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Sanders EJ, Agutu C, van der Elst E, Hassan A, Gichuru E, Mugo P, Farquhar C, Babigumira JB, Goodreau SM, Hamilton DT, Ndung'u T, Sirengo M, Chege W, Graham SM. Effect of an opt-out point-of-care HIV-1 nucleic acid testing intervention to detect acute and prevalent HIV infection in symptomatic adult outpatients and reduce HIV transmission in Kenya: a randomized controlled trial. HIV Med 2022; 23:16-28. [PMID: 34431196 PMCID: PMC9204714 DOI: 10.1111/hiv.13157] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2021] [Accepted: 07/23/2021] [Indexed: 01/28/2023]
Abstract
BACKGROUND In sub-Saharan Africa, adult outpatients with symptoms of acute infectious illness are not routinely tested for prevalent or acute HIV infection (AHI) when seeking healthcare. METHODS Adult symptomatic outpatients aged 18-39 years were evaluated by a consensus AHI risk score. Patients with a risk score ≥ 2 and no previous HIV diagnosis were enrolled in a stepped-wedge trial of opt-out delivery of point-of-care (POC) HIV-1 nucleic acid testing (NAAT), compared with standard provider-initiated HIV testing using rapid tests in the observation period. The primary outcome was the number of new diagnoses in each study period. Generalized estimating equations with a log-binomial link and robust variance estimates were used to account for clustering by health facility. The trial is registered with ClinicalTrials.gov NCT03508908. RESULTS Between 2017 and 2020, 13 (0.9%) out of 1374 participants in the observation period and 37 (2.5%) out of 1500 participants in the intervention period were diagnosed with HIV infection. Of the 37 newly diagnosed cases in the intervention period, two (5.4%) had AHI. Participants in the opt-out intervention had a two-fold greater odds of being diagnosed with HIV (odds ratio = 2.2, 95% confidence interval: 1.39-3.51) after adjustment for factors imbalanced across study periods. CONCLUSIONS Among symptomatic adults aged 18-39 years targeted by our POC NAAT intervention, we identified one chronic HIV infection for every 40 patients and one AHI patient for every 750 patients tested. Although AHI yield was low in this population, routinely offered opt-out testing could diagnose twice as many patients as an approach relying on provider discretion.
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Affiliation(s)
- Eduard J. Sanders
- KEMRI ‐ Wellcome Trust Research ProgrammeKilifiKenya,University of OxfordHeadingtonUK
| | - Clara Agutu
- KEMRI ‐ Wellcome Trust Research ProgrammeKilifiKenya
| | | | - Amin Hassan
- KEMRI ‐ Wellcome Trust Research ProgrammeKilifiKenya
| | | | - Peter Mugo
- KEMRI ‐ Wellcome Trust Research ProgrammeKilifiKenya
| | - Carey Farquhar
- Department of Medicine, Global Health, and EpidemiologyUniversity of WashingtonSeattleWAUSA
| | | | - Steven M. Goodreau
- Department of Anthropology and EpidemiologyUniversity of WashingtonSeattleWAUSA
| | - Deven T. Hamilton
- Center for Studies in Demography & EcologyUniversity of WashingtonSeattleWAUSA
| | | | | | - Wairimu Chege
- National Institutes of Allergy & Infectious DiseasesNational Institutes of HealthRockvilleMDUSA
| | - Susan M. Graham
- University of OxfordHeadingtonUK,Department of Medicine, Global Health, and EpidemiologyUniversity of WashingtonSeattleWAUSA
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Kerschberger B, Aung A, Mpala Q, Ntshalintshali N, Mamba C, Schomaker M, Tombo ML, Maphalala G, Sibandze D, Dube L, Kashangura R, Mthethwa-Hleza S, Telnov A, de la Tour R, Gonzalez A, Calmy A, Ciglenecki I. Predicting, Diagnosing, and Treating Acute and Early HIV Infection in a Public Sector Facility in Eswatini. J Acquir Immune Defic Syndr 2021; 88:506-517. [PMID: 34483294 PMCID: PMC8575170 DOI: 10.1097/qai.0000000000002794] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2021] [Accepted: 08/12/2021] [Indexed: 12/27/2022]
Abstract
BACKGROUND The lack of acute and early HIV infection (AEHI) diagnosis and care contributes to high HIV incidence in resource-limited settings. We aimed to assess the yield of AEHI, predict and diagnose AEHI, and describe AEHI care outcomes in a public sector setting in Eswatini. SETTING This study was conducted in Nhlangano outpatient department from March 2019 to March 2020. METHODS Adults at risk of AEHI underwent diagnostic testing for AEHI with the quantitative Xpert HIV-1 viral load (VL) assay. AEHI was defined as the detection of HIV-1 VL on Xpert and either an HIV-seronegative or HIV-serodiscordant third-generation antibody-based rapid diagnostic test (RDT) result. First, the cross-sectional analysis obtained the yield of AEHI and established a predictor risk score for the prediction of AEHI using Lasso logistic regression. Second, diagnostic accuracy statistics described the ability of the fourth-generation antibody/p24 antigen-based Alere HIV-Combo RDT to diagnose AEHI (vs Xpert VL testing). Third, we described acute HIV infection care outcomes of AEHI-positive patients using survival analysis. RESULTS Of 795 HIV-seronegative/HIV-serodiscordant outpatients recruited, 30 (3.8%, 95% confidence interval: 2.6% to 5.3%) had AEHI. The predictor risk score contained several factors (HIV-serodiscordant RDT, women, feeling at risk of HIV, swollen glands, and fatigue) and had sensitivity and specificity of 83.3% and 65.8%, respectively, to predict AEHI. The HIV-Combo RDT had sensitivity and specificity of 86.2% and 99.9%, respectively, to diagnose AEHI. Of 30 AEHI-positive patients, the 1-month cumulative treatment initiation was 74% (95% confidence interval: 57% to 88%), and the 3-month viral suppression (<1000 copies/mL) was 87% (67% to 98%). CONCLUSION AEHI diagnosis and care seem possible in resource-limited settings.
