Acute HIV and the North
Carolina STAT Project
Past, Present and Future
Peter Leone, MD
Associate Professor of Medicine
University of North Carolina
Medical Director
North Carolina HIV/STD Prevention and Care
B
9/10/05
Develops fever, ST, fatigue
Local PMD gives Z-pack
8/15/05-8/30/05
A&B: Sex 3-4x
D
A
Partners B&C “steady”
Sex 1-2x/wk
8/30/05
A,B,C: 3-way
7/28/05
Develops HA, Fever
Went to ER, LP, labs
DX: RMSF, doxycycline given
Symptoms worsen
2 Days later admitted
HIV Ab neg
Discharge Aseptic meningitis
Possible RMSF
C
9/30/05
Develops fever, LAD,ST
Local PMD gives Z-pack
10/15/05
B,C,D have 3-way
10/28/05
Develops fever, ST,
oral ulcers, thrush
Antibiotics given
Requests HIV test
B
D
A
C
11/15/05
HIV+
(ELISA +
WB: I)
B
12/1/05
HIV+
D
A
C
12/1/05
HIV+
11/15/05
HIV+
(ELISA +
WB: I)
B
D
A
12/20/05
HIV+
12/1/05
HIV+
C
12/1/05
HIV+
11/15/05
HIV+
(ELISA +
WB: I)
B
D
A
12/20/05
HIV+
12/1/05
HIV+
11/15/05
HIV+
(ELISA +
WB: I)
C
12/1/05
HIV+
5 infections could have been avoided if acute HIV infection
considered at first presentation
Definition of Acute HIV Infection

Time period following infection with HIV during
which HIV virus can be detected in blood but
antibodies to HIV are not
OR

Window period when routine HIV antibody tests
(EIAs) are negative but HIV virus can be
detected in blood
Primary HIV Infection

Definition: Acute HIV infection + recent infection
with HIV.

Recent Infection: patients who are positive on
HIV antibody testing (EIA), but have one of the
following:
– A recent prior negative HIV test or
– Results of detuned antibody test suggesting recent
infection.
Couthino et al., Bulletin of Mathematical Biology 2001
Detecting Acute HIV Infections
Symptoms
p24 Antigen
HIV RNA
HIV Ab Tests
0
1
2
3
4
5
6
7
Weeks Since Infection
8
9
10
PCR Testing of Pooled Sera to
Identify Acute HIV Infection
(seronegative, PCR positive)
Pooled HIV RNA Testing: Yields
Program
Population
New York City
NYC 3 STD Clinics
North Carolina
All persons tested for HIV
via North Carolina DOH
Public-Health
Seattle & King
County
Prevalence HIV
RNA+/EIA-
Increase in
Testing Yield
15%
23/109,250 (0.02%)
4%
Men who have sex with
men tested through PHSKC
21/5995 (0.35%)
13.5%
San Francisco
SF STD Clinic Patients
11/2722 (0.40%)
10.5%
Los Angeles
Men tested in 3 STD Clinics
1/1698 (0.06%)
7.1%
Maryland (not
Baltimore)
STD clinics
0/15000
0
Atlanta
STD clinics, community
testing and drug treatment
4/2128 (0.19%)
5%
Washington DC
STD clinic
6/1553 (0.39%)
10%
Source: ISSTDR, 2007
How do we pick-up Acute
HIV infection if routine
antibody tests are negative?
Acute Retroviral Syndrome

40-90% of new HIV infections are
symptomatic

Signs and symptoms typically begin 1-4
weeks following the exposure

Symptoms can last from days to several
weeks, but usually <14 days
Pilcher C et al. N Engl J Med 2005;352:1873-1883
Kahn JO, Walker BD. N Engl J Med. 1998;339:33-39
Schacker T, et al. Ann Intern Med. 1996;125:257-264
Acute HIV Incubation Periods
10
31 Patients
Average = 14 days
Frequency
8
Range: 5-30 days
6
4
Sources: Pilcher, JAMA 2001; Borrow, Nat
Med 1997; Schacker AIM 1996; Lindback,
AIDS 2001
2
0
7
14
21
28
Days from Sexual Exposure to Onset of Symptoms
Non-specific Mononucleosis-like
Signs and Symptoms
Fever
 Adenopathy
 Rash
 Sore throat/
pharyngitis
 Oral ulcer
 Muscle and/or joint
 Weight loss
pain
 Loss of appetite
 Diarrhea
 Headache
 GI upset/nausea/
 Fatigue
vomiting

