Predicting, Diagnosing, and Treating Acute and Early HIV Infection in a Public Sector Facility in Eswatini

Abstract

Background:The lack of acute and early HIV infection (AEHI) diagnosis and care contributes to high HIV incidence in resourcelimited settings. We aimed to assess the yield of AEHI, predict and diagnose AEHI, and describe AEHI care outcomes in a public sector setting in Eswatini.Setting: This study was conducted in Nhlangano outpatient department from March 2019 to March 2020.Methods: Adults at risk of AEHI underwent diagnostic testing for AEHI with the quantitative Xpert HIV-1 viral load (VL) assay. AEHI was defined as the detection of HIV-1 VL on Xpert and either an HIV-seronegative or HIV-serodiscordant third-generation antibody-based rapid diagnostic test (RDT) result. First, the crosssectional analysis obtained the yield of AEHI and established a predictor risk score for the prediction of AEHI using Lasso logistic regression. Second, diagnostic accuracy statistics described the ability of the fourth-generation antibody/p24 antigen-based Alere HIV-Combo RDT to diagnose AEHI (vs Xpert VL testing). Third, we described acute HIV infection care outcomes of AEHI-positive patients using survival analysis.Results: Of 795 HIV-seronegative/HIV-serodiscordant outpatients recruited, 30 (3.8%, 95% confidence interval: 2.6% to 5.3%) had AEHI. The predictor risk score contained several factors (HIVserodiscordant RDT, women, feeling at risk of HIV, swollen glands, and fatigue) and had sensitivity and specificity of 83.3% and 65.8%, respectively, to predict AEHI. The HIV-Combo RDT had sensitivity and specificity of 86.2% and 99.9%, respectively, to diagnose AEHI. Of 30 AEHI-positive patients, the 1-month cumulative treatment initiation was 74% (95% confidence interval: 57% to 88%), and the 3-month viral suppression (,1000 copies/mL) was 87% (67% to 98%).Conclusion: AEHI diagnosis and care seem possible in resourcelimited settings.

Laboratory-based evaluation of the 4th-generation AlereTM HIV Combo rapid point-of-care test

“…Nevertheless, the low sensitivity of the HIV antigen-detection component of the 4 th -generation Alere TM HIV Combo RDT was further confirmed in the testing of three commercial HIV-1 seroconversion panels. Other studies evaluating the 4 th -generation Alere TM HIV Combo RDT have reported sensitivities ranging from around 0.94% to 95% in the detection of HIV acute infections [11,22,24,[39][40][41][42][43][44].…”

Modeling the Impact of HIV-1 Nucleic Acid Testing Among Symptomatic Adult Outpatients in Kenya

“…In addition, a 2021 study conducted in Eswatini evaluating the use of a predictors risk score and viral load testing to identify acute and early HIV concluded that such an approach to diagnosis and care seems possible in resource-limited settings. 48 Their findings suggest that the TMP intervention is potentially feasible and impactful. Missing HIV diagnoses when patients are most infectious is no longer acceptable if we truly wish to end the HIV epidemic.…”

Brief Report: Blood and Genital Fluid Viral Load Trajectories Among Treated and Untreated Persons With Acute HIV Infection in Malawi

“…To realize the public health benefits of identifying and treating persons with AHI, early ART must effectively and efficiently reduce blood and genital tract VLs. Rapid reduction of blood VLs after ART initiation during AHI have been reported among men and women in Eswatini (median days to <40 copies/mL: 56), 7 South African women (median days to <20 copies/mL: 16), 6 and Thai men who have sex with men (MSM) (median days to <50 copies/mL: 82). 16 In the United States, the median time to viral suppression (<200 copies/mL) was 131 days after AHI diagnosis, largely reflecting delays in linkage to care.…”

“…been reported among men and women in Eswatini (median days to ,40 copies/mL: 56), 7 South African women (median days to ,20 copies/mL: 16), 6 and Thai men who have sex with men (MSM) (median days to ,50 copies/mL: 82). 16 In the United States, the median time to viral suppression (,200 copies/mL) was 131 days after AHI diagnosis, largely reflecting delays in linkage to care.…”

“…1,2 Despite the temporal brevity of acute HIV infection (AHI), unchecked viral replication and peak viremia 2,3 coupled with frequent missed diagnosis because of the absence of HIV-specific antibodies, AHI plays a disproportionate role in transmissions compared with chronic infection. [1][2][3][4][5] Immediate ART for persons with AHI rapidly reduces viremia, [5][6][7] and measuring blood viral load (VL) remains the primary clinical biomarker of infectiousness.…”