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Affiliation(s)
| | - Aung Aung
- Médecins Sans Frontières (OCG), Mbabane, Eswatini
| | | | | | | | - Michael Schomaker
- Centre for Infectious Disease Epidemiology and Research, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa;
- Institute of Public Health, Medical Decision Making and Health Technology Assessment, UMIT—University for Health Sciences, Medical Informatics and Technology, Hall in Tirol, Austria;
| | | | | | | | - Lenhle Dube
- Ministry of Health (SNAP), Mbabane, Eswatini
| | | | | | - Alex Telnov
- Médecins Sans Frontières (OCG), Geneva, Switzerland;
| | | | - Alan Gonzalez
- Médecins Sans Frontières (OCG), Geneva, Switzerland;
| | - Alexandra Calmy
- HIV/AIDS Unit, Division of Infectious Diseases, Geneva University Hospitals Geneva, Switzerland; and
- Institute of Global Health, University of Geneva, Geneva, Switzerland.
| | - Iza Ciglenecki
- Médecins Sans Frontières (OCG), Geneva, Switzerland;
- Institute of Global Health, University of Geneva, Geneva, Switzerland.
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Palmer S, Dijkstra M, Ket JCF, Wahome EW, Walimbwa J, Gichuru E, van der Elst EM, Schim van der Loeff MF, de Bree GJ, Sanders EJ. Acute and early HIV infection screening among men who have sex with men, a systematic review and meta-analysis. J Int AIDS Soc 2020; 23 Suppl 6:e25590. [PMID: 33000916 PMCID: PMC7527764 DOI: 10.1002/jia2.25590] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2020] [Revised: 07/03/2020] [Accepted: 07/14/2020] [Indexed: 12/23/2022] Open
Abstract
INTRODUCTION Screening for acute and early HIV infections (AEHI) among men who have sex with men (MSM) remains uncommon in sub-Saharan Africa (SSA). Yet, undiagnosed AEHI among MSM and subsequent failure to link to care are important drivers of the HIV epidemic. We conducted a systematic review and meta-analysis of AEHI yield among MSM mobilized for AEHI testing; and assessed which risk factors and/or symptoms could increase AEHI yield in MSM. METHODS We systematically searched four databases from their inception through May 2020 for studies reporting strategies of mobilizing MSM for testing and their AEHI yield, or risk and/or symptom scores targeting AEHI screening. AEHI yield was defined as the proportion of AEHI cases among the total number of visits. Study estimates for AEHI yield were pooled using random effects models. Predictive ability of risk and/or symptom scores was expressed as the area under the receiver operator curve (AUC). RESULTS Twenty-two studies were identified and included a variety of mobilization strategies (eight studies) and risk and/or symptom scores (fourteen studies). The overall pooled AEHI yield was 6.3% (95% CI, 2.1 to 12.4; I2 = 94.9%; five studies); yield varied between studies using targeted strategies (11.1%; 95% CI, 5.9 to 17.6; I2 = 83.8%; three studies) versus universal testing (1.6%; 95% CI, 0.8 to 2.4; two studies). The AUC of risk and/or symptom scores ranged from 0.69 to 0.89 in development study samples, and from 0.51 to 0.88 in validation study samples. AUC was the highest for scores including symptoms, such as diarrhoea, fever and fatigue. Key risk score variables were age, number of sexual partners, condomless receptive anal intercourse, sexual intercourse with a person living with HIV, a sexually transmitted infection, and illicit drug use. No studies were identified that assessed AEHI yield among MSM in SSA and risk and/or symptom scores developed among MSM in SSA lacked validation. CONCLUSIONS Strategies mobilizing MSM for targeted AEHI testing resulted in substantially higher AEHI yields than universal AEHI testing. Targeted AEHI testing may be optimized using risk and/or symptom scores, especially if scores include symptoms. Studies assessing AEHI yield and validation of risk and/or symptom scores among MSM in SSA are urgently needed.