Common Signs & Symptoms
Study of 160 patients with primary HIV infection in 3 countries
fever
86
lethargy
74
myalgias
59
rash
57
headache
55
pharyngitis
52
adenopathy
44
0
10
20
30
40
50
60
70
% of patients
Vanhems P et al. AIDS 2000; 14:0375-0381.
80
90
100
Acute HIV and Symptoms
Fever
Fatigue
Pharyngitis
Headache
Rash
GI Symptoms
Schacker
93%
93
70
55
Kinloch-de Loes
87%
26
48
39
Schacker TW, et al., AIM 1996 125:257-64
NC STD
48%
37
30
26
15
37
Common Mis-diagnoses
Mononucleosis
 Rocky Mountain Spotted Fever
 Strep throat
 Influenza
 “Viral illness”
 Secondary syphilis

Primary HIV Infection: Pathogenesis
Symptoms
CD4 Cell Count (cells/mm³)
Plasma HIV RNA (copies/mL)
10,000,000
1,000,000
100,000
Plasma HIV RNA
10,000
1,000
100
CD4 Cell
Count
10
1
4-8 Weeks
Primary
Up to 12 Years
HIV Progression
2-3 Years
AIDS
How do we pick-up Acute
HIV infection if patients
don’t have symptoms?
Our approach to Screening for AHI
Specimen pooling
•
Advantages
•
Disadvantages
Seamless (almost) incorporation into HIV testing
Reduced cost
No real change in specificity
Universal application
Requires large testing volume
Small loss in sensitivity
Logistics
Time to Dx and locating patient
STAT Testing Protocol
+
EIA/
Western
Blot
-
HIV Positive
-
HIV RNA
testing
+
F/U Testing
(Ab + HIV RNA)
HIV Negative
+
Acute HIV
Pooling and HIV RNA testing
90 individual HIV
antibody negative
specimens
9 intermediate
pools
(10 specimens)
1 master pool
(90 specimens)
A B C D E F G H I
A B C D E F G H I
1
2
3
4
5
6
7
8
9
10
A B C D E F G H I
A B C D E F G H I
Distribution of Viral Loads in Ab
Negative VCT Specimens
NC Testing Data 2002-2005 (n=58)
16
14
12
10
n
8
6
4
2
0
2
3
4
5
6
log HIV RNA cp/ml
7
8
Low viral load specimens
16
14
12
10
n
8
6
4
2
0
2
3
4
5
6
log HIV RNA cp/ml
7
8
STAT Index Case Protocol
STAT Case
Possible acute
HIV Infection
Confirmatory
Test
HIV Antibody
and RNA Testing
EIA
or
Ab(-)
EIA/Ab (+) and WB (+)
or
EIA/Ab (-)
Confirmed Acute HIV +
RNA (+)
STAT Notification
EIA or
Ab (+)
Repeat
Testing
Contact < 72 hrs
•DIS Interview
•Referral to Care
Ab -
False
RNA
Positive
STATcontact
Immediate
Post-Exposure
Dr. Leone
UNCProtocol
ID – on call
Contact < 8 weeks
STAT
Contact Protocol
Contact > 8 weeks
Routine Partner
Notification
Protocol
Notification of AHI in STAT 02-05
100
90
80
70
60
50
40
30
20
10
N
ov
-0
4
Fe
b05
4
04
Au
g-
Ap
r-0
04
Ja
n-
3
ct
-0
O
3
03
Ju
n-
ar
-0
M
-0
2
D
ec
Se
p-
02
0
Time to notification improved to ~11 days from the time of testing
(est. ~39D into 80D hyper-infectious period)
Notification and interviews successful for 41 (93%) index cases
•80% index cases were successfully entered into care.
•PCRS successful for 102 (78%) of 130 named partners
The STAT System
Disease Intervention
Specialist Team
State Laboratory
Laboratory
Identification
Notification, Interviews,
Confirmatory Testing,
Transportation to Clinic
UNC Weekly CaseConference
(Surveillance, Lab, DIS, UNC
Evaluation Teams)
Data collection
UNC Acute HIV Program
Research Database
UNC Specimen Repository
-surveillance/research testing
UNC/Duke
Collaborative
Free Urgent clinical
evaluation
Recruitment to studies
Screening and Tracing Active
Transmission (STAT) Program
• From 2003-2006, 79 cases identified
– 3 not located
– 1 refusal for PCRS
• 269 partners (from 75 AHI patients)
identified within an 8-week exposure window
– 174 (65%) named
132 (76%) located
– 95 (35%) anonymous
STAT PCRS Outcomes (2003-2006)
Previosly
positive 26%
(45)
Found and
refused 4% (7)
Not Located
24% (42)
Acute Infection
4% (3)
46% (80)
Counseled & Tested
Negative
86% (69)
Recent Infection
1% (1)
Newly Identified
Chronic
Infection 9% (7)
Why focus on Acute HIV
Infection?
HIV Epidemic in NC

