact.

Knowledge of acute human immunodeficiency virus infection among gay and bisexual male college students

OBJECTIVE

To examine human immunodeficiency virus (HIV)-related knowledge, attitudes, and behaviors in at-risk college men who have sex with men (MSM), focusing on knowledge about acute HIV infection (AHI).

PARTICIPANTS AND METHODS

A one-time anonymous survey was administered to college students attending a lesbian, gay, bisexual, transgender, and queer conference in February 2012. This article reports on a study subsample of MSM.

RESULTS

A total of 100 MSM completed the survey. Participants had an average age of 20.4 years. Sixty-six percent reported condom use the last time they had sex. Only 46% had ever heard of symptoms related to AHI. Forty-two percent would likely seek medical care when showing acute symptoms in a setting consistent with AHI.

CONCLUSION

Despite having multiple risk factors for HIV infection, many MSM college students are unaware of AHI. HIV prevention programs should target this population and include information about signs, symptoms, and diagnosis of AHI.

Lessons learned about behavioral science and acute/early HIV infection. The NIMH Multisite Acute HIV Infection Study: V

Acute/early HIV infection is a period of heightened HIV transmission and a window of opportunity for intervention to prevent onward disease transmission. The NIMH Multisite Acute HIV Infection (AHI) Study was an exploratory initiative aimed at determining the feasibility of recruiting persons with AHI into research, assessing their psychosocial and behavioral characteristics, and examining short-term changes in these characteristics. This paper reports on lessons learned in the study, including: (1) the need to establish the cost-effectiveness of AHI testing; (2) challenges to identifying persons with AHI; (3) the need to increase awareness of acute-phase HIV transmission risks; (4) determining the goals of behavioral interventions following AHI diagnosis; and (5) the need for "rapid response" public health systems that can move quickly enough to intervene while persons are still in the AHI stage. There are untapped opportunities for behavioral and medical science collaborations in these areas that could reduce the incidence of HIV infection.

Behavior change following diagnosis with acute/early HIV infection-a move to serosorting with other HIV-infected individuals. The NIMH Multisite Acute HIV Infection Study: III

Risk reductions behaviors are especially important during acute/early HIV infection, a period of high transmission risk. We examined how sexual behaviors changed following diagnosis of acute/early HIV infection. Twenty-eight individuals completed structured surveys and in-depth interviews shortly after learning of their infection and 2 months later. Quantitative analyses revealed significant changes after diagnosis, including reductions in total partners and decreases in the proportion of unprotected sex acts occurring with uninfected partners (serosorting). Qualitative findings indicated that these changes were motivated by concerns about infecting others. However, participants were less successful at increasing the frequency with which they used condoms. These results suggest that the initial diagnosis with HIV may constitute an important component of interventions to promote risk reduction during the acute/early stages of the disease.

Testing bias in calculating HIV incidence from the Serologic Testing Algorithm for Recent HIV Seroconversion

OBJECTIVE

Incidence is critical in monitoring HIV infection in populations but often difficult to measure. The Serologic Testing Algorithm for Recent HIV Seroconversion (STARHS) can estimate HIV incidence from a single specimen at low cost. Nevertheless, HIV testing patterns may introduce bias, rendering interpretation of the STARHS result problematic. We found empirical evidence of such bias in Ontario using the STARHS formula with varied window periods

METHODS

In a hypothetical population of homosexual men, we calculated HIV incidence from the STARHS assay on the basis of incidence density, study duration, STARHS window period and intertest interval. We also incorporated the increased likelihood of a newly infected person having an HIV test due to seroconversion illness or high-risk behaviours ('seroconversion effect' or SCE). We also varied the intertest interval inversely as a function of incidence density. To adjust incidence estimates for bias, we fit empirical STARHS data to an algebraic formula expressing measured HIV incidence as a function of SCE and incidence.

RESULTS

Incidence density estimates were unbiased when SCE or incidence density-interval interactions were absent. However, estimated incidence density was higher than true incidence density in the presence of SCE, as much as seven-fold higher under certain conditions. The goodness-of-fit provided estimates with an excellent fit, yielding plausible results.

CONCLUSION

HIV incidence from STARHS may be strongly biased because of early testing in recently infected persons, resulting in substantial overestimation, at least amongst men who have sex with men. Thus, incidence estimates from STARHS must be interpreted with considerable caution. Nevertheless, incidence estimates may be adjusted to yield unbiased results.

