Prevalence of Primary HIV Infection in Symptomatic Ambulatory Patients

Andrew Coco; Emily Kleinhans

doi:10.1370/afm.376

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Coco Reply
Emma M Simmons

Published on: 23 October 2005
Journal Club discussion on prevalence of primary HIV infection and the Cost-effectiveness of expanded HIV testing
Katarzyna Buzanowska

Published on: 18 October 2005

Published on: (23 October 2005)

Coco Reply
Emma M Simmons, Pawtucket, Rhode Island
Other Contributors:
Dear Sirs,
We applaud the articles by Coco (1, 2) on the feasibility and cost effectiveness of rapid testing in ambulatory settings for those patients with symptoms of acute HIV infection. In addition to testing for acute and primary HIV, we would suggest expanding routine HIV testing by offering it to all sexually active patients at predetermined intervals of three to five years. HIV/AIDS, with the widespread...
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Dear Sirs,
We applaud the articles by Coco (1, 2) on the feasibility and cost effectiveness of rapid testing in ambulatory settings for those patients with symptoms of acute HIV infection. In addition to testing for acute and primary HIV, we would suggest expanding routine HIV testing by offering it to all sexually active patients at predetermined intervals of three to five years. HIV/AIDS, with the widespread implementation of antiretroviral therapy, is now a chronic disease. HIV incidence has been stable for over the last decade. Furthermore, thousands remain unaware of their diagnosis and/or present late in the disease course. The heterosexual risk transmission of HIV is increasing most rapidly. Routine HIV testing i.e. offering HIV tests to patients without an obligatory risk history, and without regard to race, ethnicity or sexual orientation, is acceptable to primary care patients(3) as well as providers.(4) Routine testing does not have to be time consuming or disruptive to the busy primary care schedule. It has been shown to be more cost effective than other commonly screened primary care diseases.(2, 5, 6) Routine asymptomatic HIV testing with the technology of enzyme-linked immunoassay (ELISA), followed by Western Blot if positive, offers a sensitivity and specificity of greater than 99% if done beyond one month after infection. Several studies have documented decreased risky sexual behavior after being either tested or learning of a positive test result for HIV. (7, 8, 9) In addition to increasing our vigilance to diagnose acute HIV infection in ambulatory settings, we should broaden routine testing for HIV to all sexually active patients. Testing by the primary provider should be routine for patients with heterosexual risk if we are to impact HIV incidence in the United States, identify HIV earlier in the course of the disease, provide improved linkage to primary and preventative care, and reduce the morbidity and mortality of this preventable disease. Non- stigmatizing, cost effective testing is the direction that public policy should be propelled to reduce disease burden as well as to increase the nation’s overall health.
1. Coco AS. The Cost-Effectiveness of Expanded Testing for Primary HIV Infection. Ann Fam Med. 2005; 3:391-399. 2. Coco AS, Kleinhans E. Prevalence of Primary HIV Infection in Symptomatic Ambulatory Patients. 2005; 3:400-404. 3. Simmons EM, Roberts M, Ma M, Beckwith C, Carpenter C, and Flanigan TP. Routine Testing for HIV: The Intersection between Recommendations versus Practice. AIDS Patient Care and STDs. (In Press). 4. Simmons EM, Rogers M, Beckwith C, Frierson G, and Flanigan T. Racial/Ethnic Attitudes towards HIV Testing in the Primary Care Setting. J of Nat Med Assoc. 2005; 97(1): 46-52. 5. Sanders G, Bayoumi A, Sundaram V, Bilir S, Neukermans, A, Rydzak C, Douglass L, Lazzeroni L, Holodniy M, and Owen D. Cost Effectiveness of Screening for HIV in the Era of Highly Active Antiretroviral Therapy. N Engl J Med. 2005; 352(6): 570-585. 6. Paltiel A, Weinstein M, Kimmel A, Geage G, Losina E, Zhang H, Freedberg K and Walensky R. Expanded Screening for HIV in the United States-An Analysis of Cost-Effectiveness. N Engl J Med. 2005; 352(6): 586-595. 7. DiFranceisco W, Pinkerton S, Dyatlov R, Swain G. Evidence of a Brief Surge in Safer Sex Practices after HIV Testing among a Sample of High-Risk Men and Women. J Acquir Immun Defic Syndr. 2005 Aug 15; 39(5):606-612. 8. CDC. Adoption of Protective Behavior among Persons with Recent HIV Infection and Diagnosis-Alabama, New Jersey, and Tennessee, 1997-1998. MMWR 49: 512-5. 9. Kamb M, Fishbein M, Douglas J, Rogers J, Bolan et al. Efficacy of Risk- Reduction Counseling to Prevent Human Immunodeficiency Virus and Sexually Transmitted Diseases: A randomized Controlled Trial. Project RESPECT Study Group. JAMA. 1998 Oct 7;280 (13):1161-7.
Competing interests: None declared
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Competing Interests: None declared.
Published on: (18 October 2005)