7th leading cause of death for men and women
ages 25-44 in 2004

Approximately 10,600 HIV-infected NC residents
were unaware of their status in 2005

HIV incidence in the US and NC is stable or
increasing

NC ranked 2nd in the US for the number of AIDS
cases from non-metropolitan areas
New Patients in the UNC ID Clinic

The median CD4 count was 202 cells/mm3
for patients initiating HIV care.

Majority (68%) initiated HIV care within 1
year of their first positive HIV test.

75% met guidelines for starting HIV
treatment at their first visit.
NC DHHS- HIV/STD Prevention & Care Branch
HIV viremia during early infection
Peak viremia: 106-108 gEq/mL
HIV RNA (plasma)
Ramp-up viremia
DT = 21.5 hrs
HIV Antibody
HIV p24 Ag
p24 Ag EIA HIV MP-NAT -
1st gen
HIV ID-NAT -
“blip” viremia
0
11
10
Viral set-point:
102 -105 gEq/mL
2nd gen
3rd gen
16
20
22
30
40
50
60
70
80
90
100
Primary HIV-1 Infection
1000
800
+
CD4
Cells
600
Early Opportunistic Infections
Late Opportunistic Infections
400
200
0
1
Infection
2
3
4
5
6
7
8
9
Time in Years
10 11 12 13 14
Earlier HIV Diagnosis
Allows prompt entry into care
 Initiation of ART prior to CD4 decline
<200 improves mortality and morbidity
 Management of STIs and other illness
 Short-term behavioral changes can have a
large impact on HIV spread
 Improve natural history of disease with
treatment during acute HIV infection?

Public Health Benefit

Acute HIV is the most infectious period

HIV RNA levels in the genital tract
correspond to HIV RNA levels in the blood

Diagnosis is often missed even when
patients are symptomatic with acute HIV
infection
Plasma Viral Load and HIV
Transmission Risk
• Rakai (Uganda)
• 453 HIV-disc.
couples
• 11.6 % TR / year
% partners infected
30
20
10
0
<400
4003500
3500- 10'000- >50000
10'000 50'000
HIV-RNA load (cp/ml)
Quinn 2000, NEJM 342:921
Wawer, et al, JID 2005, 191:1403
Viral Loads at Initial Detection
Log HIV RNA cp/ml
Pilcher C et al. N Engl J Med 2005;352:1873-1883
10
9
8
7
6
5
4
3
2
1
0
Median Viral Loads
209,183
29,347
Established HIV+
(n=66)
Acute HIV+
(n=21)
HIV transmission prob. per male-female act:
fold-change relative to wk 16
(calculated after Chakraborty H, et al AIDS 2003)
Fold-change vs. wk 16
16
14
12
10
8
6
4
2
0
1
2
4
8
12
Weeks from Testing Positive for AHI
16
Risk of Transmission
5
HIV RNA
in Semen 4
(Log10
copies/ml)
3
Risk of Transmission
Reflects Genital Viral Burden
(1/301/200)
(1/1001/1000)
(1/1000 1/10,000)
(1/500 1/2000)
2
Acute
Asymptomatic
Infection Infection
HIV
AIDS
Progression
Further Evidence That Primary HIV
Infection Accounts for a Large
Proportion of HIV Transmission
Contribution of Primary HIV to
Ongoing HIV Transmission
Author (year)
Population
Method
Percentage New
Infections
Attributable to PHI
Swiss cohort pop. –
mostly MSM
Phylogenetic
analysis
30%
Sussex,UK cohort pop.
– mostly MSM
Phylogenetic
analysis
34%
Lab-based pop. in
Quebec with recently
acquired HIV (<6
months)- mostly MSM
Phylogenetic
analysis
49%
Yerly (2004)
Pao (2005)
Brenner
(2007)
Source: ISSTDR, 2007
Public Health Benefit

