Identification and characterization of acute cases of Human Immunodeficiency Virus (HIV-1) infection

Abstract

Universal HIV treatment with antiretrovirals and new forms of prevention are among the main strategies for controlling AIDS. In this scenario, patients in the acute phase of the disease are assuming even greater importance in the transmission and maintenance of the epidemic, since there is no consistent public policy for their identification and incorporation into our health system (SUS). Diagnostic opportunities are lost, as in Testing and Counseling Centers, since serological testing, based on current rapid diagnostic tests, does not detect infection during the immunological window in the first days of infection. Different studies estimate that a significant proportion of new infections are from newly infected individuals, with estimates reaching more than 50% in some studies (Pilcher 2001, Powers 2011, Cohen 2011). The recent phase has different definitions, but usually comprises the first year of infection. Individuals in the acute phase leave these services with the information that they are not infected with HIV, with the false perception of their transmitting potential. In addition, several studies point to a direct benefit to the patient of early treatment of the disease (Ford 2018, Goulder & Deeks 2018, Ndhlovu 2019, Sharma 2019), on the same day of diagnosis when feasible. As well, another point to consider is that early treatment may favor future cure strategies. The immediate treatment policy has been shown to be difficult to implement in the current SUS scenario, with waiting periods that may reach months for the first consultation and the beginning of treatment after diagnosis. Although the impact of this delay may be less important for cases diagnosed already in the chronic latency phase of infection, cases of advanced disease, as well as recent ones, could be screened and have a prioritization policy. The objective of this study is to contribute to better identification of the incident infection, acute or recent, inviting a part of these to participate in a clinical follow-up cohort. The evaluation of clinical-epidemiological algorithms that allow better indication of molecular tests in the suspicion of infection in the initial disease can minimize the inappropriate use of these tests, but guarantee access to cases with indication. In addition to the use of molecular technologies, such as viral load, fourth-generation serological tests may allow early diagnosis, and decision-making algorithms for SUS are useful in indicating diagnostic confirmation exams as well as prioritization for immediate treatment. The evaluation of the volunteer samples with the well characterized infection time, using laboratory tests that estimate the time of infection, will allow to validate these tests, contributing to the generation of incidence estimates in this population, as well as to improve the algorithm of identification screening cases in the early stages of HIV. This initiative will also allow the organization of a cohort of patients identified in the acute phase, with a better characterization of these incident cases, and evaluate the response to treatment, especially retention and viral suppression. The knowledge generated by the proposal may (i) implement preventive measures, (ii) promote the development of strategies for incorporation and retention of populations identified as most vulnerable, (iii) improve understanding of this phase of the disease in our country, (iv) contribute in the control of the epidemic and (v) inform the development of innovative tools. (AU)