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Affiliation(s)
- Shaun Palmer
- Centre for Geographic Medicine Research – CoastKenya Medical Research InstituteKilifiKenya
- International AIDS Vaccine InitiativeAmsterdamthe Netherlands
| | - Maartje Dijkstra
- Department of Infectious DiseasesPublic Health Service AmsterdamAmsterdamthe Netherlands
- Department of Internal MedicineDivision of Infectious Diseases, and Amsterdam Institute for Infection and Immunity (AI&II)Amsterdam UMCUniversity of AmsterdamAmsterdamthe Netherlands
| | - Johannes CF Ket
- Medical LibraryVrije Universiteit AmsterdamAmsterdamthe Netherlands
| | - Elizabeth W Wahome
- Centre for Geographic Medicine Research – CoastKenya Medical Research InstituteKilifiKenya
| | | | - Evanson Gichuru
- Centre for Geographic Medicine Research – CoastKenya Medical Research InstituteKilifiKenya
| | - Elise M van der Elst
- Centre for Geographic Medicine Research – CoastKenya Medical Research InstituteKilifiKenya
| | - Maarten F Schim van der Loeff
- Department of Infectious DiseasesPublic Health Service AmsterdamAmsterdamthe Netherlands
- Department of Internal MedicineDivision of Infectious Diseases, and Amsterdam Institute for Infection and Immunity (AI&II)Amsterdam UMCUniversity of AmsterdamAmsterdamthe Netherlands
| | - Godelieve J de Bree
- Department of Internal MedicineDivision of Infectious Diseases, and Amsterdam Institute for Infection and Immunity (AI&II)Amsterdam UMCUniversity of AmsterdamAmsterdamthe Netherlands
| | - Eduard J Sanders
- Centre for Geographic Medicine Research – CoastKenya Medical Research InstituteKilifiKenya
- Department of Global Health, and Amsterdam Institute for Global Health and DevelopmentAmsterdam UMCUniversity of AmsterdamAmsterdamthe Netherlands
- Nuffield Department of MedicineUniversity of OxfordHeadingtonUnited Kingdom
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Graham SM, Agutu C, van der Elst E, Hassan AS, Gichuru E, Mugo PM, Farquhar C, Babigumira JB, Goodreau SM, Hamilton DT, Ndung'u T, Sirengo M, Chege W, Sanders EJ. A Novel HIV-1 RNA Testing Intervention to Detect Acute and Prevalent HIV Infection in Young Adults and Reduce HIV Transmission in Kenya: Protocol for a Randomized Controlled Trial. JMIR Res Protoc 2020; 9:e16198. [PMID: 32763882 PMCID: PMC7442943 DOI: 10.2196/16198] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2019] [Accepted: 05/27/2020] [Indexed: 12/21/2022] Open
Abstract
Background Detection and management of acute HIV infection (AHI) is a clinical and public health priority, and HIV infections diagnosed among young adults aged 18 to 39 years are usually recent. Young adults with recent HIV acquisition frequently seek care for symptoms and could potentially be diagnosed through the health care system. Early recognition of HIV infection provides considerable individual and public health benefits, including linkage to treatment as prevention, access to risk reduction counseling and treatment, and notification of partners in need of HIV testing. Objective The Tambua Mapema Plus study aims to (1) test 1500 young adults (aged 18-39 years) identified by an AHI screening algorithm for acute and prevalent (ie, seropositive) HIV, linking all newly diagnosed HIV-infected patients to care and offering immediate treatment; (2) offer assisted HIV partner notification services to all patients with HIV, testing partners for acute and prevalent HIV infection and identifying local sexual networks; and (3) model the potential impact of these two interventions on the Kenyan HIV epidemic, estimating incremental costs per HIV infection averted, death averted, and disability-adjusted life year averted using data on study outcomes. Methods A modified stepped-wedge design is evaluating the yield of this HIV testing intervention at 4 public and 2 private health facilities in coastal Kenya before and after intervention delivery. The intervention uses point-of-care HIV-1 RNA testing combined with standard rapid antibody tests to diagnose AHI and prevalent HIV among young adults presenting for care, employs HIV partner notification services to identify linked acute and prevalent infections, and follows all newly diagnosed patients and their partners for 12 months to ascertain clinical outcomes, including linkage to care, antiretroviral therapy (ART) initiation and virologic suppression in HIV-infected patients, and pre-exposure prophylaxis uptake in uninfected individuals in discordant partnerships. Results Enrollment started in December 2017. As of April 2020, 1374 participants have been enrolled in the observation period and 1500 participants have been enrolled in the intervention period, with 13 new diagnoses (0.95%) in the observation period and 37 new diagnoses (2.47%), including 2 AHI diagnoses, in the intervention period. Analysis is ongoing and will include adjusted comparisons of the odds of the following outcomes in the observation and intervention periods: being tested for HIV infection, newly diagnosed with prevalent or acute HIV infection, linked to care, and starting ART by week 6 following HIV diagnosis. Participants newly diagnosed with acute or prevalent HIV infection in the intervention period are being followed for outcomes, including viral suppression by month 6 and month 12 following ART initiation and partner testing outcomes. Conclusions The Tambua Mapema Plus study will provide foundational data on the potential of this novel combination HIV prevention intervention to reduce ongoing HIV transmission in Kenya and other high-prevalence African settings. Trial Registration ClinicalTrials.gov NCT03508908; https://clinicaltrials.gov/ct2/show/NCT03508908 International Registered Report Identifier (IRRID) DERR1-10.2196/16198
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Affiliation(s)
- Susan M Graham
- Department of Global Health, University of Washington, Seattle, WA, United States.,Department of Medicine, University of Washington, Seattle, WA, United States.,Department of Epidemiology, University of Washington, Seattle, WA, United States
| | - Clara Agutu
- Kenya Medical Research Institute - Wellcome Trust Research Programme, Kilifi, Kenya
| | - Elise van der Elst
- Kenya Medical Research Institute - Wellcome Trust Research Programme, Kilifi, Kenya
| | - Amin S Hassan
- Kenya Medical Research Institute - Wellcome Trust Research Programme, Kilifi, Kenya