Identify HIV transmission networks

Allows real time prevention with index
case and partners

Awareness of HIV status has been
associated with decreased sexual risk
behaviors
Lessons for Public Health

Acute HIV infection may be unexpectedly
prevalent in common clinical scenarios

Immediate rather than deferred testing is
key
– HIV ELISA and HIV RNA

Sexual partners of acutely HIV infected
individuals are at a markedly increased
per-act risk of acquiring HIV
Lessons for Public Health

Linkage of acute HIV diagnosis with Emergent
ID Consultation is paramount
–
–
–
–

Interpretation and counseling on test results
Extensive counseling of newly diagnosed patient
Facilitate linkage to care and services
Consideration of ART for interested patients
Acutely infected individuals provide public
health officials with a unique opportunity to
understand complex sexual networks
Screening and Tracing Active
Transmission (STAT) Program
2003
Total Tests
(publicly-funded clinics)
2004
2005
2006
107,733 118,998 128,708 140,100
Antibody positive
581
552
571
592
Antibody negative,
RNA+ (acute)
22
21
21
15
November 1, 2002 – May 28, 2008
Number of True
RNA Positives
Number of
Community
Index Cases
(acute and recent)
TOTAL
2002
2003 2004 2005 2006 2007 2008
108
2
22 21 21 15 16 11
188
1
11 23 38 40 53 22
STAT Acutes by County (11/1/2002-2/1/2008)
H
H
Case Count
0
1
2
(Burke, Franklin, Pitt, Henderson, Onslow, Martin)
3
(Buncombe, New Hanover)
4
(Robeson)
8
H
Duke University Hospital
H
UNC
Hospitals
(Cumberland)
12 (Forsythe, Guilford)
15 (Wake)
15 (Mecklenburg)
0
25
50
100
150
Miles
200
Testing Site
November 2002- May 2005
Tests
HIV CTS
STD
FP
Prenatal/OB
Prison/Jail
Other
Ab+
18,299
400
117,804 526
47,476
28
47,598
39
7,158
57
37,073 320
AHI (%) % of AHI
12 (2.9)
27 (4.9)
-2 (4.9)
4 (6.6)
13(3.9)
21
48
-3
7
22
The STD/HIV Connection
• Susceptibility:
– Genital ulcers provide portal of HIV entry
– Non-ulcerative STDs increase target cells
– STD treatment has been shown to slow the spread of HIV infection
(individual & community)
• Infectiousness:
– Presence of another STD increases amount of HIV in genital secretions
– Treating STDs in PWHIV decreases
• the amount of HIV they shed
• how often they shed the virus
Potential impact of STI
co-infection on detection of AHI
HIV/STI
Co-Infection
Event
week 1
HIV RNA +
4th gen. EIA
3rd gen. EIA
week 2
week 3
week 4
GC
Trichomoniasis
Chlamydia
Syphilis
HSV
ARS Symptoms
McCoy 0-014
STI Co-infections
• 23 clients (30%) had a concurrent STI
Men
(n=13)
Women
(n=10)
STD Type
N (%)
Gonorrhea
9 (39)
7 (54)
2 (20)
Trichomoniasis
5 (22)
0 (0)
5 (50)
Syphilis
4 (17)
4 (31)
0 (0)
Herpes
3 (13)
2 (15)
1 (10)
Chlamydia
3 (13)
1 (8)
2 (20)
Bacterial vaginosis
3 (13)
- -
3 (30)
GUD, unspecified
1 (4)
1 (8)
0 (0)
Other reported STD-related sx
5 (7)
4 (7)
1 (6)
McCoy 0-014
STI Co-infections by
Race, Gender, and Risk Category
p = 0.03
25
STI Co-infection
No. of AHI cases
20
15
10
5
0
White
Non-White
MSM
MSM
McCoy 0-014
White
Non-White
MaleHetero
Hetero
Male
White
Non-White
Female
Female
Missed Opportunities in STD Clinics
• HIV testing not offered to all
• Risk factors for HIV either not obtained or not
recognized
• HIV testing not integrated into STD services
• Primary HIV Syndrome unrecognized by
patients and clinicians
• Diagnostic test for Acute HIV Infections is not
ordered
NC HIV Testing in STD Clinics
• HIV testing to be offered to all STD clients for each
new visit regardless of when last HIV test performed
• DHHS policy to offer opt-out HIV testing
• 2005 estimate ~52% of NC STD clinic clients tested
for HIV
