The Latest on HIV Testing. Dominika Seidman, MD MAS

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1 The Latest on HIV Testing Dominika Seidman, MD MAS

2 Disclosures none 2

3 Learning objectives At the conclusion of this session, participants should be able to Define the window periods for various HIV tests Describe the signs and symptoms of acute HIV Discuss HIV prevention options in conjunction with HIV testing 3

4 A 31 y.o. G9P4 comes to your clinic for repeat, on-time DMPA. She mentions to the medical assistant checking her in that her partner was recently diagnosed with HIV. She s interested in HIV testing today. 4

5 POLL You feel: a. Well equipped to counsel her a. Palpitations because she s probably HIV-positive and you ve never given someone a new diagnosis before a. Frustrated that she offhandedly mentioned this important info to the MA a. Nervous about the counseling session whether she s HIV positive or not 5

6 Back to basics: take a history History Testing Counseling When was her last HIV test? Any flu-like illnesses, rashes, lymphadenopathy, GI upset recently? Any major medical problems that she has (kidney, liver problems)? 6

7 History Testing Counseling 75% 40% 45% 40% 50% 50% 30%

8 Back to basics: take a history History Testing When was her partner diagnosed? Is he engaged in care and on treatment? Counseling Do they have condomless intercourse? What type of intercourse (vaginal, anal, oral)? 8

9 POLL The risk of acquiring HIV from condomless sex, once, with a person living with HIV is a) 1/1000 for receptive vaginal sex b) Higher from vaginal sex than from receptive anal sex c) Higher from receptive anal sex than from vaginal sex d) Essentially zero if the partner has had an undetectable viral load and no STIs for 6 months e) A, C & D 9

10 Risk of HIV transmission per condomless act Sexual Act Receptive penilevaginal sex Insertive penile-vaginal sex Risk 1/1000 1/2500 Receptive anal sex 1-2/100 Insertive anal sex 1/1000 Hughes et al JID 2012; Patel et al. AIDS 2014

11 Treatment as prevention HPTN 052: 96% reduction in transmission risk with immediate vs. delayed ARV For each log viral load: 2.9X risk per-act No reported cases of heterosexual transmission in setting of undetectable viral load Cohen MS NEJM 2011; Supervie et al. CID

12 Back to basics: take a history History When was their last condomless intercourse? Testing Counseling Any other exposures (Does she inject drugs? Share needles? When?)? 12

13 POLL She had sex 20 days ago and has had some flulike symptoms. What test(s) will most likely help you make the diagnosis if she acquired HIV at that time? a. 4 th generation antigen/antibody test b. HIV viral load/rna PCR c. 3 rd generation rapid test d. Western blot e. Multispot f. None of above g. A&B 13

14 The window period for HIV tests a.k.a. viral load a.k.a. 4 th gen test: detect IgM, IgG, p24 Ag Detect IgM, IgG. Most rapid tests are here.

15 Testing History Her 3 rd generation rapid HIV test is negative. Testing Counseling You order a 4 th generation Ag/Ab HIV test. It won t come back until Monday. What do you tell her? 15

16 Counseling: overview History HIV care & treatment Testing Counseling HIV prevention options Assess pregnancy intentions Order additional testing if interested in PrEP; wait to prescribe until acute HIV is ruled out. You re going to take good care of her no matter what. Get lots of contact info and make an appointment to see or talk to her on Monday. 16

17 HIV testing: an opportunity to educate about HIV prevention options. History Testing Counseling Patel P et al. AIDS 2014; Smith DK et al. MMWR Recomm Rep

18 Additional HIV prevention methods History Testing Counseling STI screening & treatment Ulcerative disease of HIV-negative partner increases HIV susceptibility (RR 2.7, ) Contraception (for those who want it) Pregnancy may increase HIV susceptibility (OR 1.3, 95% CI ) Safer conception Timed intercourse Sperm washing, IUI, IVF Sperm donor Adoption Patel P et al AIDS 2014; Drake AL et al. PLoS Med

