Transcript Slide

STD Co-infection Among
Acute HIV Patients in Los
Angeles County
Michael W. Chien, Ali Stirland,
Apurva Uniyal, Peter R. Kerndt
STD Program, Los Angeles County Dept. of Public Health
[email protected]
HIV Viremia and Antibody
Response
HIV RNA (plasma)
HIV Antibody
11
0
10
22
20
30
Acute HIV Infection
(Window Period)
40
50
60
Days
70
80
90
100
Detection of HIV
Symptoms
p24 Antigen
HIV RNA
HIV EIA*
Western blot
0
1
2
3
4
5
6
7
8
9
10
Weeks Since Infection
After Fiebig et al, AIDS 2003;
17(13):1871-9
*3rd generation, IgG & IgM
*2nd generation EIA IgG
*1st generation EIA IgG
Pooled NAAT Screening for Early
HIV Infection
A B C D E F G H I J
100
Individual
specimens
(HIV antibody negative)
10 Pools of 10
A B C D E F G H I J
1 Screening
Pool
HIV Testing
Vironostika® HIV1
antibody test
EIA non-reactive
Roche Amplicor® Monitor HIV-1
or GenProbe Aptima assay
Pooled NAAT
Neg.
Pos.
HIV
Negative
Presumptive
AHI
Objective
To examine the prevalence of STDs
among a cohort of acutely infected HIV
patients in Los Angeles County
Background
STDs in HIV-positive individuals increases the risk of HIV transmission
HIV RNA in Semen
(Log10 copies/ml)
•
Cohen, Pilcher, UNC Center for AIDS Research
Background II
•In acute HIV infection, individuals are highly infectious
•Studies have suggested over 40% of new infections may be caused
by persons with primary HIV infection
•Treatment of STD in HIV co-infected may reduce HIV
transmission
•After people become aware they are HIV-positive, the
prevalence of high-risk sexual behavior is reduced
substantially – reduced number of partners and sero-sorting
Study Population
• 13 Public Health Department STD clinics
• Mobile Testing Unit (MTU)
• 2 community STD clinics, majority of
clients are MSM (sites A&B)
• Jail Unit for MSM and transgenders
Data Collection
• STD/HIV Intake form
• Public Health Laboratory testing database
• STD surveillance database
Results
Pooled Testing - Acute HIV Detection Studies
Los Angeles, 02/06 – 01/08
(%)
NAAT pos. % increased
EIA neg. (n) HIV infection
detected (%)
Site
EIA +/Total EIA
Site A
Site B
Jail
STD Clinics
MTU
---------Total
140 / 7,830
1.8%
28
61 / 1,793
3.4%
4
172 / 1,595 10.8%
0
236 / 27,861 0.8%
9
31 / 2,708
1.1% 1 false+
---------------------- -------640 / 41,787
1.5%
41
20%
7%
0%
4%
0%
-----6%
Pooled Testing - Acute HIV Detection Studies
Los Angeles, 02/06– 01/08
HIV NAAT testing led to:
• 6% increase in HIV detection
• 20% increase (Site A)
• 7% increase (Site B)
• 1 in 1000
• 1 in 275 (Site A)
• 1 in 433 (Site B)
Patients with Acute HIV Infection (AHI)
VL (cp/ml) at time of initial HIV-1 Ab negative test:
•
•
•
•
•
6 <100,000 (lowest 1,502;1,827 to >500,000 in 9 days)
10
>100,000
19
>500,000
6 w/ invalid quantitative assay
1 <75 (false positive)
25/41 (61%) patients presented with symptoms
•
•
•
•
10 AHI symptoms only (flu-like &/or rash &/or fever)
4 AHI and STD symptoms
10 STD symptoms
1 cervical lymphadenopathy
N=41
Gender of Cases and Sex Partners
Gender of AHI cases
• 39 male
• 1 transgender M to F
• 1 female
male
28
female
11
2
Gender of sex partner
• 27 (66%) MSM only
• 11 (27%) MSMW/W
• 2 (5%) MSW only
• 1 (2%) WSM
N=41
Number of Sex Partners
3 months prior to diagnosis
Number of AHI Cases
12
10
10
10
8
7
6
4
4
2
2
2
0
1
2
3
4
Number of Sex Partners
N=41, range=1 to 72 partners
*6 with no information on gender of sex partner
5
≥6
Anal Intercourse & Condom Use
3 months prior to diagnosis
• 38 (93%) reported anal intercourse
– 29 insertive & receptive (incl. 2 who reported vaginal sex)
– 5 receptive only (incl. 1 who reported vaginal sex)
– 4 insertive only
N=41
• 11 (30%) never used condoms for anal
intercourse
5 (13%) always use condoms
– 21 (57%) sometimes / mostly
–
N=37
Sex Partner Risks
• 30 (73%) reported having ever met
anonymous sex partners:
– 14 internet
– 9 bar/clubs
– 6 bathhouse/sex club
•
5 (12%) reported sex with IDU in the year
prior to diagnosis
• 8 (20%) reported sex with HIV positive
partner(s) in the year prior to diagnosis
N=41
Drug Use
1 year prior to diagnosis
• 20 (56%) used one or more drugs
• 15 (41%) methamphetamines
–
9 used meth with at least 1 other drug
(ecstasy, nitrates, viagra, ketamine, poppers)
• 5 viagra
–
All used in combination with at least one other drug
(meth, ecstasy, nitrates, ketamine, cocaine, marijuana)
• 4 marijuana
• 3 alcohol only
• 3 nitrates only
N=41
AHI and STD Co-infection
• 39 / 41 AHI were tested for at least one STD
– 37 Males (24 MSM, 11 MSMW, 2 MSW)
– 39 tested for CT/GC
– 37 tested for syphilis
• 18/39 (46%) co-infected on lab tests
– 4/37 (11%) early syphilis
– 7/39 (18%) CT
– 14/39 (36%) GC
• 6 co-infected with more than 1 STD
– 3 CT/GC
– 2 early syphilis/GC
– 1 early syphilis/CT/GC
STD Prevalence
40%
36%
35%
30%
25%
AHI
20%
MSM*
18%
STD Clinics**
14%
15%
12%
11%
10%
5%
8%
7%
2%
1%
0%
Early Syphilis
Chlamydia
*MSM visiting 12 LAC STD Clinics in 2006
**All visits to 12 LAC STD Clinics in 2006
Gonorrhea
Conclusion
• STD co-infection in the acute stage of HIV infection is
common.
• Increased likelihood of AHI among MSMs w/
– Diagnosis of an STD
– Recent high risk sexual exposures (eg. anonymous
parters, sex with IDU, sex with HIV positive partner)
– Other risk history, including methamphetamine use,
viagra use and meeting of partners from the internet
– Individuals with acute HIV and an STD co-infection
provide a target for intervention to reduce HIV
transmission.
Recommendations
• Any MSM presenting for evaluation of an
STD with a negative HIV Ab. test should
be tested for acute HIV infection.
• Any individuals with acute HIV should be
tested for other STD’s.
Acknowledgements
Los Angeles County
Department Of Public Health
Sexually Transmitted Disease
Program
Staeci Morita
Lashawnda Royal
KaiJen Chen
Public Health Laboratory
Lee Borenstein
Debbie Emlein
Los Angeles Gay and Lesbian
Center (LAGLC)
Robert Bolan
Quentin O’Brien
AIDS Healthcare Foundation
Whitney Engeran
New York State Diagnostic HIV
Laboratory
Judith Wethers
Monica Parker
Tim Sullivan
Kathy Gumbel
Centers for Disease Control
and Prevention
Pragna Patel (Project Officer)