• Wake County ( 2nd largest STD clinic in North
Carolina) with ~80-85% with universal offering of
HIV testing.
• Wake County HIV testing increased to ~90% with optout approach
Acute HIV and North Carolina
STAT
Duke-UNC Acute HIV Infection
Research Consortium
Research opportunities for patients with
Acute and Recent HIV Infection:
1) “Treatment of Acute HIV Infection with Once
Daily Atripla” (24 month treatment study
which supplies Atripla)
2) “Longitudinal Assessment of Acute/Recent
HIV Infection” (Adds to limited scientific
knowledge currently available regarding
acute/recent infection)
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
CHAVI Index Cases by County of Residence, 6/2007-2/2008
n=18
Forsythe
Guilford
Durham
2
Halifax
Wake
1
2
1
D
U
1
1
7
1
2
Randolph
Pitt
Key D
U
Martin
Duke University Hospital
UNC Hospital
Cumberland
0
25
50
100
150
Miles
200
CHAVI Partners By County of Residence, 6/2007-2/2008
n=58
Durham
Forsythe
Wake
Hertford
Granville
Guilford
Northampton
Pasquotank
1
1
1
1
2
3
U
1
1
1
1
D
1
17
1
9
Mecklenburg
Bertie
1
1
Lee
Harnett
Craven
Key
Martin
Scotland
D
Duke University Hospital
U
UNC Hospitals
Cumberland
Other Partner Locations
“NC”: 3
WA: 1
SC: 1
Abroad: 2
GA: 2
Unk: 6
0
25
50
100
150
Miles
200
Advatages to Dx and Care of AHI
1.An HIV diagnosis per se results in subsequent risk
reduction
2. Initiation of HAART to reduce plasma and hence genital
viral load thus reducing transmission potential
3. As we identify more undiagnosed HIV+ and more are
successfully placed on HAART, transmission will shift
even more to AHI
4. As frequency of HIV testing increases, we will idenitfy
more AHI
5.Opportunity for short term behavior change (period of high
infectivity of weeks)
Conclusion
•
•
•
•
Make HIV testing routine
Opt-out HIV Testing for all STD clients
Screen all STD clients for AHI
Include AHI in the Differential Dx of Acute
Viral Syndrome in all Sexually Active
Adults
Conclusion
• AHI is a true Public Health Emergency!
• AHI detection and case investigation puts
identification of HIV at leading edge of
transmission
• Opportunity for both early diagnosis and
prevention
• Report all AHI cases within 24 hrs
laboratory
Given this VL distribution:
Analytical vs. Clinical Sensitivity
LL, cp/ml Ab- HIV
N=58
1000
56
Se (Ab-)
Se (all)
96.5
All HIV
N=1437
1435
99.9
3000
54
93.1
1433
99.7
5000
52
89.6
1431
99.6
10000
49
84.5
1428
99.4
Ab only
0
0
1379
95.9
Requirement for Analytical Sensitivity is
Less Stringent than for VL Monitoring
• To be recommended as part of (all)
general HIV testing, a NAAT would likely
need ~95% detection at viral loads the
equivalent of 5,000 to 10,000 HIV RNA
copies per mL
• Better sensitivity required for effective
analysis of pooled specimens
Detection of Acute HIV
• Acute HIV infections (first 2-3 months) are
estimated to account for as much as half of all HIV
transmission (Wawer at al JID 2005)
• They represent 0-10% of detectable infections
presenting for HIV testing
• Real-time recognition of acute infections creates
opportunities for highly targeted treatment,
prevention and surveillance activities
Detection of Acute HIV
• “Detuned” assays can identify recent
seroconversion, but with a 1-2 month delay from
infection. These also do not identify additional
cases over routine antibody tests.
• Real-time diagnosis of acute HIV depends on the
identification of HIV antigens (e.g., p24) or nucleic
acids (NAAT) in the absence of HIV antibodies.
The Gold Standard for Acute Screening is
RNA Group Testing of Ab - Specimens
+
+
Ab
confirm
Ab screen
-
+
Established
HIV Positive
-
NAAT