Prevalence of oral disease among adults with primary HIV infection

OBJECTIVE

To explore the type and prevalence of oral mucosal lesions among adults with primary HIV infection (PHI) compared with HIV-negative adults at high risk for HIV disease, and in relation to HIV viral load.

METHODS

We conducted standardized oral examinations to identify specific oral mucosal lesions among adults with PHI, both pre-seroconversion and post- seroconversion-recently infected, compared with HIV-negative adults. We compared the group with oral lesions to those without oral lesions with respect to HIV-RNA load and CD4 + T-cell count.

RESULTS

Among 115 adults (predominantly men), pseudomembranous candidiasis was the most common oral lesion among those with PHI, and was found in 4% of the 23 participants in pre-seroconversion and in 9% of 69 participants with post-seroconversion recent infection, compared with none found among 23 HIV negatives. Among those with PHI, the median viral load was higher and the median CD4 + T-cell count lower among the 15 participants with an oral lesion of any type than among the 77 participants without oral lesions (P = 0.02 and 0.04, respectively).

CONCLUSION

This finding suggests that individuals with PHI who have oral lesions may be more likely to transmit HIV because of their higher viral load.

Behavioral interventions to reduce risk for sexual transmission of HIV among men who have sex with men

BACKGROUND

Men who have sex with men (MSM) remain at great risk for HIV infection. Program planners and policy makers need descriptions of interventions and quantitative estimates of intervention effects to make informed decisions concerning prevention funding and research. The number of intervention strategies for MSM that have been examined with strong research designs has increased substantially in the past few years.

OBJECTIVES

1. To locate and describe outcome studies evaluating the effects of behavioral HIV prevention interventions for MSM.2. To summarize the effectiveness of these interventions in reducing unprotected anal sex.3. To identify study characteristics associated with effectiveness.4. To identify gaps and indicate future research, policy, and practice needs.

SEARCH STRATEGY

We searched electronic databases, current journals, manuscripts submitted by researchers, bibliographies of relevant articles, conference proceedings, and other reviews for published and unpublished reports from 1988 through December 2007. We also asked researchers working in HIV prevention about new and ongoing studies.

SELECTION CRITERIA

Studies were considered in scope if they examined the effects of behavioral interventions aimed at reducing risk for HIV or STD transmission among MSM. We reviewed studies in scope for criteria of outcome relevance (measurement of at least one of a list of behavioral or biologic outcomes, e.g., unprotected sex or incidence of HIV infections) and methodologic rigor (randomized controlled trials or certain strong quasi-experimental designs with comparison groups).

DATA COLLECTION AND ANALYSIS

We used fixed and random effects models to summarize rate ratios (RR) comparing intervention and control groups with respect to count outcomes (number of occasions of or partners for unprotected anal sex), and corresponding prevalence ratios (PR) for dichotomous outcomes (any unprotected anal sex vs. none). We used published formulas to convert effect sizes and their variances for count and dichotomous outcomes where necessary. We accounted for intraclass correlation (ICC) in community-level studies and adjusted for baseline conditions in all studies. We present separate results by intervention format (small group, individual, or community-level) and by type of intervention delivered to the comparison group (minimal or no HIV prevention in the comparison condition versus standard or other HIV prevention in the comparison condition). We examine rate ratios stratified according to characteristics of participants, design, implementation, and intervention content. For small group and individual-level interventions we used a stepwise selection process to identify a multivariable model of predictors of reduction in occasions of or partners for unprotected anal sex. We used funnel plots to examine publication bias, and Q (a chi-squared statistic with degrees of freedom = number of interventions minus 1) to test for heterogeneity.