| | - Evanson Gichuru
- Kenya Medical Research Institute - Wellcome Trust Research Programme, Kilifi, Kenya
| | - Peter M Mugo
- Kenya Medical Research Institute - Wellcome Trust Research Programme, Kilifi, Kenya
| | - Carey Farquhar
- Department of Global Health, University of Washington, Seattle, WA, United States.,Department of Medicine, University of Washington, Seattle, WA, United States.,Department of Epidemiology, University of Washington, Seattle, WA, United States
| | - Joseph B Babigumira
- Department of Global Health, University of Washington, Seattle, WA, United States.,Department of Pharmacy, University of Washington, Seattle, WA, United States
| | - Steven M Goodreau
- Department of Epidemiology, University of Washington, Seattle, WA, United States.,Department of Anthropology, University of Washington, Seattle, WA, United States
| | - Deven T Hamilton
- Center for Studies in Demography and Ecology, University of Washington, Seattle, WA, United States
| | - Thumbi Ndung'u
- Africa Health Research Institute, Durban, South Africa.,HIV Pathogenesis Programme, Doris Duke Medical Research Institute, University of KwaZulu-Natal, Durban, South Africa.,Max Planck Institute for Infection Biology, Berlin, Germany.,Division of Infection and Immunity, University College London, London, United Kingdom
| | - Martin Sirengo
- Department of Health Infrastructure Management, Ministry of Health, Nairobi, Kenya
| | - Wairimu Chege
- Division of AIDS, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Rockville, MD, United States
| | - Eduard J Sanders
- Kenya Medical Research Institute - Wellcome Trust Research Programme, Kilifi, Kenya.,University of Oxford, Headington, United Kingdom
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Rucinski KB, Rutstein SE, Powers KA, Pasquale DK, Dennis AM, Phiri S, Hosseinipour MC, Kamanga G, Nsona D, Massa C, Hoffman IF, Miller WC, Pettifor AE. Sustained Sexual Behavior Change After Acute HIV Diagnosis in Malawi. Sex Transm Dis 2019; 45:741-746. [PMID: 29870501 DOI: 10.1097/olq.0000000000000873] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
BACKGROUND Identification of acute HIV infection (AHI) allows for important opportunities for HIV prevention through behavior change and biomedical intervention. Here, we evaluate changes in sexual risk behaviors among persons with AHI enrolled in a combined behavioral and biomedical intervention designed to reduce onward transmission of HIV. METHODS Participants were randomized to standard HIV counseling, a multisession behavioral intervention, or a multisession behavioral intervention plus antiretrovirals. Sexual behaviors were assessed periodically over 1 year. RESULTS Four weeks after diagnosis, the predicted probability of reporting multiple sexual partners decreased from 24% to 9%, and the probability of reporting unprotected sex decreased from 71% to 27%. These declines in sexual risk behaviors were sustained over follow-up irrespective of study arm. CONCLUSIONS Diagnosis of AHI alone may be sufficient to achieve immediate and sustained behavior change during this highly infectious period.
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Affiliation(s)
| | - Sarah E Rutstein
- Infectious Diseases, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | | | | | - Ann M Dennis
- Infectious Diseases, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | | | | | | | | | | | - Irving F Hoffman
- Infectious Diseases, University of North Carolina at Chapel Hill, Chapel Hill, NC
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Agutu CA, Ngetsa CJ, Price MA, Rinke de Wit TF, Omosa-Manyonyi G, Sanders EJ, Graham SM. Systematic review of the performance and clinical utility of point of care HIV-1 RNA testing for diagnosis and care. PLoS One 2019; 14:e0218369. [PMID: 31246963 PMCID: PMC6597060 DOI: 10.1371/journal.pone.0218369] [Citation(s) in RCA: 33] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2018] [Accepted: 05/31/2019] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND Point of-care (POC) HIV-1 RNA tests which are accurate and easy to use with limited infrastructure are needed in resource-limited settings (RLS). We systematically reviewed evidence of POC test performance compared to laboratory-based HIV-1 RNA assays and the potential utility of these tests for diagnosis and care in RLS. METHODS Studies published up to July 2018 were identified by a search of PUBMED, EMBASE, Web of Science, CINAHL and Cochrane Central Register of Controlled Trials. Studies evaluating the use of POC HIV-1 RNA testing for early infant diagnosis (EID), acute HIV infection (AHI) diagnosis, or viral load monitoring (VL), compared to centralized testing, were included. Separate search strategies were used for each testing objective. RESULTS 197 abstracts were screened and 34 full-text articles were assessed, of which 32 met inclusion criteria. Thirty studies evaluated performance and diagnostic accuracy of POC tests compared to standard reference tests. Two of the thirty and two additional studies with no comparative testing reported on clinical utility of POC results. Five different POC tests (Cepheid GeneXpert HIV-1 Quantitative and Qualitative assays, Alere q HIV-1/2 Detect, SAMBA, Liat HIV Quant and Aptima HIV-1 Quant) were used in 21 studies of VL, 11 of EID and 2 of AHI. POC tests were easy to use, had rapid turnaround times, and comparable accuracy and precision to reference technologies. Sensitivity and specificity were high for EID and AHI but lower for VL. For VL, lower sensitivity was reported for whole blood and dried blood spots compared to plasma samples. Reported error rates for Cepheid GeneXpert Qual (2.0%-5.0%), GeneXpert Quant (2.5%-17.0%) and Alere q HIV-1/2 Detect (3.1%-11.0%) were higher than in WHO prequalification reports. Most errors resolved with retesting; however, inadequate sample volumes often precluded repeat testing. Only two studies used POC results for clinical management, one for EID and another for VL. POC EID resulted in shorter time-to-result, rapid ART initiation, and better retention in care compared to centralised testing. CONCLUSIONS Performance of POC HIV-1 RNA tests is comparable to reference assays, and have potential to improve patient outcomes. Additional studies on implementation in limited-resources settings are needed.
