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

Sarah Rutstein (1) , Jintanat Ananworanich (2, 3) , Sarah Fidler (4) , Cheryl Johnson (5, 6) , Eduard Sanders (7, 8, 9) , Omar Sued (10) , Asier Sáez-Cirión (11) , Christopher Pilcher (12) , Christophe Fraser (9) , Myron Cohen (1) , Marco Vitoria (5) , Meg Doherty (5) , Joseph Tucker (1)

1 UNC - University of North Carolina [Chapel Hill]
2 Walter Reed Army Institute of Research
3 HJM - Henry M. Jackson Foundation for the Advancement of Military Medicine
4 Imperial College London
5 OMS / WHO - Organisation Mondiale de la Santé / World Health Organization Office
6 LSHTM - London School of Hygiene and Tropical Medicine
7 UvA - University of Amsterdam [Amsterdam] = Universiteit van Amsterdam
8 KEMRI - Kenya Medical Research Institute
9 Big Data Institute - Nuffield Department of Medicine [Oxford, UK]
10 Fundación Huésped [Buenos Aires]
11 HIV, Inflammation et persistance - HIV, Inflammation and Persistence
12 UC San Francisco - University of California [San Francisco]

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.

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

Domaines: Sciences du Vivant [q-bio]; Médecine humaine et pathologie; Maladies infectieuses

Sarah Rutstein, Jintanat Ananworanich, Sarah Fidler, Cheryl Johnson, Eduard Sanders, et al.. Clinical and public health implications of acute and early HIV detection and treatment: a scoping review. Journal of the International AIDS Society, 2017, 20 (1), pp.21579. ⟨10.7448/IAS.20.1.21579⟩. ⟨pasteur-02549964⟩