Journal Club discussion on prevalence of primary HIV infection and the Cost-effectiveness of expanded HIV testing
Katarzyna Buzanowska, Cleveland, USA
Other Contributors:
Knowing the prevalence of primary HIV infection (PHI) in symptomatic ambulatory patients is of great value to the practicing physicians. Viral illnesses are among the most common reasons for outpatient visits, and often the uncommon causes of these common illnesses (such as PHI) are not included in the differential diagnoses. The estimated prevalence of acute HIV infection was surprisingly high in our perception.
...
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Knowing the prevalence of primary HIV infection (PHI) in symptomatic ambulatory patients is of great value to the practicing physicians. Viral illnesses are among the most common reasons for outpatient visits, and often the uncommon causes of these common illnesses (such as PHI) are not included in the differential diagnoses. The estimated prevalence of acute HIV infection was surprisingly high in our perception.
Although approximately 90% of outpatient visits were accounted for in determining the denominator of prevalence, the methods used for inclusion/exclusion criteria of patients with symptoms consistent with viral illness were indirect and solely dependent on past medical records. A study designed to prospectively assess the prevalence would be more sensitive in detecting the patient population with viral symptoms.
The goal of calculating the prevalence of HIV infection was to predict the cost-effectiveness of expanded testing for primary HIV infection in all patients with signs and symptoms consistent with viral illness, regardless of their risk factors. We can understand its value in high risk populations, however, we are skeptical in applying this practice in low-risk, general population settings. Some of the concerns include: 1. lack of high sensitivity and specificity tests to detect PHI, which leads to many false positives in population with low prevalence; 2. stigmatizing patients by accusing them of risky behavior, even when stated otherwise by the patient; 3. “brainless” practice of medicine, by depending solely on tests in making diagnoses, rather than using a test to confirm the potential and suspected diagnosis; 4. wasted resources, which could be applied toward HIV prevention and patient education. Availability of more specific and sensitive tests would make the testing more appealing to patients and physicians.
We believe that taking the proper sexual history to assess the risk factors is an important factor in deciding whether or not to perform the HIV test. Asking clear and detailed questions to the patients should be a good screening tool in selecting patients with risk factors for HIV infection. There is a possibility of missing some percentage of the HIV patients by doing this; however the benefit will likely outnumber the multiple harms of expanded HIV testing.
Another ethical issue worth bringing up is the fact that early detection of infection is more beneficial and protective to people who interact with the patient (i.e. potential sexual partners) rather than to the patient himself. In fact, the stress, decreased quality of life resulting from the awareness of being infected, and limited treatment options until the relatively late stages of the disease, all speak against the benefits of early diagnosis when considering the direct benefits to the patients. Therefore, we are faced with the ethical questions analogous to the ones encountered in genetic counseling.
Finally, it is important to realize that HIV is a relatively recent disease. We are the first generation of patients and doctors who need to deal with this illness. We are all fearful of it, we all have emotional reactions to it, and we tend to stigmatize and judge people who have contracted the disease. As we learn to live with the awareness of its presence, the social stigma and emotional burden attached to this illness will hopefully become less powerful, and we will learn to treat this disease as any other chronic disease, such as asthma or hypertension.
Competing interests: None declared
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Competing Interests: None declared.