screen
Possible Acute HIV
Pilcher, CD et al. JAMA 2002;288:216-221
HIV Negative
Testing to Identify Acute HIV
• NAAT is highly sensitive and with pooling, may be
made specific.
• However, even pooled NAAT may be inefficient in
high prevalence areas (>5%) and is technically
demanding.
• ‘Fourth generation’ HIV ELISAs detect both antigen
and antibody simultaneously
– Easy to perform
– Equipment available in most HIV laboratories
Window Periods for HIV Tests
Stekler J. et al CID 2007
Commercial Assays Comparative Timing of
Detection of Acute HIV Infection
Source HPA -UK
= combined antigen-antibody
= immunometric
= Class specific antibody capture
Ricardo da
Silva de Souza – August 2006
= antiglobulin
/ indirect
Reducing time to case identification
Summary:
Pooling vs. Individual NAAT
• Pooled screening (even with ‘minipools’) makes testing
possible by reducing costs and improving predictive
value
• More complex but more efficient for through put and
cost
• Single specimen NAAT screening should be reserved
for situations where the pre-test likelihood of acute HIV
infection is >/= 1% (e.g., suspected AHI, ?ED/urgent
care screening)
Opportunities
for
New Technologies and Approaches
• Need to reduce time to identification of AHI
• NC median time to identification is ~9D
• Fast Track can reduce time to 2-4 days
• Current POC HIV tests only test for Ab
• 4th generation EIA can reduce time to Dx and
reduce cost
• Strategy may need to combine individual NAAT or
discrepant POC 3rd generation EIA to identify AHI
Rapid Antibody Testing
The Good
• Makes testing feasible in non-traditional settings
– Highly effective for outreach situations (needle exchange, bathhouse testing,
“street-corner” outreach)
• Increases receipt of positive HIV test results
– Where HIV results notification (PCRS) not in place
• May increase requests for HIV testing
The Not So Good
• Confidentiality
• Cost 2-3x ELISA Ab tests
• May defer resource allocation/personal to HIV negatives
• May miss AHI
• Requires Confirmation
Alternative Approaches
• North Carolina AHI referral network
• Educate community providers about AHI
• Educate high risk community about AHI
• Linkage of ED testing to ID clinic and local health
departments…… strongly encourage partnerships .
EDs will test if burden for referral to care is met.
• Raise awareness of 3rd generation EIA +/ WB I as
possible AHI
Cost-effectiveness of the STAT Program:
Decision Tree Analysis
• The expected savings from averting new HIV cases
offset 22% of the testing costs
• Overall cost per QALY of $4,345
• Conclusion: the program appears to be well below the
cost effectiveness threshold of $50,000 which is often
used as an indicator of good public health investment
opportunities in the US.
• Still, cost a barrier for new programs
Targeting NAAT Screening by Site
• Over 2 years, at 135 public testing sites in NC, 325 acute and recent
infections were identified among 224,124 testing clients (66%
females, 4% MSM)
• Only 1/3 acute clients had HIV symptoms at testing
• There were no cases in 48 of 100 counties
Targeted Screening:
• If NAAT used only in HIV C&T, STD, prison, and field visit sites in
counties with  1 case, 95.4% of acute cases identified testing only
54.0% of the population with NAAT
• Testing only in STD clinics identified 40.1% of cases while testing
41.4% of the population.
Targeting is necessary; but be wary of
preconceptions
• It is possible to construct a targeting algorithm for NAAT testing based
on knowledge of local incidence, prevalence and individual risk factors
associated with having recent infection
