PPubMed18 Dec 2019Cited 110×

Challenges of HIV diagnosis and management in the context of pre‐exposure prophylaxis (PrEP), post‐exposure prophylaxis (PEP), test and start and acute HIV infection: a scoping review Elliott T et al.

Tamara Elliott, Eduard J Sanders, Meg Doherty, Thumbi Ndung'u, Myron Cohen, Pragna Patel, Gus Cairns, Sarah E Rutstein, Jintanat Ananworanich, Colin Brown, Sarah Fidler

Abstract

1## Introduction In the current era of immediate antiretroviral therapy (ART), and pre- or post-exposure prophylaxis, confidently diagnosing HIV is becoming increasingly complex. Cases of diagnostic uncertainty can be confusing and distressing to both clinicians and patients, and can lead to difficult management decisions, particularly in regard to initiation of ART for treatment or prophylaxis. ART has dramatically improved survival for people living with HIV (PLHIV) and globally there has been an improvement in treatment coverage [jia225419-bib-0001]. Viral suppression on ART confers an indi

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Increasing use of PrEP and immediate ART creates diagnostic challenges for acute HIV infection, requiring new testing algorithms and research.

What’s new

i.Comprehensive scoping review of challenges in diagnosing acute HIV infection in the context of PrEP, PEP, test‑and‑start and immediate ART
ii.Synthesis of evidence from clinical trials, observational studies, systematic reviews and international guidelines
iii.Identification of diagnostic gaps caused by ART/PrEP suppressing viral markers and recommendation for modified testing algorithms

How they did it

The review originated from an invited symposium on diagnosing and managing acute HIV infection at the 22nd International AIDS Conference (July 2018) and was later supplemented with evidence from clinical trials, observational studies, systematic reviews and international best‑practice guidelines. It collates reported challenges and data on current HIV testing strategies in the era of PrEP and immediate ART.

What they found

FRESH study enrolled >1,600 women; 71 incident infections were identified in the acute phase, 57 initiated rapid ART within a median of one day, 87% did not develop detectable HIV‑specific antibodies and 48% remained antibody‑negative up to 340 days
ADAPT trial reported 12 new HIV infections; in 9 cases both POCTs were non‑reactive at first positive visit, 8 were acute infections, 5 also had negative laboratory Ag/Ab tests, and viral load was ≤400 copies/mL in 4 of these cases
Abbott Architect® Ag/Ab Combo detected 85% of acute HIV infections but missed two early infections with HIV RNA <500 copies/mL
Partners PrEP study found 11% of seroconverters in the PrEP arm had undetectable HIV RNA compared with 3% in the placebo arm

Caveats

✕Current HIV testing algorithms may miss acute infections when ART or PrEP suppresses viral load or antibody responses
✕Many recommended assays (e.g., NAAT, p24 antigen) require venous blood, sophisticated laboratory infrastructure and trained personnel, limiting use in resource‑limited settings
✕Insufficient data on optimal, affordable testing algorithms for the PrEP/PEP era; further research and surveillance are needed

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Challenges of HIV diagnosis and management in the context of pre‐exposure prophylaxis (PrEP), post‐exposure prophylaxis (PEP), test and start and acute HIV infection: a scoping review Elliott T et al.

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