Focusing Efforts on Early-Stage HIV Interventions May Help Prevent Spread of Disease

August 24, 2009 • Science Update

Screening and early intervention with people in the earliest stages of HIV infection may reduce the spread of the disease, according to NIMH-funded researchers. A series of five papers from a small, multisite study were published online ahead of print in June 2009 in the journal AIDS and Behavior.

Background

The risk of spreading HIV is considerably higher during acute and early infection. Acute HIV infection (AHI) is defined as the time between initial infection and development of detectable HIV antibodies in the blood (seroconversion). Early infection refers to the time period up to six months after seroconversion. The increased risk of HIV transmission stems from extremely high levels of the virus during the time that a person may also be engaged in high risk sexual behaviors and is unaware of his or her infection. One study has suggested that transmission during early infection accounts for up to half of all new HIV infections.

Diagnosing early or acute HIV infection can be difficult. Symptoms of AHI, such as fever, headache, sore throat, and general aches and pains, are similar to many other types of illnesses. Also, commonly used HIV antibody tests will often give negative or inconclusive results during this stage of infection. This may lead people to mistakenly think that they are uninfected and unknowingly engage in behaviors that will transmit HIV to their sex partners.

To address this challenge, researchers at seven universities teamed up in the NIMH Multisite Acute HIV Infection Study. They recruited 34 adults, average age 33, within approximately one month of acute HIV diagnosis. Each participant completed two in-depth interviews, one near the time they first learned they were infected with HIV and the second interview about two months later. Through these interviews, the researchers explored participants’ knowledge and awareness of AHI symptoms, elevated infectiousness, and testing procedures, individual circumstances surrounding HIV transmission, and changes in sexual behavior, substance use, or mental health before and after HIV diagnosis.

Results of the Study

The researchers identified study participants using two methods: provider referral based on suspected AHI symptoms and pooled testing of people who were HIV antibody negative, using a method similar to what is routinely done when screening blood donors. Both approaches were successful in identifying cases of acute or early HIV infections that would not have been caught by traditional screening methods. 

Participants in this study showed a high prevalence of alcohol or substance use disorders and mental disorders in the range of those reported in “chronically” infected populations. Specifically:

• More than 85 percent had ever had an alcohol or substance use disorder
• About half (18 of 34 participants) had a history of more than one co-occurring disorder (for example, alcohol use disorder and a mood disorder at the same time)
• Almost 40 percent of the study population had symptoms of major depression
• About 20 percent had bipolar disorder, consistent with earlier studies showing people with this disorder are at higher risk of HIV, possibly related to impaired impulse control and risky sexual behaviors during an episode
• A history of suicidal thoughts or suicide attempts was much more common among study participants than has been reported for the community, but these results support past findings that most suicidal behaviors are more likely to be related to mood or substance use disorders than HIV.

Despite the high prevalence of these conditions, the participants overall showed relatively mild symptoms of psychiatric distress at the time of the study.

The participant interviews revealed a marked lack of awareness about AHI symptoms, testing, and other disease-related information. Such data represent the first in-depth analysis of knowledge about AHI among those affected.

A key finding was that, after diagnosis, many study participants reduced their number of sexual partners and reported decreases in unprotected sex with uninfected partners. These changes were mostly motivated by concerns about infecting others. The results suggest that the initial diagnosis may be an important first step in efforts to reduce transmission risk during acute and early HIV infection.

In terms of coping with an HIV diagnosis, participants were more likely to rely on adaptive strategies—for example, using emotional supports, turning to religion, and accepting their diagnosis—than less-adaptive strategies, such as venting, turning to substance use, or self-blaming. Another key finding was that participants were far more open than expected to transmission risk reduction counseling, despite experiencing stress over the new diagnoses.

The researchers note that these findings, particularly the estimates of mental and substances use disorders, should be interpreted with caution in light of the small study population. Thus, the prevalence estimates may not apply to larger groups. Also, the majority of participants were recruited from well-established, urban gay communities. Compared with those living in rural or underserved areas, people in these communities may have greater access to clinical and social services, which may in turn promote more positive coping strategies.

Significance

Based on their findings, the researchers emphasized the need for targeted education within at-risk communities to raise awareness and reduce the rapid spread of HIV associated with acute and early infection. Given the relatively mild psychiatric symptoms and generally positive outlook and coping strategies in the face of an HIV positive diagnosis, the researchers suggest that preventive efforts at this stage “would have a high probability of success.”

What’s Next

As described in the fifth paper in this series, the researchers noted a number of “lessons learned” from their preliminary study. These include the need for further research to:

• Establish the cost-effectiveness of the type of testing needed to identify acute and early HIV infections
• Address challenges in identifying people with AHI in a timely manner
• Increase awareness of AHI transmission risks among at-risk communities and the healthcare providers that serve them
• Determine the goals of behavioral interventions following AHI diagnosis, as well as possible preventive interventions among those at-risk who have a history of alcohol or substance use disorder or a mental disorder
• Develop rapid-response public health systems that can intervene during the AHI stage.

The sites coordinating on this study include Brown University, Colombia University, University of California at Los Angeles, University of California at San Diego, University of California at San Francisco, Medical College of Wisconsin, and Yale University.

References

Kerndt PR, Dubrow R, Aynalem G, Mayer KH, Beckwith C, Remien RH, Truong HH, Uniyal A, Chien M, Brooks RA, Vigil OR, Steward WT, Merson M, Rotheram-Borus MJ, Morin SF. Strategies Used in the Detection of Acute/Early HIV Infections. The NIMH Multisite Acute HIV Infection Study: I . AIDS Behav. 2009 Jun 3. [Epub ahead of print]
PubMed PMID: 19495954.

Remien RH, Higgins JA, Correale J, Bauermeister J, Dubrow R, Bradley M, Steward WT, Seal DW, Sikkema KJ, Kerndt PR, Mayer KH, Truong HH, Casey CY, Ehrhardt AA, Morin SF. Lack of Understanding of Acute HIV Infection among Newly-Infected Persons-Implications for Prevention and Public Health: The NIMH Multisite Acute HIV Infection Study: II . AIDS Behav. 2009 Jun 16. [Epub ahead of print]
PubMed PMID: 19533323.

Steward WT, Remien RH, Higgins JA, Dubrow R, Pinkerton SD, Sikkema KJ, Truong HH, Johnson MO, Hirsch J, Brooks RA, Morin SF. Behavior Change Following Diagnosis with Acute/Early HIV Infection-A Move to Serosorting with Other HIV-Infected Individuals. The NIMH Multisite Acute HIV Infection Study: III . AIDS Behav. 2009 Jun 6. [Epub ahead of print]
PubMed PMID: 19504178.

Atkinson JH, Higgins JA, Vigil O, Dubrow R, Remien RH, Steward WT, Casey CY, Sikkema KJ, Correale J, Ake C, McCutchan JA, Kerndt PR, Morin SF, Grant I. Psychiatric Context of Acute/Early HIV Infection. The NIMH Multisite Acute HIV Infection Study: IV . AIDS Behav. 2009 Jun 11. [Epub ahead of print]
PubMed PMID: 19517225.

Kelly JA, Morin SF, Remien RH, Steward WT, Higgins JA, Seal DW, Dubrow R, Atkinson JH, Kerndt PR, Pinkerton SD, Mayer K, Sikkema KJ. Lessons Learned about Behavioral Science and Acute/Early HIV Infection. The NIMH Multisite Acute HIV Infection Study: V . AIDS Behav. 2009 Jun 6. [Epub ahead of print]
PubMed PMID: 19504179.