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Affiliation(s)
- Clara A. Agutu
- Kenya Medical Research Institute-Wellcome Trust Research Programme, Kilifi, Kenya
| | - Caroline J. Ngetsa
- Kenya Medical Research Institute-Wellcome Trust Research Programme, Kilifi, Kenya
| | - Matt A. Price
- International AIDS Vaccine Initiative (IAVI), Department of Medical Affairs, New York, New York, United States of America
| | - Tobias F. Rinke de Wit
- Department of Global Health, Academic Medical Centre, University of Amsterdam, Amsterdam, the Netherlands
| | - Gloria Omosa-Manyonyi
- School of Medicine, College of Health Sciences, University of Nairobi, Nairobi, Kenya
| | - Eduard J. Sanders
- Kenya Medical Research Institute-Wellcome Trust Research Programme, Kilifi, Kenya
- Department of Global Health, Academic Medical Centre, University of Amsterdam, Amsterdam, the Netherlands
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom
| | - Susan M. Graham
- Kenya Medical Research Institute-Wellcome Trust Research Programme, Kilifi, Kenya
- Departments of Global Health, Medicine, and Epidemiology, University of Washington, Seattle, Washington, United States of America
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7
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Point-of-care HIV RNA testing and immediate antiretroviral therapy initiation in young adults seeking out-patient care in Kenya. AIDS 2019; 33:923-926. [PMID: 30882493 PMCID: PMC6426340 DOI: 10.1097/qad.0000000000002110] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
We evaluated outcomes of an HIV-1-testing intervention using rapid HIV tests followed by point-of-care Xpert Qual testing for HIV-1 RNA. Of 706 young urgent-care seeking participants evaluated, 24 (3.4%) had chronic HIV (antibody-positive), 3 (0.4%) acute HIV-1 (Qual-positive, antibody-negative), and 3 (0.4%) early HIV-1 infection (Qual-positive, antibody-discordant). Overall, 21 (70.0%) diagnosed patients started antiretroviral therapy after a median of 4 days (range 0–71). HIV-1 RNA testing led to an increase in confirmed diagnoses by 25%.
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Grodensky CA, Golin CE, Pack AP, Pettifor A, Demers M, Massa C, Kamanga G, McKenna K, Corneli A. Adaptation and delivery of a motivational interviewing-based counseling program for persons acutely infected with HIV in Malawi: Implementation and lessons learned. PATIENT EDUCATION AND COUNSELING 2018. [PMID: 29519656 PMCID: PMC6003622 DOI: 10.1016/j.pec.2018.02.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/12/2023]
Abstract
OBJECTIVE Individuals diagnosed with acute HIV infection (AHI) are highly infectious and require immediate HIV prevention efforts to minimize their likelihood of transmitting HIV to others. We sought to explore the relevance of Motivational Interviewing (MI), an evidence-based counseling method, for Malawians with AHI. METHODS We designed a MI-based intervention called "Uphungu Wanga" to support risk reduction efforts immediately after AHI diagnosis. It was adapted from Options and SafeTalk interventions, and refined through formative research and input from Malawian team members and training participants. We conducted qualitative interviews with counselors and participants to explore the relevance of MI in this context. RESULTS Intervention adaptation required careful consideration of Malawian cultural context and the needs of people with AHI. Uphungu Wanga's content was relevant and key MI techniques of topic selection and goal setting were viewed positively by counselors and participants. However, rating levels of importance and confidence did not appear to help participants to explore behavior change as intended. CONCLUSION Uphungu Wanga may have provided some added benefits beyond "brief education" standard of care counseling for Malawians with AHI. PRACTICE IMPLICATIONS MI techniques of topic selection and goal setting may enhance prevention education and counseling for Malawians with AHI.
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Affiliation(s)
- Catherine A Grodensky
- Department of Medicine, Institute of Global Health and Infectious Disease, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States; Cecil G. Sheps Center for Health Services Research, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States; Center for AIDS Research, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
| | - Carol E Golin
- Cecil G. Sheps Center for Health Services Research, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States; Center for AIDS Research, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States; Department of Health Behavior, Gillings School of Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States.
| | - Allison P Pack
- Center for AIDS Research, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States; Department of Health Behavior, Gillings School of Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
| | - Audrey Pettifor
- Department of Epidemiology, Gillings School of Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
| | - Michele Demers
- Center for Sexuality and Health Disparities, University of Michigan, Ann Arbor, MI, United States
| | | | | | - Kevin McKenna
- Department of Social, Behavioral, and Health Sciences, FHI 360, Durham, NC, United States(1); Department of Population Health Sciences, Duke University School of Medicine, Durham, NC, United States
| | - Amy Corneli
- Department of Social, Behavioral, and Health Sciences, FHI 360, Durham, NC, United States(1); Department of Population Health Sciences, Duke University School of Medicine, Durham, NC, United States
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Abstract
OBJECTIVE Symptoms of acute retroviral syndrome (ARS) may be used to identify patients with acute HIV-1 infection who seek care. ARS symptoms in African adults differ by region. We assessed whether reporting of ARS was associated with HIV-1 subtype in a multicentre African cohort study representing countries with predominant HIV-1 subtypes A, C, and D. METHODS ARS symptoms were assessed in adults enrolling within 6 weeks after the estimated date of infection in an acute and early HIV-1 infection cohort study. HIV-1 subtype was determined by POL genotyping. We used log-binomial regression to compare ARS symptom prevalence among those with subtype A vs. C or D, adjusting for sex, time since enrolment, and enrolment viral load. RESULTS Among 183 volunteers ascertained within 6 weeks after estimated date of infection, 77 (42.0%) had subtype A, 83 (45.4%) subtype C, and 23 (12.6%) subtype D infection. Individuals with subtype A were 1.40 (95% confidence interval: 1.17, 1.68) times as likely as individuals with subtypes C or D to report any ARS symptoms; each individual symptom other than rash was also more prevalent in subtype A than in subtype C or D, with prevalence ratios ranging from 1.94 (1.40, 2.70) for headache to 4.92 (2.24, 10.78) for lymphadenopathy. CONCLUSION Individuals with subtype A were significantly more likely than individuals with subtypes C or D to report any ARS symptoms. HIV-1 subtypes may help explain differences in ARS that have been observed across regions in Africa, and may impact the yield of symptom-based screening strategies for acute HIV infection detection.
