Interview:
Peter Leone, M.D.
Medical Director, HIV/STD Prevention & Care Branch
Associate Professor of Infectious Diseases, UNC-Chapel Hill School of Medicine
The state identified two college students infected with acute HIV in 2002, which led to a retrospective investigation that uncovered an outbreak of HIV on college campuses statewide. What did the investigation find?
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We decided we would narrow or focus because of these two cases to 18-30 year old men in the state, newly diagnosed with HIV, and we went back to 2000. What we found was very few cases in 2000, but a gradual increase from 2000 through 2003, so that by 2003 we had 30 new cases of HIV in college students that had been diagnosed that year. That represented about four percent, in 2000, of all HIV cases in 18-30 year old men. By the time we got to 2003, about 16 percent of all the cases in that age range were in college students.
It did not stay in one area or one type of school, so we're talking about state schools, private schools, historically black colleges, technical schools, and community colleges.
Most of these men seem to be meeting partners over the internet and by going into bars and clubs, so even though it's spread out over the state and we have 30 colleges and universities involved in this outbreak in the state of North Carolina, it seems to gravitate more toward the metropolitan areas where people can meet or hook up.
The Centers for Disease Control and Prevention also investigated this outbreak. What did they find?
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They did a behavioral investigation, and what we found in that study was behaviors in the college students that were newly diagnosed with HIV aren't very different than in non-infected college students, suggesting there may be a really large group of individuals at risk for HIV infection. A lot of these students grossly underestimated their own risk. Even though they were engaging in relatively high-risk sexual behavior, and what I mean by that is we're talking 30 to 40 percent of these students engaging in unprotected receptive anal intercourse, probably the highest risk activity you can engage in, yet none of them - zero - thought they were likely or very likely to contract HIV.
I just counseled a student yesterday, newly diagnosed, very bright kid. He said well, I knew about some of these cases but didn't think there was that many and I took steps to protect myself. He only had two partners, really, in the last six months, but he underestimated his own personal risk. So we're doing everything we can to get the message out to students that if they're sexually active, that's true whether they're male or female, whether they're straight, gay, or bi, they're potentially at risk for HIV. They need to know their status, their partner's status, if they're going to engage in sex. If they're going to engage in sex, they need to use barrier methods, and if they want to protect themselves the best thing they can do is not have sex.
You believe this outbreak should be a call to action?
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Because these are future leaders, they are people that are respected in their communities, and they're kids, we really need to respond to this in a way we haven't responded before.
This is devastating for the African American community in this state, it really is. And we've seen a galvanization around a message among African Americans in North Carolina, in fact in the country, that I've never seen before, and it really should spur much more in the way of activity and prevention messages getting out there.
I'm hoping in all of this we can sort of address some of the issues around HIV and homosexuality because what I think really fuels this is the stigma associated with HIV and the fear associated around homosexuality. And until we actually open that dialogue and create an environment that is safe for individuals and their lifestyles, I think we're going to continue to see transmission of HIV and high risk activity that we can't change.
What is Acute HIV?
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Acute HIV refers very specifically to the period in time after someone's infected with HIV in which virus appears in the bloodstream but there's no antibodies yet that we can detect in the blood. And that pretty much occurs a week to two weeks after someone's infected, so if someone's having, say, unprotected sex and gets infected with HIV, about 7 to 14 days after their sexual contact, the virus will move from sort of the local, regional lymph nodes, areas where virus first enters into the main part of the body and then breaks out into the bloodstream. It takes about 4 to 8 weeks after that happens for the body's immune system to really respond and produce antibodies that we can detect, so acute HIV really refers to this window of time where the virus, HIV, is replicating without much control from the body's immune system. Our traditional ways of detecting HIV were dependent on an antibody response, so this is a period that we can miss because of that.
As a result it is the most infectious period of HIV. Period. It's a very short window of time we're talking about yet some estimates put as much as 40 to 50 percent of transmission occur during this acute period. So when you're looking at a lifelong infection with hiv - 10, 20 years - and almost half of transmission events can be attributable to the first two months of infection, it's a very critical time to find folks.
North Carolina became the first state in the country to test for acute HIV in November 2002. Why, and what is the benefit?
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So we think from a public health standpoint it's very important to identify these folks because the likelihood of their transmitting HIV to their partners is extremely high. The second reason we think it's important is you have people coming in for HIV testing. They want to know if they're infected. We know we have a scheme, or a way at least, to identify these folks during this period, we should try to do everything we can to identify folks when they come in and tell them yes, you're infected, or no, you're not. To have folks come in to us and tell them you're probably not infected, we want you to come back in three months, a lot of individuals just assume they're not infected. We could lose those folks for years.
HIV is a series of epidemics, geographically local or within different risk groups. By looking at acute HIV, we know we have transmission events. We know that that person got infected from someone else who has HIV and they got infected within about a 6 to 8 week window period. That allows us to be very focused in interventions. We know where those transmissions occur. We can then look at risk groups and plan interventions that are targeted geographically and with very specific messages to get that at risk population. If we don't have this tool we may be years at recognizing changes.
The benefit of identifying acute HIV is on the individual level, to find out you're infected, get you into care, maybe make a difference in your long term progression. We benefit you and your partners by preventing transmission, at least we hope so. And third it allows us to actually intervene with a prevention message that's very targeted and gets us to the point where transmission is occurring.
There is no other state in the union that's doing this program. Many states are interested in doing it, but it's somewhat unique in that we've combined laboratory services through the state lab with our field service activities where we go out and notify individuals and notify their partners, or help them notify their partners.
This sort of new model is very different than anything that's been done in HIV anywhere in the world, and we think that it puts North Carolina in a real advantageous position to do something about the epidemic.
Why should people care about the HIV/AIDS epidemic in North Carolina?
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You should care because if you're sexually active you're potentially at risk for HIV. This epidemic is far from over in the United States. We're seeing more and more young adults get infected in North Carolina, particularly young black men. We've seen a doubling of the rates of HIV infection in the last three years in young black men in North Carolina. We haven't seen that increase in any other group to that extent. So if you're young and sexually active you should be concerned and you should take steps to protect yourself, but also we want you to know that if you go in to get an HIV test we're doing everything we can to find out whether you're infected. If you're not at risk you should care because whether or not you care about individuals getting a life threatening disease - which I argue you should be - it's costing you money. So if you don't have compassion or empathy for some of the folks that I care about a great deal and a lot of us in the state do, not identifying HIV and preventing transmission will cost money. It will cost the system money. It will destroy lives. It will disrupt families.
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