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Acute HIV JoAnn Kuruc, MSN, RN University of North Carolina

Acute HIV JoAnn Kuruc, MSN, RN University of North Carolina. Acknowledgements. NC Department of Health and Human Services Evelyn Foust Steve Cline Leah Devlin Leslie Wolf Todd Vanhoy Rhonda Ashby Del Williams John Barnhart North Carolina Disease Intervention Specialist

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Acute HIV JoAnn Kuruc, MSN, RN University of North Carolina

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  1. Acute HIV JoAnn Kuruc, MSN, RNUniversity of North Carolina

  2. Acknowledgements NC Department of Health and Human Services Evelyn Foust Steve Cline Leah Devlin Leslie Wolf Todd Vanhoy Rhonda Ashby Del Williams John Barnhart North Carolina Disease Intervention Specialist North Carolina State Laboratory of Public Health University of North Carolina at -Chapel Hill Myron S. Cohen Susan A. Fiscus Melissa Kerkau Joseph J. Eron Peter Leone Cynthia Gay Sandi McCoy Lisa Hightow Steve Beagle Alyssa Sugarbaker NIMH-R01 068686 (C. Pilcher)

  3. Acute HIV Infection (AHI) Figure adapted from Fauci A, Ann Intern Med 1996;124:654-663.

  4. 0 10 20 30 40 50 60 70 80 90 100 HIV viremia during early infection Peak viremia: 106-108gEq/mL HIV RNA (plasma) Ramp-up viremia HIV Antibody HIV p24 Ag p24 Ag EIA - Viral set-point: 102 -105gEq/mL 1stgen 2ndgen 4th gen 3rdgen 11 16 22

  5. HIV Testing Behavior • Detection of AHI is rare – about 4% of all cases in NC • 25% of HIV infections in the U.S. are unrecognized (Fleming PL. 9th CROI, 2002) • Risk awareness is key • Onset of symptoms or illness acts as a cue for testing • 42% of HIV positive in U.S. tested due to illness (MMWR 2003) • Factors influencing detection of AHI are not well understood - a key period for public health intervention

  6. Viral Loads at Initial Detection: NCFiscus et al. 2004 10 9 8 median 209,183 7 6 29,347 5 4 3 2 1 0 Established HIV+ (n=66) Acutely HIV + (n=21)

  7. NC Approach to AHI DetectionSTAT Program • Screen all HIV Ab negative or WB indeterminate blood for HIV RNA • Review of all community cases - Antibody (Ab) negative, HIV RNA (+) - Ab+ with a history of an HIV Ab (-) within 3 mo - Ab+ with recent acute symptoms or STD symptoms within 1 mo

  8. The Screening and Tracing Active Transmission (STAT) Program • Possible AHI clients are notified by disease investigation specialists (DIS) within 72 hours • Confirmatory testing • Referrals to care • Partner notification & testing • Interview with AHI clients includes symptoms, STD symptoms and diagnoses, and partner information

  9. Acute HIV Incubation Periods N=31 Median [Range] = 14 d [5-30] Mean (+/- SD) = 15 d+/- 6.3 Sources: Pilcher JAMA 2001 Lindback AIDS 2001 Borrow Nat Med 1997 Schacker AIM 1996 10 8 6 Frequency 4 2 0 7 14 21 28 Days from Unique Sexual Exposure to Onset of Symptoms

  10. Acute Retroviral Symptoms • 45 clients (59%) had symptoms either at testing or in the 4 weeks prior to testing • 87% had ≥2 sx(51% of total) • 58% had ≥3 sx (43% of total)

  11. Diagnostic Testing for PHI 1 mil HIV RNA 100,000 + HIV RNA HIV-1 Antibodies _ 10,000 Ab 1,000 Exposure 100 Symptoms 10 0 20 30 40 50 Days

  12. Testing Site November 2002- May 2005 Tests Ab+ AHI (%) % of AHI HIV CTS 18,299 400 12 (2.9) 21 STD 117,804 526 27 (4.9) 48 FP 47,476 28 -- -- Prenatal/OB 47,598 39 2 (4.9) 3 Prison/Jail 7,158 57 4 (6.6) 7 Other 37,073 320 13(3.9) 22

  13. Potential Impact of STI Co-infection on Detection of AHI McCoy 0-014: ISSTDR 2007 HIV/STI Co-Infection Event HIV RNA + 4th gen. EIA 3rd gen. EIA week 1 week 3 week 4 week 2 GC Trichomoniasis Chlamydia Syphilis HSV ARS Symptoms

  14. NC HIV Testing in STD Clinics • HIV testing offered to all STD clients at each new visit • Policy to offer opt-out HIV testing • Fast tracked or expedited testing for person who present with documented symptoms compatible with Antiretroviral Syndrome (ARV) and other high risk behaviors such as an STI, multiple sex partners or anal sex. • Contact acute HIV Program 919 – 966-8533 for review and possible expedited testing.

  15. Fast Track or Expedited Testing • Fast-track HIV RNA testing is indicated if the following criteria are met within the preceding 4 weeks and documented by a medical provider: • HIV risk exposure * • Documented fever ≥100.5°F or >38.0°C Contact acute HIV Program 919 – 966-8533

  16. Care of AHI at UNC • Immediate appointment with an ID specialist for evaluation • Treatment Options • No standard guidelines for treatment • Research Options • Treatment studies (Atripla) • Observational studies • Standard of care testing and large blood draws

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