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10
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Rutstein SE, Ananworanich J, Fidler S, Johnson C, Sanders EJ, Sued O, Saez-Cirion A, Pilcher CD, Fraser C, Cohen MS, Vitoria M, Doherty M, Tucker JD. Clinical and public health implications of acute and early HIV detection and treatment: a scoping review. J Int AIDS Soc 2017; 20:21579. [PMID: 28691435 PMCID: PMC5515019 DOI: 10.7448/ias.20.1.21579] [Citation(s) in RCA: 84] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2016] [Accepted: 05/29/2017] [Indexed: 01/13/2023] Open
Abstract
INTRODUCTION The unchanged global HIV incidence may be related to ignoring acute HIV infection (AHI). This scoping review examines diagnostic, clinical, and public health implications of identifying and treating persons with AHI. METHODS We searched PubMed, in addition to hand-review of key journals identifying research pertaining to AHI detection and treatment. We focused on the relative contribution of AHI to transmission and the diagnostic, clinical, and public health implications. We prioritized research from low- and middle-income countries (LMICs) published in the last fifteen years. RESULTS AND DISCUSSION Extensive AHI research and limited routine AHI detection and treatment have begun in LMIC. Diagnostic challenges include ease-of-use, suitability for application and distribution in LMIC, and throughput for high-volume testing. Risk score algorithms have been used in LMIC to screen for AHI among individuals with behavioural and clinical characteristics more often associated with AHI. However, algorithms have not been implemented outside research settings. From a clinical perspective, there are substantial immunological and virological benefits to identifying and treating persons with AHI - evading the irreversible damage to host immune systems and seeding of viral reservoirs that occurs during untreated acute infection. The therapeutic benefits require rapid initiation of antiretrovirals, a logistical challenge in the absence of point-of-care testing. From a public health perspective, AHI diagnosis and treatment is critical to: decrease transmission via viral load reduction and behavioural interventions; improve pre-exposure prophylaxis outcomes by avoiding treatment initiation for HIV-seronegative persons with AHI; and, enhance partner services via notification for persons recently exposed or likely transmitting. CONCLUSIONS There are undeniable clinical and public health benefits to AHI detection and treatment, but also substantial diagnostic and logistical barriers to implementation and scale-up. Effective early ART initiation may be critical for HIV eradication efforts, but widespread use in LMIC requires simple and accurate diagnostic tools. Implementation research is critical to facilitate sustainable integration of AHI detection and treatment into existing health systems and will be essential for prospective evaluation of testing algorithms, point-of-care diagnostics, and efficacious and effective first-line regimens.
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Affiliation(s)
- Sarah E. Rutstein
- Department of Health Policy and Management, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
- Division of Infectious Diseases, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Jintanat Ananworanich
- U.S. Military HIV Research Program, Walter Reed Army Institute of Research, Silver Spring, MD, USA
- Henry M. Jackson Foundation for the Advancement of Military Medicine, Bethesda, MD, USA
| | - Sarah Fidler
- Department of Medicine, Imperial College London, London, UK
| | - Cheryl Johnson
- HIV Department, World Health Organization, Geneva, Switzerland
- Department of Clinical Research, London School of Hygiene and Tropical Medicine, London, UK
| | - Eduard J. Sanders
- Department of Global Health, University of Amsterdam, Amsterdam, The Netherlands
- Kenya Medical Research Institute-Wellcome Trust Research Programme, Kilifi, Kenya
- Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Omar Sued
- Fundación Huésped, Buenos Aires, Argentina
| | - Asier Saez-Cirion
- Institut Pasteur, HIV Inflammation and Persistance Unit, Paris, France
| | | | - Christophe Fraser
- Big Data Institute, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Myron S. Cohen
- Division of Infectious Diseases, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
- Department of Epidemiology, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Marco Vitoria
- HIV Department, World Health Organization, Geneva, Switzerland
| | - Meg Doherty
- HIV Department, World Health Organization, Geneva, Switzerland
| | - Joseph D. Tucker
- Division of Infectious Diseases, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
- Department of Epidemiology, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
- UNC Project-China, Institute for Global Health and Infectious Diseases, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
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Global implementation of PrEP as part of combination HIV prevention - Unsolved challenges. J Int AIDS Soc 2016. [DOI: 10.7448/ias.19.7.21479] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
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Cowan FM, Delany-Moretlwe S, Sanders EJ, Mugo NR, Guedou FA, Alary M, Behanzin L, Mugurungi O, Bekker LG. PrEP implementation research in Africa: what is new? J Int AIDS Soc 2016; 19:21101. [PMID: 27760680 PMCID: PMC5071780 DOI: 10.7448/ias.19.7.21101] [Citation(s) in RCA: 70] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2016] [Revised: 07/11/2016] [Accepted: 07/16/2016] [Indexed: 01/09/2023] Open
