Why Acute HIV Treatment Is Crucial

Acute HIV infection describes the initial period of high viral load after exposure, but before seroconversion.

HIV testing is difficult in this period because patients lack anti-HIV antibodies. However, p24 antigen and characteristic nucleic acids will be present at least 5 days before seroconversion, but p24 antigen subsides 17 days after infection. There are no commercially available point-of-care nucleic acid tests, and the only p24 antigen test has poor sensitivity.

Effective diagnosis of patients during the acute period is crucial to accurately assess HIV incidence, identify transmission hotspots, offer immediate treatment, reduce the risk of transmission, and personalize prevention services.

The fourth-generation, laboratory-based HIV-1/2 antigen/antibody combination assay is currently recommended to diagnose acute or chronic HIV infection.

Now, an article published ahead-of-print in the journal

Topics in Antiviral Medicine

argues that prompt antiretroviral therapy of acute HIV infection reduces the central viral reservoir and more robustly recovers the CD4-positive cell count.

The INSIGHT START trial found HIV incidence appears to decrease 1.1% for every 1% increase in antiretroviral therapy coverage. Providers should initiate antiretroviral therapy as soon as the patient is ready and willing to be adherent to therapy and follow-up.

Acutely infected patients cause up to 50% of HIV transmissions because of high viral load and lack of neutralizing antibodies. Antiretroviral therapy options for acute HIV infection are identical to those for established infections. The International Antiviral Society recommends genotypic drug resistance testing upon antiretroviral initiation.

D

elayed initiation of antiretroviral therapy decreases the likelihood of CD4-positive cell count returning to normal by 10% per month.

Prompt antiretroviral initiation in cases of neonatal transmission was initially thought to prevent viral genomic incorporation into long-lived immune cells. Unfortunately, sustained virologic control did not occur because virus particles were present at single copy levels that are difficult to measure with current technology.

Antiretroviral initiation during the acute phase of HIV infection is not equivalent to HIV cure. It may, however, protect long-lived immune cells from infection and allow the body to slow or stop disease progression.

Providers should provide outreach to at-risk individuals and provide the proper testing to identify patients during the acute phase.