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

Materials and Methods

Study Settings and Study Design

The immediate ART initiation programme was implemented at the Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán (INCMNSZ), a public, university-affiliated, tertiary-care centre in Mexico City. The HIV clinic at INCMNSZ provides care to approximately 2100 adults. As a tertiary care, referral hospital, it does not offer any primary care interventions for the general population, including HIV screening. This intervention was designed for all patients diagnosed with acute HIV infection and enrolled in care. Acute HIV infection was defined as a Fiebig stage of 5 or lower, or as a Fiebig stage of 6 with a negative fourth-generation enzyme-linked immunosorbent assay (ELISA) for HIV in the previous 3 months. All patients were enrolled for participation in the VIHIA observational cohort study.

In addition, to investigate the effectiveness of our rapid ART initiation programme, we conducted an observational, retrospective cohort study comparing two different cohorts of patients enrolled at our centre. The intervention group was composed of all patients enrolled in the VIHIA cohort from May 2015 to February 2016 in our institution. The comparison group comprised all ART-naïve, chronically HIV-infected patients enrolled at our site during the same time period. These patients underwent the regular enrolment process. VIHIA cohort data were collected in real time, while demographic and clinical data for chronically HIV-infected patients were retrieved from the HIV clinic database. This database prospectively collects information on all patients receiving care in our clinic as part of our collaboration with the Caribbean, Central and South America network for HIV epidemiology (CCASAnet) group.[15] We excluded patients for whom, according to guidelines, prompt initiation of ART was not recommended (for example those with central nervous system cryptococcosis). In order to exclusively perform an intention-to-treat analysis, we did not exclude patients who rejected the option of immediate initiation of ART.

Description of the Intervention to Start ART Immediately

Personnel from the key areas involved in the care of HIV-infected patients in our hospital (infectious disease specialists, attending physicians, social workers, nurses, and laboratory and administrative staff) were sensitized to the importance of prompt ART for acute HIV infection and taught an algorithm for immediate treatment initiation (Figure 1). To facilitate a coordinated response, we created an encrypted instant-messaging group using software available to smart-phone users that included the aforementioned staff. The main purpose of sharing information in this group was to elicit an alert when any participating member became aware of a patient with probable acute HIV infection.

Figure 1.

Detection and treatment algorithm Tx, treatment; ARV, antiretroviral; ASAP, as soon as possible; ER, emergency room.

When any of the members of the group identified a probable case of acute HIV infection (out-patient referrals with discordant HIV tests, patients identified by screening in the blood bank and in the out-patient clinic, or a suggestive clinical presentation in the emergency room or hospitalization areas), a conversation was initiated in the group to discuss the likelihood of the diagnosis with the attending physicians. If the scenario was deemed a possible case, an infectious disease specialist performed a directed clinical evaluation, and blood samples were taken to run confirmatory tests as soon as possible.

The laboratory personnel prioritized execution of the tests (fourth-generation ELISA, western blot, viral load and CD4 lymphocyte count) in order to obtain the results as soon as possible and share them immediately with the group. Patients with a confirmed diagnosis of acute HIV infection received a prescription for ART, as well as an additional evaluation that included HIV counselling, adherence counselling and standard HIV care. Immediately afterwards, the administrative personnel processed the paperwork to enrol the patient in the Mexican HIV drug programme and provided the patient with ART. Patients received treatment even if their administrative process was incomplete and the necessary admission paperwork was completed at subsequent visits if needed. Routine laboratory testing was available for some patients as part of their work-up. HIV-negative patients received post-test counselling and were referred to the appropriate care and follow-up. Patients with chronic HIV infection followed standard clinic procedures and thus were scheduled for a later visit with all the necessary paperwork to enrol in the clinic and undergo a complete clinical evaluation.

Assessment of effectiveness of the intervention to reduce time to ART initiation and its impact on retention in care, treatment acceptability and viral suppression

The primary outcome was the time from the patient's first medical contact with the HIV clinic to the initiation of ART. The first medical contact was defined as the day of the patient's first visit to the clinic when referred from another centre, the blood bank or the out-patient clinic, or the day that the first screening HIV test was performed in cases in which the patient was hospitalized in our centre. ART initiation was defined as the day of ART provision, as patients were instructed to start treatment on the same day. Secondary outcomes were the proportion of patients with complete viral suppression (defined as an HIV RNA < 40 HIV-1 RNA copies/mL) and sustained engagement in care (defined as attendance at a follow-up visit at the HIV clinic or laboratory in the assigned time period on a subsequent time period) in the patient's first year of follow-up. As a consequence of the heterogeneity of the follow-up among both cohorts, the secondary outcomes were analysed in three different time bins (1–4, 5–8 and 9–12 months). To further characterize the impact of immediate ART initiation on the secondary outcomes, we also compared all patients who started ART after the first 48 h of their first clinical contact with those who started earlier (regardless of their status as acutely or chronically infected).

Statistical Analysis

Demographic, clinical and laboratory data from the electronic database in the HIV clinic and VIHIA cohort were de-identified and exported into STATA v12 software (StataCorp, College Station, TX) for analysis. The time to ART initiation was imported to and analysed in GRAPHPAD PRISM v6 (GraphPad Inc., San Diego, CA), and represented using a Nelson–Aalen cumulative hazards curve and compared using the log-rank test. The secondary outcomes were compared using the χ 2 test.

Ethical Considerations

Patients with acute HIV infection provided informed consent to participate in the VIHIA cohort. Our Institutional Review Board evaluated and approved separately both the VIHIA study and the use of de-identified data for research purposes as part of our CCASAnet collaboration.

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