Prevalence of primary HIV infection in symptomatic ambulatory patients

Management of Newly Diagnosed HIV Infection

No field in medicine has moved as swiftly as HIV/AIDS over the past 35 years. Because of the rapid turnover of key information, this In the Clinic focuses on essential principles of care for newly diagnosed adults with HIV-1 infection and how to prevent infection in persons at risk. To ensure continued usefulness, future directions in therapy and how to access updated information on a continuous basis are emphasized.

Acute human immunodeficiency virus (HIV) infection presenting with fever, elevated amylase/lipase, and hematologic abnormalities

BACKGROUND

Many cases of acute human immunodeficiency virus (HIV) infection (AHI) present to the Emergency Department (ED). Early diagnosis allows a patient to modify their behavior and seek early treatment. The Emergency Physician should know that the antibody response may be absent.

OBJECTIVE

We report a case of AHI and review its presentation to increase the awareness of this important diagnosis.

CASE REPORT

A 20-year-old black man who had a history of sex with men initially presented to the ED with a chief complaint of blood per rectum when he passed stool, and chills for the prior few days. His work-up was normal, including a rapid HIV screen, and he was discharged. He returned 2 weeks later with constipation, fatigue, myalgias, decreased urination, chills, and a productive cough. His physical examination was unremarkable, HIV antibody test was negative, but his laboratory tests showed an elevation of creatine phosphokinase, amylase, and lipase. His blood count showed a normal hematocrit and white blood cell count, but there were juvenile and vacuolated white cells and giant platelets reported. HIV viral load was reported as > 1,000,000 copies/mL.

CONCLUSIONS/SUMMARY

This case illustrates that AHI can present as a non-specific illness. Patients at risk should be screened for HIV. However, AHI can occur before there is a significant antibody response. In such cases, a viral load test may help make the diagnosis, allowing for early treatment and patient counseling.

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.

Diagnosing acute HIV infection

Individuals with acute HIV infection (AHI) pose a greater transmission risk than most chronically HIV-infected patients and prevention efforts targeting these individuals are important for reducing the spread of HIV infection. Rapid and accurate diagnosis of AHI is crucial. Since symptoms of AHI are nonspecific, its diagnosis requires a high index of suspicion and appropriate HIV laboratory tests. However, even 30 years after the start of the HIV epidemic, laboratory tools remain imperfect and only a few individuals with AHI are identified. We review the clinical presentation of the acute retroviral syndrome, the laboratory markers and their detection methods, and propose an algorithm for the laboratory diagnosis of AHI.

Medical encounter characteristics of HIV seroconverters in the US Army and Air Force, 2000–2004

BACKGROUND AND METHODS

Active duty US Army and Air Force military personnel undergo mandatory biennial HIV antibody screening. We compared pre- and post-HIV seroconversion health status by conducting a case-control study, which evaluated all medical encounters and sociodemographic factors among incident HIV seroconverters and HIV-negative controls from June 2000 through February 2004.

RESULTS

A total of 274 HIV seroconverters and 6205 HIV-negative personnel were included. In multivariate analysis restricted to male personnel (cases = 261, controls = 5801), single marital status (adjusted odds ratio [AOR] = 14.37), clinical indicators or symptoms within four years of HIV diagnosis (AOR = 6.22), black race (AOR = 5.88), nonindicator clinical syndromes within 2 years of HIV diagnosis (AOR = 3.31), any mental disorder within 4 years of HIV diagnosis (AOR = 3.04), increasing service-connected time (AOR = 1.69), and older age (AOR = 1.12) were associated with HIV diagnosis among males. A prior history of a sexually transmitted infection (STI) was associated with post-HIV seroconversion STI (OR(M-H) = 4.10). Similarly, a prior history of mental disorder was associated with post-HIV seroconversion mental disorder (OR(M-H) = 4.98). Forty-seven (18%) male cases were hospitalized at least once after HIV diagnosis; infectious diseases, and mental disorders made up 53% of initial admissions.

CONCLUSIONS

HIV seroconversion was associated with increased health care-seeking behavior, STIs, and mental disorders, some of which may be amenable to screening. The higher STI rate after HIV diagnosis may partially be a consequence of monitoring, but secondary transmission of STI and possibly HIV require further definition and subsequent tailored preventive interventions.

In utero and intra-partum HIV-1 transmission and acute HIV-1 infection during pregnancy: using the BED capture enzyme-immunoassay as a surrogate marker for acute infection

OBJECTIVE

The BED assay was developed to estimate the proportion of recent HIV infections in a population. We used the BED assay as a proxy for acute infection to quantify the associated risk of mother-to-child-transmission (MTCT) during pregnancy and delivery. Design A total of 3773 HIV-1 sero-positive women were tested within 96 h of delivery using the BED assay, and CD4 cell count measurements were taken. Mothers were classified according to their likelihood of having recently seroconverted.

METHODS

The risk of MTCT in utero and intra-partum was assessed comparing different groups defined by BED and CD4 cell count, adjusting for background factors using multinomial logistic models.

