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The HIV treatment cascade in acutely infected people

informing global guidelines

Rutstein, Sarah E.a,b,*; Sellers, Christopher J.b,*; Ananworanich, Jintanatc,d; Cohen, Myron S.b,e

Current Opinion in HIV and AIDS: November 2015 - Volume 10 - Issue 6 - p 395–402
doi: 10.1097/COH.0000000000000193

Purpose of review Acute and early HIV (AHI) is a pivotal time during HIV infection, yet there remain major shortfalls in diagnosis, linkage to care, and antiretroviral therapy (ART) initiation during AHI. We introduce an AHI-specific cascade, review recent evidence pertaining to the unique challenges of AHI, and discuss strategies for improving individual and public health outcomes.

Recent findings Presentation during AHI is common. Expanding use of fourth-generation testing and pooled nucleic acid amplification testing has led to improved AHI detection in resource-wealthy settings. Technologies capable of AHI diagnosis are rare in resource-limited settings; further development of point-of-care devices and utilization of targeted screening is needed. Rapid ART initiation during AHI limits reservoir seeding, preserves immunity, and prevents transmission. Reporting of AHI cascade outcomes is limited, but new evidence suggests that impressive rates of diagnosis, linkage to care, rapid ART initiation, and viral suppression can be achieved.

Summary With advancements in AHI diagnostics and strong evidence for the therapeutic and prevention benefits of ART initiated during AHI, improving AHI cascade outcomes is both crucial and feasible. HIV guidelines should recommend diagnostic algorithms capable of detecting AHI and prescribe rapid, universal ART initiation during AHI.

aDepartment of Health Policy and Management, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA

bDivision of Infectious Diseases, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA

cU.S. Military HIV Research Program, Walter Reed Army Institute of Research, Silver Spring

dHenry M. Jackson Foundation for the Advancement of Military Medicine, Bethesda, Maryland

eDepartment of Epidemiology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA

*Sarah E. Rutstein and Christopher J. Sellers contributed equally to the writing of this article.

Correspondence to Sarah E. Rutstein, PhD, Department of Health Policy and Management, CB #7411, University of North Carolina at Chapel Hill Chapel Hill, NC 27599-7411, USA. Tel: +1 206 419 8151; fax: +1 919 966 6961; e-mail:

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