Immediate Treatment of Acute HIV in a Tertiary Healthcare Center

Bridging Gaps in Communication Using Smartphones

S Perez-Patrigeon; A Camiro-Zúñiga; MR Jaramillo-Jante; PF Belaunzarán-Zamudio; B Crabtree-Ramírez; LE Soto-Ramírez; JJ Calva; C Hernández-León; JL Mosqueda-Gómez; S Navarro-Alvarez; JG Sierra-Madero

Disclosures

HIV Medicine. 2019;20(5):308-316. 

In This Article

Abstract and Introduction

Abstract

Objectives: Early initiation of antiretroviral therapy (ART) during acute HIV infection is associated with favourable clinical and epidemiological outcomes. Barriers to prompt treatment initiation limit the benefits of universal access to ART in Mexico. We sought to create an algorithm for the immediate detection and treatment of patients with acute HIV infection.

Methods: A nationwide cohort of patients with acute HIV infection was created in 2015. In order to identify cases and treat them promptly at our centre, an interdisciplinary group coordinated through an instant-messaging tool using smart phones was established. When a probable case was detected, a discussion was initiated to confirm the diagnosis and facilitate the administrative processes to initiate ART as soon as possible. We compared time to ART initiation with that in a comparison group of patients with chronic HIV infection enrolled during the same period (May 2015 to February 2017) through routine care, using survival analysis estimators and log-rank tests.

Results: We recruited 29 patients with acute HIV infection. The median time to ART initiation was 2 days in these patients, in contrast to 21 days for patients with chronic infection. There were no significant differences in the percentages of patients engaged in care, on treatment or virologically suppressed at 1 year of follow-up.

Conclusions: Implementing immediate ART initiation programmes is feasible in Mexico, in spite of the substantial administrative barriers that exist in the country. More extensive replication of this model in other centres and in patients with chronic infection is warranted to evaluate its effect on the continuum of care.

Introduction

Recent studies have demonstrated that immediate initiation of antiretroviral therapy (ART) in patients with chronic HIV infection is associated with significant benefits in time to viral suppression and engagement in care.[1–3] In theory, this translates into reduced HIV transmission in the community[4] and an improved continuum of care.[3] Additionally, several studies have demonstrated that initiating ART during acute HIV infection results in patients having a lower probability of clinical progression to advanced Centers for Disease Control and Prevention (CDC) stages, a lower viral reservoir and RNA set point, and several other significant immunological benefits.[5–7] This should also hypothetically result in improved clinical outcomes.[7] Due to the effectiveness of these interventions, the development of, strategies for early identification of HIV infections and their immediate treatment have become priority targets in implementation science research in the fight against HIV.[8]

In Mexico, although universal access to ART has been the standard since 2003,[9] numerous administrative and operational barriers exist in the public health system, which hamper the implementation of immediate ART initiation programmes on a large-scale basis. For example, patients cannot receive benefits from most of the specialized health care programmes (including access to ART) before they complete the necessary registration paperwork. This entails a lengthy multi-step process that requires the patient to physically provide a number of personal documents (birth certificate, photographic ID and proof of address), obtain a certificate of affiliation, and finally enroll in care at the nearest HIV clinic,[10,11] effectively delaying ART initiation.

Another problem is that acute HIV infection remains an underdiagnosed condition as a consequence of a lack of awareness, the absence of specialized staff in areas where patients present with symptoms, poor communication channels among the personnel involved in the care of these patients, and suboptimal pre-designed processes for HIV care.[12] In Mexico, ART is rarely initiated when patients are in the acute phase of the infection, with up to 79% of all patients initiating ART with CD4 counts of < 200 cells/μL.[13] Furthermore, there are no national guidelines designed to effectively detect acute HIV infection. Most diagnostic guidelines only recommend the repetition of the screening test after a designated period of time in the context of a negative screening test in a patient with a probable acute HIV infection.[14]

In order to improve detection and treatment of acute HIV infection, in the year 2015, we established the cohort 'Virus de la Inmunodeficiencia Humana Infección Aguda' (VIHIA), a multicentre cohort of such patients in Mexico. At our centre, we implemented a clinical procedure based on communications via instant messaging tools readily available for smart phones, and involving key personnel in all areas related to HIV care. The goals of this strategy are to detect probable cases, rapidly diagnose HIV infection and provide same-day ART to this population of patients. The aim of this report is to describe the implementation of this programme and to show the resulting trend in the time from first clinical contact until treatment initiation, by comparing it to the usual practice in place for patients with chronic infection. Additionally, we evaluated the impact of same-day ART on retention in care and viral suppression in both groups of patients.

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