RESULTS

Compared with women with BED ≥ 0.8/CD4 ≥ 350 (typical of HIV-1 chronic patients) there was insufficient evidence to conclude that women presenting with BED < 0.8/CD4 ≥ 350 (typical of recent infections) were more likely to transmit in utero [adjusted odds ratio (aOR) = 1.37, 96% confidence interval (CI) 0.90-2.08, P = 0.14], whereas women with BED < 0.8/CD4 200-349 (possibly recently infected patients) had a 2.57 (95% CI 1.39-4.77, P-value < 0.01) odds of transmitting in utero. Women who had BED < 0.8/CD4 < 200 were most likely to transmit in utero (aOR 3.73, 95% CI 1.27-10.96, P = 0.02). BED and CD4 cell count were not predictive of intra-partum infections.

CONCLUSIONS

These data provide evidence that in utero transmission of HIV might be higher among women who seroconvert during pregnancy.

HIV testing in a high-incidence population: is antibody testing alone good enough?

BACKGROUND

The Centers for Disease Control and Prevention recently recommended the expansion of human immunodeficiency virus (HIV) antibody testing. However, antibody tests have longer "window periods" after HIV acquisition than do nucleic acid amplification tests (NAATs).

METHODS

Public Health-Seattle & King County offered HIV antibody testing to men who have sex with men (MSM) using the OraQuick Advance Rapid HIV-1/2 Antibody Test (OraQuick; OraSure Technologies) on oral fluid or finger-stick blood specimens or using a first- or second-generation enzyme immunoassay. The enzyme immunoassay was also used to confirm reactive rapid test results and to screen specimens from OraQuick-negative MSM prior to pooling for HIV NAAT. Serum specimens obtained from subsets of HIV-infected persons were retrospectively evaluated by use of other HIV tests, including a fourth-generation antigen-antibody combination assay.

RESULTS

From September 2003 through June 2008, a total of 328 (2.3%) of 14,005 specimens were HIV antibody positive, and 36 (0.3%) of 13,677 antibody-negative specimens were NAAT positive (indicating acute HIV infection). Among 6811 specimens obtained from MSM who were initially screened by rapid testing, OraQuick detected only 153 (91%) of 169 antibody-positive MSM and 80% of the 192 HIV-infected MSM detected by the HIV NAAT program. HIV was detected in serum samples obtained from 15 of 16 MSM with acute HIV infection that were retrospectively tested using the antigen-antibody combination assay.

CONCLUSIONS

OraQuick may be less sensitive than enzyme immunoassays during early HIV infection. NAAT should be integrated into HIV testing programs that serve populations that undergo frequent testing and that have high rates of HIV acquisition, particularly if rapid HIV antibody testing is employed. Antigen-antibody combination assays may be a reasonably sensitive alternative to HIV NAAT.

Rare post-tonsillectomy complication in human immunodeficiency virus positive patient: ulcero-necrotic lesion of tonsillar fossa

OBJECTIVE

Post-tonsillectomy complications are common. The majority are easily recognised because of their frequent occurrence and can be managed as required. Infrequent complications may be misdiagnosed or managed inappropriately. We present a previously unreported complication of tonsillectomy.

CASE REPORT

A 45-year-old Afro-Caribbean man underwent routine tonsillectomy. Eight weeks post-operatively, he developed an ulcero-necrotic lesion of the tonsillar fossa. Subsequent investigation revealed that he was human immunodeficiency virus positive. It is highly likely that the patient's underlying immuno-compromised state, secondary to human immunodeficiency virus infection, contributed to this ulcero-necrotic lesion.

CONCLUSIONS

This case highlights the importance of clinician awareness of rare complications of tonsillectomy, in order to facilitate identification and appropriate investigation.

The cost-effectiveness of expanded testing for primary HIV infection

PURPOSE

Primary infection with the human immunodeficiency virus (HIV) is a major factor in the HIV epidemic. Most patients become symptomatic and seek care, but seldom are they tested or is their condition diagnosed. The objectives of this study are to determine whether it is cost-effective to expand testing for primary HIV infection to a larger cohort of patients, and, if so, which diagnostic assay is most cost-effective.

METHODS

We undertook a cost-effectiveness analysis of testing a hypothetical cohort of more than 3 million outpatients with fever and other viral symptoms regardless of HIV risk factors using 3 diagnostic assays: p24 antigen enzyme immunosorbent assay (EIA), HIV-1 RNA assay, and third-generation HIV-1 EIA. Antiretroviral therapy was started when the CD4 cell count decreased to 350/microL. Outcome measures were the incremental cost-effectiveness of the diagnostic assays, number of cases identified, cases avoided in sexual partners, and threshold prevalence. For sensitivity analyses, we used 50,000 dollars as the threshold for cost-effectiveness.

RESULTS

At the baseline prevalence of 0.66%, p24 antigen EIA testing was the most cost-effective option at a cost of 30,800 dollars per quality-adjusted life-year gained when compared with no testing. There were 17,054 cases identified, and infection was avoided in 435 partners. Probabilistic sensitivity analysis, in which the estimates for all variables are varied simultaneously, determined that expanded testing with p24 antigen EIA compared with no testing had a 67% probability of being cost-effective at the baseline prevalence and a 71% probability at a prevalence of 1%.

CONCLUSIONS

Expanded testing for primary HIV infection with p24 antigen EIA may be a sound expenditure of health care resources.