1. Acute HIV JoAnn Kuruc, MSN, RN University 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. HIV viremia during early infection HIV RNA (plasma) HIV Antibody 11 0102030405060708090100 HIV p24 Ag 1622 Ramp-up viremia 1 st gen 2 nd gen 3 rd gen p24 Ag EIA - Peak viremia: 10 6 -10 8 gEq/mL Viral set-point: 10 2 - 10 5 gEq/mL 4 th gen

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. 9 th 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: NC Fiscus et al. 2004 0 1 2 3 4 5 6 7 8 9 10 Established HIV+ (n=66) median 209,183 29,347 Acutely HIV + (n=21)

7. NC Approach to AHI Detection STAT 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 Days from Unique Sexual Exposure to Onset of Symptoms 282114 7 Frequency 10 8 6 4 2 0 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. 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) SymptomsN(%) Fever28(62.2) Night sweats18(40.0) Fatigue18(40.0) Body aches16(35.6) Nausea16(35.6) Headache15(33.3) Diarrhea15(33.3) Sore throat14(31.1) Loss of appetite11(24.4) Cough8(17.8) Rash7(15.6) Other17(37.8)

11. Diagnostic Testing for PHI 1 mil 100,000 10,000 1,000 100 10 + _ HIV RNA HIV-1 Antibodies Exposure 020304050 Symptoms Days HIV RNA Ab

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

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: 1.HIV risk exposure * 2.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