Abstract
INTRODUCTION Of the two million new HIV infections in adults in 2014, 70% occurred in sub-Saharan Africa. Several African countries have already approved guidelines for pre-exposure prophylaxis (PrEP) for individuals at substantial risk of HIV as part of combination HIV prevention but key questions remain about how to identify and deliver PrEP to those at greatest need. Throughout the continent, individuals in sero-discordant relationships, and members of key populations (sex workers, men who have sex with men (MSM), transgender women and injection drug users) are likely to benefit from the availability of PrEP. In addition, adolescent girls and young women (AGYW) are at substantial risk in some parts of the continent. It has been estimated that at least three million individuals in Africa are likely to be eligible for PrEP according to WHO's criteria. Tens of demonstration projects are planned or underway across the continent among a range of countries, populations and delivery settings. DISCUSSION In each of the target populations, there are overarching issues related to (i) creating demand for PrEP, (ii) addressing supply-side issues and (iii) providing appropriate and tailored adherence support. Critical for creating demand for PrEP is the normalization of HIV prevention. Community-level interventions which engage opinion leaders as well as empowerment interventions for those at highest risk will be key. Critical to supply of PrEP is that services are accessible for all, including for stigmatized populations. Establishing accessible integrated services provides the opportunity to address other public health priorities including the unmet need for HIV testing, contraception and sexually transmitted infections treatment. National policies need to include minimum standards for training and quality assurance for PrEP implementation and to address supply chain issues. Adherence support needs to recognize that social and structural factors are likely to have an important influence. Combining interventions that build self-efficacy, empowerment and social cohesion, with evidence-based individualized adherence support for PrEP, are most likely to be effective. CONCLUSIONS Efficacy of tenfovir-based PrEP is proven but many issues related to implementation remain unclear. Here, we have summarized some of the important implementation questions that need to be assessed as PrEP is rolled out across Africa.
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Affiliation(s)
- Frances M Cowan
- Department of International Public Health, Liverpool School of Tropical Medicine, Liverpool, UK
- Centre for Sexual Health and HIV AIDS Research (CeSHHAR), Harare, Zimbabwe;
| | - Sinead Delany-Moretlwe
- Wits Reproductive Health and HIV Institute, University of Witwatersrand, Johannesburg, South Africa
| | - Eduard J Sanders
- Kenya Medical Research Institute, Nairobi, Kenya
- Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Nelly R Mugo
- Center for Clinical Research, Kenya Medical Research Institute, Nairobi, Kenya
- Department of Global Health, University of Washington, Seattle, WA, USA
- Partners in Health Research and Development, Thika, Kenya
| | | | - Michel Alary
- Centre de Recherche du CHU de Québec, Université Laval, Québec, Canada
| | | | | | - Linda-Gail Bekker
- The Desmond Tutu HIV Centre, University of Cape Town, Cape Town, South Africa
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Sanders EJ, Wahome E, Powers KA, Werner L, Fegan G, Lavreys L, Mapanje C, McClelland RS, Garrett N, Miller WC, Graham SM. Targeted screening of at-risk adults for acute HIV-1 infection in sub-Saharan Africa. AIDS 2015; 29 Suppl 3:S221-30. [PMID: 26562811 PMCID: PMC4714928 DOI: 10.1097/qad.0000000000000924] [Citation(s) in RCA: 46] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
BACKGROUND Patients with acute HIV-1 infection (AHI) have elevated infectivity, but cannot be diagnosed using antibody-based testing. Approaches to screen patients for AHI are urgently needed to enable counselling and treatment to reduce onward transmission. METHODS We pooled data from four African studies of high-risk adults that evaluated symptoms and signs compatible with acute retroviral syndrome and tested for HIV-1 at each visit. AHI was defined as detectable plasma viral load or p24 antigen in an HIV-1-antibody-negative patient who subsequently seroconverted. Using generalized estimating equation, we identified symptoms, signs, and demographic factors predictive of AHI, adjusting for study site. We assigned a predictor score to each statistically significant predictor based on its beta coefficient, summing predictor scores to calculate a risk score for each participant. We evaluated the performance of this algorithm overall and at each site. RESULTS We compared 122 AHI visits with 45 961 visits by uninfected patients. Younger age (18-29 years), fever, fatigue, body pains, diarrhoea, sore throat, and genital ulcer disease were independent predictors of AHI. The overall area under the receiver operating characteristics curve (AUC) for the algorithm was 0.78, with site-specific AUCs ranging from 0.61 to 0.89. A risk score of at least 2 would indicate AHI testing for 5-50% of participants, substantially decreasing the number needing testing. CONCLUSION Our targeted risk score algorithm based on seven characteristics reduced the number of patients needing AHI testing and had good performance overall. We recommend this risk score algorithm for use by HIV programs in sub-Saharan Africa with capacity to test high-risk patients for AHI.
