Case 2: HIV Testing as the Gateway to Care: A 24-Year-Old Man With A New Diagnosis of HIV Infection

A 24-year-old Latino man comes to the New York City Riverside STI Clinic located in upper Manhattan. He is undocumented and uninsured. He is married to a woman in the Dominican Republic, but since coming to New York City, he has been sexually active with men only. His only contact with the health care system was a visit to the emergency room in the Bronx 2 years ago after he suffered a minor injury at work. During that visit, he was offered a rapid HIV test and he accepted after it was framed as a matter of routine care. The test result was negative. He has not been tested for HIV infection or any other STI since then. The patient recently saw a social marketing campaign promoting the services of STI clinics for all New York City without regard for insurance or immigration status. The patient has been engaging in condomless insertive and occasionally receptive anal sex with multiple male partners that he met at social functions and online. He does not recall the names or Internet handles of most of his sex partners. The patient consents to HIV and syphilis testing and is willing to provide specimens for STI testing including urine, a self-collected rectal swab, and a throat swab. He does not report any symptoms of acute HIV infection or STIs. The patient’s HIV testing includes a fourth-generation rapid HIV test supplemented with pooled NAAT for acute HIV infection if the rapid HIV test result is nonreactive. The point-of-care test result is negative for HIV antigen and positive for HIV antibody.

Clinical Decision Point D

The preliminary test results for this patient are suggestive of established HIV infection (positive for HIV antibody and negative for HIV antigen). Which is the best next step in managing HIV infection in this individual?

Case Presentation 2 (Continued)

The patient’s preliminary positive HIV test result triggers the activation of the STI clinic’s immediate antiretroviral therapy team. This team includes an HIV clinician, a social worker, and a navigator who function to expedite the delivery of HIV care and treatment to individuals qualifying for these interventions. The patient is informed of his test result and is introduced to the HIV clinician who explains the result, educates the patient about HIV infection, and reassures the patient that a new HIV diagnosis is not a death sentence but instead an opportunity to prevent disease progression and further transmission. Once the patient is more comfortable with his HIV diagnosis, a brief medical evaluation is conducted that focuses on stigma of advanced disease, neurologic findings, and a complete evaluation for STIs. The results of the exam are benign, and the patient is offered immediate antiretroviral therapy.

Clinical Decision Point E

Should HIV medications be prescribed for this patient on the same day as his HIV diagnosis?