Identification of primary HIV-1C infection in Botswana

Abstract

Methods for identification of primary HIV infections seem increasingly important to understand pathogenesis, and to prevent transmission, which is particularly efficient during acute infection. Most current algorithms for HIV testing are based on detection of HIV antibodies and are unable to identify early infections before seroconversion. The efficiency of prospective cohorts, which is a standard approach for identifying primary HIV-1 infection, depends on a variety of epidemiological and cultural factors including HIV incidence and stigma and, not surprisingly, varies significantly in different geographical areas. We report a voluntary counseling and testing (VCT)-based approach to identifying primary HIV-1C infection that was developed as part of a primary HIV-1 subtype C infection study in Botswana. The referral strategy was based on: (1) collaboration with VCT centers at city clinics operated by the Ministry of Health; (2) partnering with the busiest non-government VCT center; (3) educating healthcare workers and the community about primary HIV infection; and (4) pairing with diverse VCT providers, including NGOs and private-sector organizations. Acute HIV-1 infections were defined by a negative HIV-1 serology combined with a positive HIV-1 RT-PCR test. Recent HIV-1 infections were identified by detuned EIA testing according to the classic STARTH algorithm. The VCT-based referral strategy resulted in the successful identification of 57 cases of acute and early HIV infection. A referral strategy of expanded VCT with viral RNA (Ribonucleic acid) testing to a national program in Botswana may be a promising approach for identification of primary HIV infections on a countrywide level. The program should offer VCT with viral RNA testing to the general public, facilitate proper counseling and risk reduction, and allow initiation of early HAART, and may reduce new viral transmissions.

Keywords:

• HIV-1 subtype C
• Acute infection
• Recent infection
• Primary infection
• Southern Africa
• Botswana

Acknowledgements

We are grateful to the patients who participated in the Tshedimoso study in Botswana. We thank Gaseboloke Mothowaeng, Florence Modise, S'khatele Molefhabangwe and Sarah Masole for their dedication and outstanding work in the clinic and outreach. We express thanks to Lemme Kebaabetswe, Busisiwe Mlotshwa and David Nkwe for excellent laboratory support. We greatly appreciate the enthusiasm and strong commitment of Carl Davis, Kenneth Onyait and Erik van Widenfelt in achieving the overall study goals. We thank the Botswana Ministry of Health, Gaborone City Council clinics and the Gaborone VCT Tebelopele for their ongoing support and collaboration. Finally, we thank Lendsey Melton for excellent editorial assistance. The primary HIV-1 subtype C infection study in Botswana, the Tshedimoso study, is supported and funded by NIH grant R01 AI057027. This work was also supported in part by the NIH grant D43 TW000004 through the AAMC FIC/Ellison Overseas Fellowships in Global Health and Clinical Research (EM and MK).