• “Detuned” test results can be used to develop NAAT targeting criteria
• A priori assumptions about who to test with NAAT are likely to be
incorrect (i.e., limiting testing to only “high risk” clinics, or to
symptomatic clients would be counterproductive)
Opportunities for New Approaches
• Need to reduce time to identification of AHI
• NC median time to identification is ~9D
• Fast Track can reduce time to 2-4 days
• We are implementing Fast track to all STD clinics
based on symptoms and requiring STAT clinician
approval
Fast Track Targeted AHI Testing :
1.
Screen all clients for HIV Ab
2.
Target
Problem: Which symptoms (fever?)
What time period (2-4 wks)?
What duration ( >2 days)?
Symptoms at best will detect 40%
- Targeted testing
Risk based ( i.e. MSM, anal/vaginal sex in past 2 weeks,etc )
Symptoms based (Fever + for >2 days within past 4 weeks)
Site based ( prevalence 0.5% or type STD,CTS, etc.)
3.
Need for further research to define symptom screen and develop
predictive models for targeted AHI testing
Opportunities for New Technology
• Current POC HIV tests only test for Ab
• 4th generation EIA can reduce time to Dx and
reduce cost
• Plan to do real time side by side comparison of
NAAT pooling with 4th generation assay
• May need to combine individual NAAT or
discrepant POC 3rd generation EIA to identify AHI
Biology
Determining the Genetic Linkage of HIV-1
Subtype B Transmission Pairs: Analyses of
Viral env Sequences From Donor and
Recipient
Jeffrey A. Anderson, MD-PhD
University of North Carolina
Background
• A genetic bottleneck occurs during mucosal transmission,
resulting in a subset of viruses responsible for transmission of
HIV.
DONOR
RECIPIENT
Background
• Determining the genetic composition of the transmitted virus is
critical to developing insight into disease progression, HIV
pathogenesis, and candidate vaccines.
• Key questions:
– From the donor quasispecies, what are the properties of the specific
variant(s) being transmitted?
– Are genital tract secretions a separate compartment from blood plasma?
3 MSM Transmission pairs from CHAVI 001:
Donor vs. Recipient
Sampling Time
Weeks
Post-infection ELISA
# of env
amplicons
# of env
amplicons
WB
Stage
blood
semen
174 D1
9
11
+
+
+
+
Chronic
Chronic
20
22
0
32
150 R1
2
5
+
+
Fiebig 1/2
Fiebig 5/6
29
25
0
1
148 D2
22
+
+
Chronic
36
0
40 R2
2
4
+
NA
+
Fiebig 1/2
Fiebig 5/6
43
29
0
0
135 D3
9
11
+
+
+
+
Chronic
Chronic
14
22
0
36
81 R3
2
5
6-7
+
+
+
+
Fiebig 1/2
Fiebig 5/6
Fiebig 5/6
1
28
0
0
0
17
269
86
Experimental design
Identify patients with acute HIV-1 infection, and sexual partners through contact tracing
After informed consent, obtain blood plasma and semen/cervicovaginal lavage
Isolate HIV-1 viral RNA from blood/semen/CVL fluid
Generate a copy of the viral DNA and amplify by PCR
Direct DNA sequence analysis to determine characteristics of HIV
Chromatograms from a single
DNA sequence
Donor env blood plasma
populations are heterogeneous
D1
D2
D3
Recipient env blood plasma
populations are homogeneous
22 identical sequences
33 identical sequences
3
2
3
10
2
3
R1
R2
R3
Phylogenetic analysis of D1/R1
1.
Blood and semen populations are well-mixed
Phylogenetic analysis of D1/R1
*
*
*
*
1.
2.
Blood and semen populations are well-mixed
However, a subset of duplicated semen
amplicons suggests selective outgrowth
*
*
Phylogenetic analysis of D1/R1
*
*
*
*
1.
2.
3.
Blood and semen populations are well-mixed
However, a subset of duplicated semen
amplicons suggests selective outgrowth
No blood amplicons were duplicated
Unique Duplicate
*
*
Blood
42
0
Semen
21
11
