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Provider-Initiated Testing Turns Up Large Portion of Acute HIV Cases in MSM
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7th IAS Conference on HIV Pathogenesis, Treatment and Prevention, June 30-July 3, 2013, Kuala Lumpur
Mark Mascolini
Healthcare provider-initiated HIV tests accounted for a big proportion of acute HIV diagnoses among men who have sex with men (MSM) in France, more than doubling chances of HIV diagnosis during acute infection [1]. Only 21% of recently diagnosed MSM in this 530-man study had primary HIV infection.
Research indicates that 19% of HIV-positive people in France do not know they carry the virus. Rates are similar in other high-income countries, including the United States. In France health authorities estimate that people unaware of their HIV infection account for 43% of HIV transmissions. Diagnosing primary HIV infection could limit transmission by quickly curbing the high viral load of acute infection through prompt antiretroviral therapy.
ANRS Opportunity Study investigators set out to define differences between MSM diagnosed with acute HIV and those diagnosed during chronic infection. This cross-sectional study involved men attending 69 HIV care centers across France between June 2009 and October 2010. All study participants were at least 18 years old, lived in France for at least 1 year, and had newly diagnosed HIV infection. They answered a questionnaire about HIV testing and relevant behaviors.
The Opportunity Study cohort includes 1008 newly diagnosed people, 530 of them (53%) MSM. Of those 530 men, 111 (21%) had acute HIV infection, defined as (1) an incomplete Western blot, or (2) gp24 antigen or RNA positive while ELISA negative, or (3) a last negative HIV test within 3 months.
The researchers compared these 111 men with 297 men diagnosed with chronic HIV infection. The groups were similar in age, but the acutely infected men had more education (2 years of postgraduate education, 52% versus 48%; more than 2 years of postgraduate education, 25% versus 18%). Compared with chronically infected men, a higher proportion of acutely infected men lived alone rather than in a couple (77% versus 68%, univariate odds ratio [OR] 1.62, 95% confidence interval [CI] 0.96 to 2.72, P = 0.06). A higher proportion of acutely infected men had 15 to 29 sex partners (versus fewer) in the past 3 years (19% versus 16%) or 30 or more sex partners (29% versus 22%).
Among men who sought HIV testing on their own, a higher proportion had chronic infection than had acute infection. In contrast, among men tested at a healthcare provider's prompting, 42% had acute infection and 29% chronic infection (for provider-initiated versus MSM-initiated testing, univariate OR 1.69, 95% CI 1.07 to 2.68, P = 0.008 favoring acute infection).
The investigators created four categories to describe each man's HIV-testing history:
-- Tested never or rarely: 0 lifetime tests or testing more than 3 years ago
-- Tested occasionally: more than 1 test within 1 to 3 years
-- Tested regularly: 1 to 3 tests within 1 year
-- Tested very frequently: more than 3 tests within 1 year
Compared with men tested never or rarely, those tested regularly had almost quadrupled odds of acute HIV infection in univariate analysis (OR 3.73, 95% CI 1.78 to 7.82) and those tested very frequently had almost 6 times higher odds (OR 5.91, 95% CI 3.01 to 11.56) (P < 0.0001).
Multivariate analysis determined that provider-initiated HIV testing and regular or very frequent HIV testing independently raised odds of acute HIV infection:
-- Provider- vs MSM-initiated: adjusted OR (aOR) 2.50, 95% CI 1.48 to 4.21, P = 0.0007
-- Regular testing vs never or rarely tested: aOR 5.02, 95% CI 2.27 to 11.06, P < 0.0001
-- Very frequent testing vs never or rarely tested: aOR 8.34, 95% CI 4.00 to 17.37, P < 0.0001
The ANRS team believes these findings have implications for providers and for HIV testing policy. They proposed that healthcare providers need training to (1) recognize acute HIV infection symptoms, (2) systematically offer testing to HIV-exposed people, and (3) identify acute infection by using HIV RNA PCR rather than relying on ELISA for HIV testing. The investigators maintained that different HIV testing strategies should be promoted: (1) more provider-based HIV testing, (2) community-based voluntary counseling and testing, and (3) rapid testing outreach at sex venues.
Link to webcast
http://pag.ias2013.org/flash.aspx?pid=37
Reference
1. Champenois K, Le Vu S, Cuzin L, Semaille C, Yazdanpanah Y. Factors associated with acute HIV infection diagnosis in MSM, ANRS-Opportunity study. 7th IAS Conference on HIV Pathogenesis, Treatment and Prevention, June 30-July 3, 2013, Kuala Lumpur. Abstract MOAC0103. http://pag.ias2013.org/session.aspx?s=6
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