19 POLL She comes back on Monday and her HIV test is negative. She had condomless sex yesterday. What HIV prevention method is she now eligible for (that she wasn t before)? a) Condoms b) Treatment as prevention c) Post-exposure prophylaxis d) Pre-exposure prophylaxis 19

20 Testing algorithm for a recent exposure Grant & Smith. Open Forum Infect Dis

21 History Counseling pearls Shared decision-making to guide discussion Offer methods; don t recommend Testing Counseling Women want integrated sexual and reproductive healthcare Remember to incorporate pregnancy intentions HIV prevention preferences may change, just like pregnancy intentions Assess regularly! Don t create undue barriers to access Use lessons learned from contraception 21

22 Take-home points Know the HIV test(s) available to you, and know the window period for those test(s) Take a history when you do HIV testing Use HIV testing as an opportunity to counsel about prevention methods but don t let counseling be a barrier to testing! 22

23 Resources 23

Provides clinicians of all experience levels with cost-free, confidential, timely, expert responses to questions on: HIV/AIDS management Occupational and non-occupational exposure management

24 Provides clinicians of all experience levels with cost-free, confidential, timely, expert responses to questions on: HIV/AIDS management Occupational and non-occupational exposure management Management of HIV in pregnant women and their infants Providing PrEP as part of HIV prevention HIV Management: am 8 pm EST, M-F PEPline: am 2 am EST, every day Perinatal HIV Hotline: am 2 am EST, every day PrEPline: a.m. 6 p.m. EST, M-F Online Consultation: nccc.ucsf.edu The CCC at UCSF/SFGH is a project of the HRSA AETC Program & the CDC.

25 Resources for Providers CDC testing CDC PrEP guidelines and provider supplement idersupplement2014.pdf Perinatal HIV Guidelines (safer conception): erinatalgl.pdf ACOG Committee Opinion Preexposure Prophylaxis for Prevention of HIV, May 2014

26 HIVE Online: Resources for providers Integrated resources on sexual & reproductive health Videos of how to counsel patients Sample order sheets Resources for patients Information sheets on prevention options in and around pregnancy Videos of patient experiences

27 Resources for Patients Centers for Disease Control and Prevention: Project inform: lets A new option for safer loving for women in Spanish and English PrEP watch: Positively Negative:

28 Acknowledgements Office of Population Affairs HIVE 28

29 References Hughes et al, Determinants of Per-Coital-Act HIV-1 Infectivity Among African HIV-1 Serodiscordant Couples. JID 2012: 205 (Feb. 1) Patel et al. Estimating per-act HIV transmission risk: a systematic review. AIDS (2014) volume: 28 issue: 10 page: Cohen MS, Chen YQ, McCauley M, et al., HPTN 052 Study Team. Prevention of HIV-1 infection with early antiretroviral therapy. N Engl J Med. 2011;365(6): Supervie et al. Heterosexual Risk of HIV Transmission Per Sexual Act Under Combined Anti- Retroviral Therapy: Systematic Review and Bayesian Modeling. Clin Infect Dis Apr 9. Smith DK et al. Antiretroviral postexposure prophylaxis after sexual, injection-drug use, or other nonoccupational exposure to HIV in the United States: recommendations from the U.S. Department of Health and Human Services. MMWR Recomm Rep. 2005;54:1-20. Drake AL et al. Incident HIV during pregnancy and postpartum and risk of mother-to-child HIV transmission: a systematic review and meta-analysis. PLoS Med. Feb 2014;11(2):e Grant, Smith. Integrating Antiretroviral Strategies for Human Immunodeficiency Virus Prevention: Post- and Pre-Exposure Prophylaxis and Early Treatment. Open Forum Infect Dis Dec; 2(4): ofv

30 Questions Contact info: 30

So you have HIV and you want to have a baby?

So you have HIV and you want to have a baby? Judy Levison, MD, MPH Associate Professor Department of Obstetrics and Gynecology Baylor College of Medicine Objectives Describe methods of safe conception