P < 0.0001
Phylogenetic analysis of D1/R1
*
*
*
*
1.
2.
3.
Blood and semen populations are well-mixed
However, a subset of duplicated semen
amplicons suggests selective outgrowth
No blood amplicons were duplicated
Unique Duplicate
*
4.
*
Blood
42
0
Semen
21
11
P < 0.0001
R1 is clearly genetically linked to D1 semen
(99% nt identity), and did not arise from a
duplicated semen sequence
Summary
• Genetic linkage of 3 subtype B transmission pairs was confirmed
by SGA and DNA sequence analysis.
• All donor (D1-D3) populations had heterogeneous env populations,
although D1 had low heterogeneity.
• A single variant was transmitted to each recipient (R1-R3).
• Semen populations were well-dispersed among blood populations.
• Clusters of duplicated sequences in semen of D1 and D3 suggest
outgrowth of specific variants.
• These data suggest that semen sequences, in general, represent
sequences present in blood; however, semen populations can be
disrupted by selective outgrowth.
• Analyses of additional transmission pairs are ongoing and will lead
to a greater knowledge of:
– compartmentalization of viral sequences within semen vs. blood
– the specific viral variant(s) transmitted from donor to recipient
– viral sequences important for HIV-1 vaccine design
Acknowledgments
•
•
•
•
•
•
Ron Swanstrom and lab members
Beatrice Hahn
Brandon Keele
Jesus Salazar
Susan Fiscus and lab
Julie Nelson
•
•
•
•
•
Myron Cohen
Lihua Ping
Kristen Dang and Christina Burch
CHAVI 001 Clinical Core
NC Dept. of Health and Human
Services
• DIS Training Program and Officers
North Carolina may have lower attribution of
AHI on Transmission
27 individuals (12%) were in closely related (<1% divergence) clusters
Still, a 4-6 week period accounts for 10-15% of Transmission
Frost s et al. CROI 2007
Network Analysis: Project
SNAP
• Acutely/Recently infected MSM and high
risk HIV-negative men recruited for indepth ACASI interview and qualitative
interview
• Respondent driven sampling to derive
sexual and social network (2 generations)
• Better understanding of network
formation, HIV/STD transmission, sex
partner selection and Internet use among
NC MSM
If you have an STD, Get Tested for HIV.
Early Detection is Best!
Learn to Recognize IT. Tell a Friend.
Acute HIV is Easily Misdiagnosed.
IT CAN BE MISTAKEN FOR COMMON ILLNESSES
Common Symptoms of Acute HIV:
High Fever
Rash
Fatigue
Swollen Glands
Sore Throat
Nausea/Vomiting
Night Sweats
Symptoms usually appear about
2 weeks after exposure
What Puts You At Risk?
Unprotected Sex
Sharing Needles
The Acute HIV Program 919-966-8533
If you suspect you may have Acute HIV, get tested at your Local Health Department or at your doctor’s office.
FREE Screening for acute HIV is done on all HIV tests done through the NC Health Departments
Screening for acute HIV can be done at your doctor’s office – ask for an HIV RNA test in addition to the standard HIV antibody test.
Conclusions
• HIV antibody screening is a necessary first step in targeting
prevention activities
• Assays able to detect antibody-negative infections should be
incorporated into current HIV screening/testing
• NAAT may not be reasonable for low-risk ‘routine’ screening in
well patients and low prevalence populations
• Models for establishing criteria for targeting NAAT are need
• 4th generation EIAs may present an alternative for diagnosis of
acute HIV infection and merit urgent large-scale clinical
evaluations
Window Periods for HIV Tests
Stekler J. et al CID 2007
Tests to DX HIV
•
•
•
•
Antibody ELISA $47
Western Blot
$212
p24 Antigen
$38
Individual HIV RNA PCR
$218