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Affiliation(s)
- Eduard J. Sanders
- Centre for Geographic Medicine Research – Coast, Kenya Medical Research Institute (KEMRI) – Kilifi, Kenya
- Nuffield Department of Medicine, University of Oxford, Headington, UK
- Department of Global Health, Academic Medical Centre, University of Amsterdam, Amsterdam, the Netherlands
| | - Elizabeth Wahome
- Centre for Geographic Medicine Research – Coast, Kenya Medical Research Institute (KEMRI) – Kilifi, Kenya
| | - Kimberly A. Powers
- Department of Epidemiology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Lisa Werner
- Centre for the AIDS Programme of Research in South Africa (CAPRISA), University of KwaZulu-Natal, Durban, South Africa
| | - Greg Fegan
- Centre for Geographic Medicine Research – Coast, Kenya Medical Research Institute (KEMRI) – Kilifi, Kenya
- Nuffield Department of Medicine, University of Oxford, Headington, UK
| | | | | | - R. Scott McClelland
- Departments of Medicine, Global Health, and Epidemiology, University of Washington, Seattle, Washington
| | - Nigel Garrett
- Centre for the AIDS Programme of Research in South Africa (CAPRISA), University of KwaZulu-Natal, Durban, South Africa
| | - William C. Miller
- Department of Epidemiology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
- Department of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Susan M. Graham
- Centre for Geographic Medicine Research – Coast, Kenya Medical Research Institute (KEMRI) – Kilifi, Kenya
- Departments of Medicine, Global Health, and Epidemiology, University of Washington, Seattle, Washington
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Rutstein SE, Sellers CJ, Ananworanich J, Cohen MS. The HIV treatment cascade in acutely infected people: informing global guidelines. Curr Opin HIV AIDS 2015; 10:395-402. [PMID: 26371460 PMCID: PMC4739850 DOI: 10.1097/coh.0000000000000193] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
PURPOSE OF REVIEW Acute and early HIV (AHI) is a pivotal time during HIV infection, yet there remain major shortfalls in diagnosis, linkage to care, and antiretroviral therapy (ART) initiation during AHI. We introduce an AHI-specific cascade, review recent evidence pertaining to the unique challenges of AHI, and discuss strategies for improving individual and public health outcomes. RECENT FINDINGS Presentation during AHI is common. Expanding use of fourth-generation testing and pooled nucleic acid amplification testing has led to improved AHI detection in resource-wealthy settings. Technologies capable of AHI diagnosis are rare in resource-limited settings; further development of point-of-care devices and utilization of targeted screening is needed. Rapid ART initiation during AHI limits reservoir seeding, preserves immunity, and prevents transmission. Reporting of AHI cascade outcomes is limited, but new evidence suggests that impressive rates of diagnosis, linkage to care, rapid ART initiation, and viral suppression can be achieved. SUMMARY With advancements in AHI diagnostics and strong evidence for the therapeutic and prevention benefits of ART initiated during AHI, improving AHI cascade outcomes is both crucial and feasible. HIV guidelines should recommend diagnostic algorithms capable of detecting AHI and prescribe rapid, universal ART initiation during AHI.
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Affiliation(s)
- Sarah E. Rutstein
- Department of Health Policy and Management, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
- Division of Infectious Diseases, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Christopher J. Sellers
- Division of Infectious Diseases, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Jintanat Ananworanich
- U.S. Military HIV Research Program, Walter Reed Army Institute of Research, Silver Spring, Maryland, USA
- Henry M. Jackson Foundation for the Advancement of Military Medicine, Bethesda, Maryland, USA
| | - Myron S. Cohen
- Division of Infectious Diseases, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
- Department of Epidemiology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
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Abstract
PURPOSE OF REVIEW Detection of early HIV infections (EHIs), including acute HIV infection (AHI), is important for individual health, prevention of HIV transmission, and measurement of HIV incidence. We describe markers of EHI, diagnostic strategies for detecting these markers, and ways to incorporate these strategies into diagnostic and HIV incidence algorithms. RECENT FINDINGS For individual diagnosis in the USA and Europe, laboratory-based diagnostic algorithms increasingly incorporate fourth-generation HIV antigen tests, allowing for earlier detection. In some sub-Saharan African settings, symptom-based screening is being explored to identify subsets of persons at high risk for AHI. Point-of-care diagnostics designed for AHI detection are in the pipeline and, if validated, represent an opportunity for real-time AHI diagnosis. At the population level, multiassay algorithms are promising new strategies for estimating HIV incidence on the basis of several assays applied to cross-sectional samples. These algorithms can be developed to optimize performance, in addition to cost and logistical considerations. SUMMARY There are important recent advances in detection of EHIs at the individual and population levels. Applying optimal combinations of tests in diagnostic and HIV incidence algorithms is urgently needed to support the multiple goals derived from enhanced detection and discrimination of EHIs.
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Brief Report: Health-Seeking Behavior and Symptoms Associated With Early HIV Infection: Results From a Population-Based Cohort in Southern Malawi. J Acquir Immune Defic Syndr 2015; 69:126-30. [PMID: 25942464 DOI: 10.1097/qai.0000000000000536] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
HIV transmission is most likely to occur during the first few months after infection, yet few cases are identified during this period. Using a population-based cohort of young Malawian women, we identify the distinct symptomology and health-seeking behavior marking early HIV infection by comparing it with periods of seronegativity and chronic infection. During early HIV infection, women are more likely to report malaria-like symptoms and visit clinics for malaria care. In malaria-endemic contexts, where acute HIV symptoms are commonly mistaken for malaria, early diagnostic HIV testing and counseling should be integrated into health care settings where people commonly seek treatment for malaria.
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