MAIN RESULTS

We found 44 studies evaluating 58 interventions with 18,585 participants. Formats included 26 small group interventions, 21 individual-level interventions, and 11 community-level interventions. Sixteen of the 58 interventions focused on HIV-positives. The 40 interventions that were measured against minimal to no HIV prevention intervention reduced occasions of or partners for unprotected anal sex by 27% (95% confidence interval [CI] = 15% to 37%). The other 18 interventions reduced unprotected anal sex by 17% beyond changes observed in standard or other interventions (CI = 5% to 27%). Intervention effects were statistically homogeneous, and no independent variable was statistically significantly associated with intervention effects at alpha=.05. However, a multivariable model selected by backward stepwise elimination identified four study characteristics associated with reduction in occasions of or partners for unprotected anal sex among small group and individual-level interventions at alpha=.10. The most favorable reductions in episodes of or partners for unprotected anal sex (33% to 35% decreases) were observed among studies with count outcomes, those with shorter intervention spans (<=1 month), those with better retention in the intervention condition than in the comparison condition, and those with minimal to no HIV prevention intervention delivered to the comparison condition. Because there were only 11 community-level studies we did not search for a multivariable model for community-level interventions. In stratified analyses including only one variable at a time, the greatest reductions (40% to 54% decreases) in number of episodes of or partners for unprotected anal sex among community-level interventions were observed among studies where groups were assigned randomly rather than by convenience, studies with shorter recall periods and longer follow-up, studies with more than 25% non-gay identifying MSM, studies in which at least 90% of participants were white, and studies in which the intervention addressed development of personal skills.

AUTHORS' CONCLUSIONS

Behavioral interventions reduce self-reported unprotected anal sex among MSM. These results indicate that HIV prevention for this population can work and should be supported. Results of previous studies provide a benchmark for expectations in new studies. Meta-analysis can inform future design and implementation in terms of sample size, target populations, settings, goals for process measures, and intervention content. When effects differ by design variables, which are deliberately selected and planned, awareness of these characteristics may be beneficial to future designs. Researchers designing future small group and individual-level studies should keep in mind that to date, effects of the greatest magnitude have been observed in studies that used count outcomes and a shorter intervention span (up to 1 month). Among small group and individual-level studies, effects were also greatest when the comparison condition included minimal to no HIV prevention content. Nevertheless, statistically significant favorable effects were also seen when the comparison condition included standard or other HIV prevention content. Researchers choosing the latter option for new studies should plan for larger sample sizes based on the smaller expected net intervention effect noted above. When effects differ by implementation variables, which become evident as the study is conducted but are not usually selected or planned, caution may be advised so that future studies can reduce bias. Because intervention effects were somewhat stronger (though not statistically significantly so) in studies with a greater attrition in the comparison condition, differential retention may be a threat to validity. Extra effort should be given to retaining participants in comparison conditions. Among community-level interventions, intervention effects were strongest among studies with random assignment of groups or communities. Therefore the inclusion of studies where assignment of groups or communities was by convenience did not exaggerate the summary effect. The greater effectiveness of interventions including more than 25% non-gay identifying MSM suggests that when they can be reached, these men may be more responsive than gay-identified men to risk reduction efforts. Non-gay identified MSM may have had less exposure to previous prevention messages, so their initial exposure may have a greater impact. The greater effectiveness of interventions that include efforts to promote personal skills such as keeping condoms available and behavioral self-management indicates that such content merits strong consideration in development and delivery of new interventions for MSM. And the finding that interventions were most effective for majority white populations underscores the critical need for effective interventions for MSM of African and Latino descent. Further research measuring the incidence of HIV and other STDs is needed. Because most studies were conducted among mostly white men in the US and Europe, more evaluations of interventions are needed for African American and Hispanic MSM as well as MSM in the developing world. More research is also needed to further clarify which behavioral strategies (e.g., reducing unprotected anal sex, having oral sex instead of anal sex, reducing number of partners, avoiding serodiscordant partners, strategic positioning, or reducing anal sex even with condom use) are most effective in reducing transmission among MSM, the messages most effective in promoting these behaviors, and the methods and settings in which these messages can be most effectively delivered.

Diagnosis and management of acute HIV infection

HIV infection starts as an acute, systemic infection, followed by a chronic period of clinical latency, usually lasting 3 to 10 years, which precedes the eventual collapse of the immune system. It is increasingly recognized that events occurring during acute HIV infection may determine the natural course of the disease. The very dynamic events of acute HIV infection provide multiple opportunities for biologic interventions, such as anti-retroviral or immune-based therapies. Similarly, the implementation of public health measures during acute HIV infection could help control epidemics or outbreaks. Many of the dramatic possibilities for intervention in acute HIV infection remain unproved, not the least because of traditional difficulty of diagnosing patients during this early period. This article reviews the natural history, pathogenesis and clinical presentation of acute HIV infection, and suggests a diagnostic and therapeutic approach to guide clinicians dealing with patients with suspected or confirmed acute HIV infection.