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Abstract & Commentary
By Dean L. Winslow, MD, FACP, FIDSA
Clinical Professor of Medicine and Pediatrics Division of Infectious Diseases and Geographic Medicine, Stanford University School of Medicine, Associate Editor, Infectious Disease Alert
Dr. Winslow is a consultant for Siemens Diagnostic.
SYNOPSIS: Among 3602 young adults from coastal Kenya, the overall prevalence of HIV-1 infection was 3.9%. Of 241 patients presenting with fever, 4 patients (1.7%) had acute HIV infection (AHI). 1 of 265 (0.4%) of non-febrile patients had AHI. Malaria was confirmed by PCR in 4 (1.7%) of the febrile patients.
SOURCE: Sanders EJ, et al. Acute HIV-1 infection is as common as malaria in young febrile adults seeking care in coastal Kenya. AIDS 2014;28:357-63.
Between February and July 2013, 3602 young adults were screened for this study (out of 8013 young adults seeking care). Overall 24.9% of patients met criteria for AHI risk. 3.9% of these patients were found to have previously undiagnosed HIV infection using a combination antibody and p24 antigen assay. (Patients with "prevalent" HIV infection had HIV antibodies present on the initial test. Patients with AHI had initially negative or positive p24 antigen with negative antibodies and were subsequently found to seroconvert 2-4 weeks following enrollment.) Patients with prevalent HIV infection were more likely to meet AHI risk criteria than seronegative patients (7.6% vs. 2.6%). Patients with fever were more likely to be HIV-infected than those without fever (9.1% vs. 3.3%). Of the 897 patients meeting AHI risk criteria, 375 did not enroll in the study but were more likely to be found to be HIV-infected than patients who enrolled (18.1% vs. 3.1%). Testing and counseling identified 139 patients who were found to have previously-undiagnosed prevalent HIV infection. Of the 506 HIV seronegative or serodiscordant patients enrolled (including 241 with documented fever), AHI was diagnosed in 5. AHI prevalence was 1.7% among patients with fever vs. 0.4% among patients without fever. All 5 patients (4 women and 1 man) had positive p24 antigen and negative rapid HIV-1 antibody tests at initial screening. 4/241 (1.7%) febrile HIV-1 seronegative patients had malaria confirmed by PCR and none were found to have AHI.
This study rather alarmingly shows that AHI has become as common as malaria as a cause of fever in young adults in Coastal Kenya. While great gains have been made in dissemination of antiretroviral therapy in Africa, transmission of HIV continues at a high rate. Both in the developed world and in the developing world, much HIV transmission is thought to be driven by patients with either early asymptomatic HIV infection or even acute HIV infection. Patients with AHI may be particularly efficient at transmitting HIV to others due to the very high viral loads they typically have (often running in millions of copies/mL in blood and body fluids). Awareness of the common occurrence of AHI in young adults presenting with fever, and incorporating p24 antigen testing (in addition to rapid diagnostic tests for HIV-1 antibodies) should significantly improve the early diagnosis of HIV infection. One other unique aspect of this study is that some of the screening sites were pharmacies, which could potentially initiate antiretroviral therapy at the same visit where the diagnosis of AHI was made. This would likely have the beneficial effects of reducing HIV transmission and potentially would have direct clinical benefit for the patient since some studies suggest that early treatment of AHI may favorably affect immunologic reconstitution and alter "viral set-point."