STAT

1. STAT Steve Beagle UNC CHAVI Field Coordinator University of North Carolina at Chapel Hill

2. Acknowledgements • North Carolina D.I.S. and all Public Health Colleagues and Clients • Evelyn Foust, Peter Leone, Todd VanHoy, and Rhonda Ashby (HIV/STD Prevention and Care) • JoAnn Kuruc - STAT Program, University of North Carolina (UNC)

4. What is STAT? • Acronym for “Screening and Tracing of Active Transmission” (Acute HIV) • Collaboration between UNC and the NC HIV/STD Prevention and Care Branch (Field Services Unit) • Statewide program that has enormous public health impact

5. Acute HIV The STAT Program

6. Public Health Impact? Most infectious period of HIV infection • Early linkage to care • HIV education to help prevent downstream transmissions • Rapid partner contact and tracing, counseling and testing • Research: medical evaluations, treatment interventions and vaccine studies

7. History of STAT • Pilot project in 2001: 8,155 Specimens pooled • Two [2] “two month” testing periods (May-June and August-September) • Identified five antibody negative, HIV RNA positive samples (four were positive for acute HIV infection and one was a false positive) • November 2002: STAT Program Implemented Statewide (SLPH/Field Services/UNC)

8. STAT Program • Testing sites: >110 publicly funded sites across NC • Laboratory detection of incident HIV infection • Routine HIV Antibody (Ab or EIA) testing • HIV-1 QL RNA screening of all Ab (-) specimens • Rapid notification of RNA (+) Ab (-) individuals by the NC DHHS STAT DIS • Rapid partner notification and testing • Systematic data collection on social/sexual networks • Ongoing monitoring of transmission patterns by the UNC/NC DHHS STAT Team

9. STAT ProgramClassification System • STAT Acutes • Community Acutes • Community Recents

10. STAT Acutes • One of the following test result combinations from the North Carolina State Laboratory of Public Health (NCSLPH) • EIA (-), RNA (+) • EIA (+), RNA (+), WB (-) • EIA (+), RNA (+), WB (I) (“I”= indeterminate)

11. Community Acutes • HIV test results usually the same as with STAT acutes • Can test EIA (+) WB (+) with documentation of a negative HIV antibody test within the past 30 days. • Cases are discovered by PMDs, hospitals and Field Services • HIV testing is usually performed in labs other than SLPH (i.e. LabCorp, Quest)

12. Community Recent • EIA/WB(+) with a documented EIA(-) test within the previous 6 months • Our focus: Community recents with … • An EIA(-) test ≤ 3 months of the EIA/WB+ result • An STD (diagnosed and treated) ≤ 1 month of the first HIV positive test • Symptoms consistent with an acute retroviral syndrome (ARS) ≤ 1 month of the first HIV positive test • Consider last exposure and any circumstances that would clearly suggest transmission 3 months prior to an +EIA/WB

13. Acute Retroviral Syndrome or ARS Often overlooked by patients and/or physicians Frequently misdiagnosed as: • Flu or viral syndrome • Meningitis • Rash • Rocky Mountain Spotted Fever

14. ARS (continued) 5. Urinary Tract Infection • Sore throat/pharyngitis • Upper Respiratory Infection • “Viral Syndrome” “Viral illness” • Herpes • Mononucleosis (mono)

15. STAT AcutesHow are they identified ? ? • The NCSLPH detects a positive pool. The pool is deconstructed to identify the positive sample – John Barnhart (ESSU) notified. • John notifies Rhonda Ashby, who then notifies the appropriate regional supervisor • Regional supervisor assigns the case to a STAT D.I.S. in their region • STAT D.I.S. begins investigation, locates and interviews the “possible” acutely HIV infected individual within 72 hours of the testing result

16. STAT Index Case Protocol Ab + or Confirmatory Ab ( - ) RNA + STAT Case Confirmed Acute HIV + Test Possible acute HIV Infection HIV Antibody and RNA Testing STAT Notification Ab + Ab - False Repeat Testing RNA Weeks 4 & 12 Ab - Positive STAT STAT Post Post - - Exposure Exposure Contact < 72 hrs Protocol Protocol • DIS Interview STAT Contact < 8 weeks • Referral to Care Contact Protocol Routine Partner Contact > 8 weeks Notification Protocol

17. What happens once a person is identified and suspected of having acute HIV infection? STAT DIS locates Index • Post test counseling and field blood • “It is likely that you are infected with HIV” • DIS conducts a detailed patient interview • Discuss acute HIV’s impact on personal and public health • Elicit partner information • Discuss importance of medical evaluation • Assess for recent viral symptoms, illnesses and STDs

18. Anything else ? “Health Information Release” form • Allows evaluation of STAT and HIV incidence in NC • Allows DIS to schedule the appointment at UNC or with other ID specialist and to discuss the patient with the STAT and medical team “Blood Storage” consent: • Allows specimens to be used in research Medical Evaluation • Arrange medical evaluation (UNC or local provider) • Provide transportation to UNC or other ID specialist for a free medical exam with a doctor who specializes in Acute HIV infection • Care options and (if available) study opportunities are addressed during the ID visit

23. …and the STAT patient’s partners? Partners exposed < 72 hours prior • STAT DIS calls Dr. Leone to discuss • “You may have been exposed to HIV” • Draw field blood - flag for individual RNA testing • Cluster interview

24. …and the STAT patient’s partners? Partner exposure >72 hours and <8 weeks • “You may have been exposed to HIV” • Obtain field blood – flag for RNA testing • Cluster interview

25. …and the STAT patient’s partners? • Partners exposed >8 weeks • Routine partner notification within 14 days after WB confirmation of the STAT acute • Cluster interview

26. 21 W 30’s W 30’s W 23 H 30’s W 21 W 27 W 26 W 30’s W 30’s W 30’s W 15 male partners 27 W 20+ Partners 30’s W 25 B 9 Partners: E-mail addresses/screen names only, Age race Chronic HIV Acute HIV 30’s W HIV and/or Syphilis negative Syphilis 29 W Not tested/ Unknown HIV status HIV/Syphilis coinfection 31 B Crystal Meth Use Gay.com Manhunt AOL 30 W Courtesy of Dr. Lisa Hightow-Weidman College Student Non-Internet sex partner

27. Duke-UNC Acute HIV Infection Research Consortium Research opportunities for patients with Acute and Recent HIV Infection: “Treatment of Acute HIV Infection with Once Daily Atripla” (24 month treatment study which supplies Atripla) “Longitudinal Assessment of Acute/Recent HIV Infection” (Adds to limited scientific knowledge currently available regarding acute/recent infection)

28. Duke-UNC Acute HIV Infection Research Consortium 3) “CHAVI 001: Acute HIV-1 Infection Prospective Cohort Study” Acquire information to develop an HIV vaccine The most relevant information may come from people with acute HIV infection and their partners