Seek and treat: HIV update 2011
ABSTRACTAlthough mortality rates from human immunodeficiency virus (HIV) infection have declined dramatically in the United States, the incidence of new infections has not improved for more than a decade. The case is now strong for routine screening and early treatment of HIV infection to reduce transmission of the infection and to give patients an opportunity to live a reasonably healthy life. Clinicians in all health care settings should routinely and matter-of-factly test their patients for HIV infection, just as they screen for other diseases.
KEY POINTS
- Recommendations from the US Centers for Disease Control and Prevention call for routine HIV screening for all people ages 13 to 64 at least once regardless of their risk profile, and annual testing for people with known risk factors for acquiring HIV.
- Early treatment of HIV infection may reduce the risk of cancer, cardiovascular disease, neurocognitive disorders, and osteoporotic fractures and improve the rate of survival compared with patients treated late in the course of HIV infection.
- Finding and treating patients early in the course of infection has the potential to reduce infectivity in the community.
- Reliable rapid testing is now available to screen for HIV in community settings, emergency departments, and public health clinics, and during labor for those not tested in the prenatal period. It is also useful when follow-up is uncertain.
Cancer risk increases with lower CD4 counts
The cumulative incidence of AIDS-defining cancers (Kaposi sarcoma, non-Hodgkin lymphoma, cervical carcinoma) has decreased steadily from 8.7% in the 1980s to 6.4% during the years 1990 to 1995, and to 2.1% between 1996 and 2006. This is attributable to improved immune function as a result of treatment success with antiviral therapy.12
But the incidence of non-AIDS-defining cancers (Hodgkin disease, anal cancer, oral and respiratory cancers) has increased.11 As therapy has regenerated the immune system, patients are surviving longer and are developing the more common cancers but with higher rates than in the general population.
Higher cancer risk is attributed to reduced immune surveillance. Many of these cancers are associated with viruses, such as human papillomavirus (anal and oral or pharyngeal cancers) and Epstein-Barr virus (Hodgkin disease), which can usually be controlled by a fully functioning immune system. The lower the CD4 count, the higher the risk of cancer, which highlights the need to diagnose HIV and start treatment early.13
Cardiovascular disease increases with lower CD4 counts
Associations have recently been identified between coronary disease and HIV as well as with HIV medications. Protease inhibitors tend to raise the levels of triglycerides, low-density lipoprotein cholesterol, and total cholesterol and increase the risk of heart attack.14
Regardless of therapy, HIV appears to be an independent risk factor for coronary disease. Arterial stiffness, as measured by carotid femoral pulse-wave velocity, was found to be increased among a sample of 80 HIV-infected men. This was associated with the usual risk factors of increasing age, blood pressure, and diabetes, as well as with lower nadir CD4 count.15
Fractures and neurocognitive disorders increase with HIV
Osteoporotic fractures are also more common in patients with HIV than in the general population. Risk factors include the traditional risks of older age, hepatitis C infection, diabetes, and substance abuse, but also nadir CD4 count less than 200.16
The risk of neurocognitive disorders is also associated with lower nadir CD4 counts. The lower the CD4 count, the higher the risk of developing neurocognitive deficits.17 The potential benefits of earlier diagnosis and treatment are obvious based upon the multiple recent findings outlined above.
CLINICAL PRESENTATION OF PRIMARY HIV INFECTION
During primary HIV infection, when patients are first infected, 50% to 90% are symptomatic. Symptoms usually appear in the first 6 weeks. The viral load tends to be highest at this time. Higher viral loads appear directly correlated with the degree of infectivity, highlighting the urgency of finding and treating new infections promptly to help avoid transmission to others.18
The clinical picture during primary infection is similar to that of acute mononucleosis. Signs and symptoms include fever, fatigue, rash, headache, lymphadenopathy, sore throat, and muscle aches. Although this presentation is common to many viral infections, questioning the patient about high-risk behavior (unprotected sex, multiple partners, intravenous drug use) will lead the astute physician to the correct testing and diagnosis.
Other early manifestations include mucocutaneous signs, such as seborrheic dermatitis, psoriasis, folliculitis, and thrush. Laboratory test results demonstrating leukopenia, thrombocytopenia, elevated total protein levels, proteinuria, and transaminitis are also suggestive of HIV infection.
THE CASE FOR INCREASED TESTING AND TREATMENT
The estimated prevalence of HIV in the United States is approximately 0.3%. However, its prevalence in Washington, DC, is 3%, which rivals rates in some areas of the developing world. From 2004 to 2008, health officials made a concerted effort in Washington, DC, to screen more people, particularly those at high risk. The number of publicly funded HIV tests performed increased by a factor of 3.7, and the number of newly reported cases increased by 17%. There was also a significant increase in the median CD4 count at the time of HIV diagnosis and a significant delay in time to progression to AIDS after HIV diagnosis.19
A study in British Columbia expanded access to highly active antiretroviral therapy during 2004 through 2009. High-risk individuals were targeted for increased screening. All those diagnosed with HIV were provided free medication. This resulted in a 50% reduction in new diagnoses of HIV infection throughout the community, especially among injectable drug users, a usually marginalized population. The proportion of patients with HIV-1 RNA levels above 1,500 copies/mL fell from about 50% to about 20%, indicating that the viral load—a measure of infectivity throughout the community—was reduced. Interestingly, this trend occurred during a time of increased rates of gonorrhea, syphilis, and other sexually transmitted diseases known to be associated with enhanced HIV transmission.20
In Africa, antiretroviral therapy was offered to discordant couples (one partner was infected with HIV and the other was not). Among those who chose therapy, the rate of HIV transmission was 92% lower than in those not receiving antiretroviral drugs,21 once again demonstrating that control of HIV by treatment can lead to decreased transmission.
US HIV testing is inadequate
The current state of HIV testing in the United States needs to be improved. Testing is not performed routinely, leading to delayed diagnosis when patients present with symptomatic, advanced disease. Patients who are tested late (within 12 months before being diagnosed with AIDS) tend to be younger and less educated and are more likely to be heterosexual and either African American or Hispanic than patients who are tested earlier.22 When retrospectively evaluated, these patients often have been in the health care system but not tested. Routine universal screening and targeted testing could lead to a much earlier diagnosis and potential better long-term outcomes.
A 1996 survey of 95 academic emergency departments found that for patients with suspected sexually transmitted infections, 93% of physicians said they screen for gonorrhea, 88% for Chlamydia infection, 58% for syphilis, but only 3% for HIV.23 Sexually transmitted infections and HIV are often transmitted together.
A similar 2002 survey of 154 emergency department providers who saw an average of 13 patients with sexually transmitted infections per week found that only 10% always recommend HIV testing to these patients. Reasons given for not testing were concern about follow-up (51%), not having a “certified” counselor (45%), HIV testing being too time-consuming (19%), and HIV testing being unavailable (27%).24
Although most HIV tests are given by private doctors and health maintenance organizations, the likelihood of finding patients with HIV is greatest in hospitals, emergency departments, outpatient clinics, and public community clinics.
The Advancing HIV Prevention initiative of the US Centers for Disease Control and Prevention (CDC) has four priorities:
- To make voluntary HIV testing a routine part of medical care
- To implement new models for diagnosing HIV infection outside medical settings
- To prevent HIV infection by working with patients with HIV and their partners
- To further decrease the rate of perinatal HIV transmission.
