Prevention during Acute HIV Infection (AHI)

Date of Report: 01/2006
Source: New York/New Jersey AETC

Prevention of HIV transmission is of paramount importance. Historically, HIV prevention efforts have focused on HIV-uninfected subjects, whereas prevention directed at infected subjects has gained attention only recently. In 2003, the CDC, HRSA, NIH, and the HIV Medicine Association published guidelines for incorporating HIV prevention into the medical care of persons living with HIV. As important as these recommendations were, they did not address the public health importance of identifying persons in acute HIV infection (AHI).

AHI describes roughly the first three weeks following infection. At the peak of AHI, persons can be up to 1,000 times more likely to transmit HIV than those who have been infected six months or longer. Because HIV antibody tests only become detectable four?six weeks into the infection, accurate diagnosis requires the use of HIV viral load testing, which can detect the HIV virus as early as five days after infection. And therein lies the problem?few healthcare providers are diagnosing AHI. In fact, worldwide, only about one in 60,000 persons is diagnosed in the AHI phase of infection. One possible explanation for this nation's unchanging HIV transmission rate of 40,000 per year may be that the most sexually active, most highly infectious people are routinely misdiagnosed as uninfected with HIV. Identifying and intervening with such individuals would have enormous public health benefits.

With this in mind, Saint Vincent's Catholic Medical Center, a local performance site (LPS) of the New York/New Jersey AETC (NY/NJ AETC), established a training curriculum on AHI. The curriculum consists of two Level 1 training modules. The first module reviews how to identify and diagnose AHI. Included in this module is a 12-minute instructional DVD that describes AHI (available to view or download at http://www.nynjaetc.org/clinPop6.htm ). The second module reviews prevention counseling techniques after persons with AHI have been identified and how to best streamline those recently diagnosed into appropriate HIV care settings. Before instituting these trainings, the NY/NJ AETC staff met with the Medical Director of the training site to identify key personnel to be trained and to identify barriers to testing.

The first training took place in the Emergency Department (ED) at Saint Vincent's Hospital. Eight ED physicians, four RNs and three administrators attended the CME-approved training and were encouraged to play the DVD on a loop in the ED waiting room. Approximately one month after training, one of the ED physicians identified a young man in AHI. One of the patient's sexual partners with a history suggestive of recent AHI was also identified and referred for care. Both patients were counseled on the highly infectious stage of their HIV infection and received prevention counseling. Due to the importance of these case findings, the New York City Department of Health issued a health alert on April 29, 2005, urging all providers to consider the diagnosis of AHI in patients with risk factors for HIV.

Undiagnosed AHI is a public health concern because persons who are not aware of their HIV status but who have high viral loads may continue to practice unsafe sex. Front line ED healthcare staff and community health centers that see at-risk clients should be educated on how to identify, diagnose and counsel persons in AHI.

For additional information on this AHI training curriculum, please visit the New York/New Jersey AETC website at http://www.nynjaetc.org or call (212) 305-8291.