Clinical and public health implications of acute and early HIV detection and treatment: a scoping review

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.

Home-based HIV testing: Using different strategies among transgender women in Argentina

“…Although the inclusion of Ag/Ab assays in the algorithm allows reduction of the diagnostic window, they fail to identify participants in Fiebig stage I, a situation where early treatment could potentially provide additional benefits in regard to the reservoir's size [20,21]. The above mentioned molecular techniques are usually expensive, so, alternative approaches such as pooling are proposed as a way to increase its cost-effectiveness [28]. In our study, the estimated that the HIV prevalence was 19.6% which is lower than the previously reported 34% in the country for TGW [2,3,1].…”

A public health approach to addressing and preventing misdiagnosis in the scale‐up of HIV rapid testing programmes

“…False negative diagnoses could also lead to further HIV transmission by providing a false sense of security. As many as 70% of new HIV transmissions may be attributable to undiagnosed HIV infection [35], with early/acute infection contributing to 10–50% of new HIV transmissions [36]. Furthermore, misdiagnoses may also undermine public trust in test results as well as trust in health services.…”

Acute HIV Infection in Youth: Protocol for the Adolescent Trials Network 147 (ATN147) Comprehensive Adolescent Research and Engagement Studies (CARES) Study (Preprint)

“…In 2015, among youth ages [13][14][15][16][17][18][19][20][21][22][23][24] diagnosed in the United States, 81% were gay and bisexual males. Out of newly diagnosed male youth, 55% were black and 24% were Latino [33].…”

“…Studies have shown that early detection and treatment of HIV infection has many clinical and public health benefits [14]. Studies of perinatally infected infants have been able to provide important insights about the pathogenesis of acute HIV infection and the need for prompt initiation of antiretroviral therapy.…”