The period of acute HIV infection (AHI) is a relatively brief window of time -- roughly 10 weeks after initial infection -- but its impact on the spread of HIV may be very significant. During this early period, which likely continues through the first six months of infection, that people are considerably more infectious to others than at other stages of infection. However, since most individuals are not yet aware that they have HIV, risk behaviors often persist; indeed, some studies have suggested that up to half of transmissions to new partners may take place during the acute and early infection stages. Further, quick detection of new infections may also provide opportunities for early intervention among people with HIV.

This window of time, and the fact that those infected do not think of themselves as being HIV-positive, makes it exceptionally difficult for public health and biomedical systems to detect and intervene with the newly infected.  To explore the practical and behavioral dimensions of AHI, the HIV Center has been part of an exploratory initiative known as the NIMH Multisite AHI Study. HIV Center investigators, under the leadership of Center Director Anke A. Ehrhardt, Ph.D., and Robert H. Remien, Ph.D., collaborated with researchers from the Center for AIDS Prevention Studies (CAPS, University of California at San Francisco), the Center for AIDS Intervention Research (CAIR, the Medical College of Wisconsin), the Center for Interdisciplinary Research on AIDS (CIRA, Yale University),  the HIV Neurobehavioral Research Center (University of California, San Diego), the Kerndt Center for HIV Prevention, Treatment, and Services (CHIPTS, University of California, Los Angeles), Brown University, Princeton University, and Duke University.

A series of articles has resulted from the multi-site collaboration., all published in the journal AIDS and Behavior. The first, regarding detection of AHI, reported on the identification in six US cities of persons with acute/early HIV infection. Identification was done either by using HIV RNA testing of pooled blood from persons screened HIV antibody negative or through clinical referral of persons with acute or early infections. Fifty-one cases were identified, and 34 (68%) were enrolled into the study; 28 (82%) were acute infections and 6 (18%) were early infections. Of those enrolled, 13 (38%) were identified through HIV pooled testing of 7,633 HIV antibody negative sera and 21 (62%) through referral. The article concluded that "Both strategies identified cases that would have been missed under current HIV testing and counseling protocols. Efforts to identify newly infected persons should target specific populations and geographic areas based on knowledge of the local epidemiology of incident infections."¹

The second article was first-authored by Dr. Remien and focused on awareness and understanding of AHI. Through in-depth interviews with study participants, the investigators found a marked lack of awareness of AHI-related acute retroviral symptoms and a lack of clarity about AHI testing methods. Most participants knew little about the meaning and/or consequences of AHI, particularly that it is a period of elevated infectiousness. Over time and after the acute stage of infection, many participants acquired understanding of AHI from varied sources, including the Internet, HIV-infected friends, and health clinic employees. The authors concluded "There is a need to promote targeted education about AHI to reduce the rapid spread of HIV associated with acute/early infection within communities at risk for HIV."²

The third article in the series shifted focus to the issue of "serosorting," or choosing sexual sexual partners based on shared HIV status, in the context of AHI.  The study examined how sexual behaviors changed following diagnosis of acute/early HIV infection. Twenty-eight individuals completed structured surveys and in-depth interviews shortly after learning of their infection and 2 months later. Quantitative analyses revealed significant changes after diagnosis, including reductions in total number of partners and decreases in the proportion of unprotected sex acts occurring with uninfected partners (serosorting). Qualitative findings indicated that these changes were motivated by concerns about infecting others. However,participants were less successful at increasing the frequency with which they used condoms. "These results suggest that the initial diagnosis with HIV may constitute an important component of interventions to promote risk reduction during the acute/early stages of the disease," concluded the authors.³

The emphasis was next placed on the psychiatric context of AHI, given that better understanding of behavioral aspects during this period could improve interventions to limit further transmission. Of the 34 study participants with acute/early HIV infection, most had a pre-HIV history of alcohol or substance use disorder (85%), and a majority (53%) had a history of major depressive or bipolar disorder. However, post-diagnosis coping was predominantly adaptive, with only mild to moderate elevations of anxious or depressive mood. Respondents described challenges managing HIV in tandem with pre-existing substance abuse problems, depression, and anxiety. Integration into medical and community services was associated with adaptive coping. The authors noted that: "The psychiatric context of acute/early HIV infection may be a precursor to infection, but not necessarily a barrier to reducing forward transmission of HIV among persons newly infected."⁴

The final article presented "lessons learned” in the study and identified ongoing needs, including: (1) the need for further research on the cost-effectiveness of AHI screening and testing; (2) the need to develop community and clinic-level interventions to increase awareness of acute-phase HIV transmission risks; (3) the need to develop targeted behavioral interventions following AHI diagnosis; and (4) the need for ‘‘rapid response’’ public health systems that can move quickly enough to intervene while persons are still in the AHI stage. The authors came to the conclusion that while numerous challenges to identify persons with AHI remain, "there are untapped opportunities for behavioral and medical science collaborations in these areas that could reduce the incidence of HIV infection."⁵

To read an article on Dr. Remien's work on acute HIV infection published on the Columbia University website, click here.

For further background information on the HIV Center's work on acute HIV infection, click here.

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1. "Strategies Used in the Detection of Acute/Early HIV Infections," Peter R. Kerndt, et al. AIDS and Behavior. Vol 13, No. 6, page 1037 - 1045

2. "Lack of Understanding of Acute HIV Infection among Newly-Infected Persons—Implications for Prevention and Public Health" Robert H. Remien, et al. AIDS and Behavior. Vol 13, No. 6, page 1046 - 1053

3. "Behavior Change Following Diagnosis with Acute/Early HIV Infection—A Move to Serosorting with Other HIV-Infected Individuals," Wayne T. Steward et al. AIDS and Behavior. Vol 13, No. 6, page 1054 - 1060

4. "Psychiatric Context of Acute/Early HIV Infection," J. Hampton Atkinson, et al.  AIDS and Behavior, Vol 13, No. 6, page 1061 - 1067

5. "Lessons Learned about Behavioral Science and Acute/Early HIV Infection. The NIMH Multisite Acute HIV Infection Study," Jeffrey A. Kelly et al. AIDS and Behavior,. Vol 13, No. 6, page 1068 - 1074