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More Acute HIV Diagnoses, Shorter Time to Undetectable HIV, in Amsterdam MSM Program
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10th IAS Conference on HIV Science (IAS 2019), July 21-24, 2019, Mexico City
Mark Mascolini
Targeted screening for HIV yielded a higher acute HIV diagnosis rate than routine screening in Amsterdam men who have sex with men (MSM) [1]. A "rapid trajectory" program plus changes in HIV treatment guidelines greatly shortened the time between HIV diagnosis and viral suppression.
Research and early clinical experience suggest that faster diagnosis and treatment of HIV infection lower the size of an infected person's HIV reservoir [2], offer clinical benefits to treated individuals, and stop onward transmission of HIV. Aiming to attain these goals, San Francisco clinicians launched the Getting to Zero campaign [3,4]. Similarly, Amsterdam health workers devised a "rapid diagnostic and referral trajectory" for MSM at a sexually transmitted infection (STI) clinic, aiming to boost the number of acute HIV diagnoses and start antiretroviral therapy [ART] within 24 hours of diagnosis [1].
The Amsterdam analysis compared MSM in the rapid trajectory to those receiving routine diagnostics and care with endpoints of acute HIV diagnoses and time from diagnosis to intake at an HIV treatment center and viral suppression. The trajectory program relies on a mass media campaign to raise acute HIV awareness among MSM, help them recognize the symptoms, and encourage immediate treatment. Health workers use the Amsterdam Score [5] to assist screening for acute HIV in men attending the STI clinic and use a point-of-care viral load test to identify infected men. Those with HIV are immediately referred for treatment and encouraged to start ART promptly.
The analysis involved 19,728 MSM with 63,278 HIV testing visits from 2008 through 2017. During that period, 1013 men got a new HIV diagnosis, including 20 with acute HIV (Fiebig stage I-II), 269 with recent HIV (Fiebig stage III-V), and 724 with chronic HIV (Fiebig stage VI). For those three groups, median days since last STI clinic visit were 84, 148, and 282.
HIV positivity rate stood at 7.6% among MSM in the rapid diagnostic and referral trajectory and at 0.7% among those in routine care. Acute HIV positivity rates were 4.0% for men in the trajectory and 0.03% for men in routine care. The acute HIV diagnosis rate stood at 0% in 2008, rose to 4.6% in 2014 and 4.2% in 2015-2017, then jumped to 52.6% in 2017 with the rapid trajectory program.
Median viral load of diagnosed men at clinic intake was 6.5 log10 copies/mL (about 3.2 million copies/mL) for acute HIV (Fiebig I-II), 4.9 log10 copies/mL (about 80,000 copies/mL) for recent HIV (Fiebig III-V), and 4.5 log10 copies/mL (about 32,000 copies/mL) for chronic HIV (Fiebig VI). Respective median CD4 counts at clinic intake were 440, 520, and 460.
Median days from HIV diagnosis to HIV clinic intake stood at 14 in 2008. That number fell to 13 days in 2012, 9 in 2015-2017, and 1 in 2017 with the rapid trajectory. Median days from diagnosis to viral suppression plunged from 569 in 2008, to 228 in 2012, to 95 in 2015-2017, and to 55 in 2017.
The researchers concluded that targeted HIV screening resulted in a higher proportion of acute HIV diagnoses among MSM at an Amsterdam STI clinic. The rapid acute HIV trajectory, plus changes in treatment guidelines, sliced the time between HIV diagnosis and viral suppression. Fast diagnosis and treatment meant men spent only about 8 weeks with a detectable viral load after HIV diagnosis. And in 2017 more than half of these MSM got diagnosed with acute HIV.
References
1. Dijkstra M, van Rooijen MS, Hillebregt MM, et al. Targeted screening and immediate start of treatment for acute HIV infection decreases time between HIV diagnosis and viral suppression among MSM at a sexual health clinic in Amsterdam. 10th IAS Conference on HIV Science (IAS 2019), July 21-24, 2019, Mexico City. Abstract WEAB0101.
2. Lee SA, Deeks SG. The benefits of early antiretroviral therapy for HIV infection: how early is early enough? EBioMedicine. 2016;11:7-8.
3. Getting to Zero. San Francisco. http://www.gettingtozerosf.org/
4. Scheer S, Hsu L, Schwarcz S, Pipkin S, Havlir D, Buchbinder S, Hessol NA. Trends in the San Francisco human immunodeficiency virus epidemic in the "getting to zero" era. Clin Infect Dis. 2018;66:1027-1034.
5. Dijkstra M, de Bree GJ, Stolte IG, et al. Development and validation of a risk score to assist screening for acute HIV-1 infection among men who have sex with men. BMC Infect Dis. 2017;17:425.
https://bmcinfectdis.biomedcentral.com/articles/10.1186/s12879-017-2508-4
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