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. 2017 Jun 28;20(1):21579.
doi: 10.7448/IAS.20.1.21579.

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

Sarah E Rutstein  1   2 , Jintanat Ananworanich  3   4 , Sarah Fidler  5 , Cheryl Johnson  6   7 , Eduard J Sanders  8   9   10 , Omar Sued  11 , Asier Saez-Cirion  12 , Christopher D Pilcher  13 , Christophe Fraser  14 , Myron S Cohen  2   15 , Marco Vitoria  6 , Meg Doherty  6 , Joseph D Tucker  2   15   16
Affiliations

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

Sarah E Rutstein et al. J Int AIDS Soc. .

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.

Keywords: acute HIV infection; antiretroviral therapy; diagnostics; early HIV; guidelines; low- and middle-income countries; primary HIV.

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Conflict of interest statement

MSC receives advisory board honorariums and/or travel reimbursement from Janssen Global Services, Roche Molecular Systems, and Merck Research outside the submitted manuscript. AS-C has received advisory board honorarium and/or speaker honorarium from ViiV healthcare, Gilead, Merck Sharp and Dohme and BMS and research grant from Merck Sharp and Dohme outside the submitted manuscript.

Figures

Figure 1.
Figure 1.
Algorithm for targeting acute HIV screening resources using clinical risk score.
Figure 2.
Figure 2.
Projected viral load, CD4 cell count, reservoir seeding, and symptom duration comparing untreated vs. treated acute HIV infection.
See this image and copyright information in PMC

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