New Advances in HIV testing in Vietnam Welcome to the 4th Generation of Rapid Tests

March 20, 2014

Presentation by Nguyen Nhat Quang

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The contents
1. Review the knowledge of basic HIV testing And New Advances in HIV testing in Vietnam 2. The results of HIV testing study in San Francisco 3. Current Vietnam HIV testing Algorithm. 4. Mountainous Model Pilot Approach 5. Recommendations 4th Generation Test Use in Vietnam

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HIV: Serotypes, Groups, and Subtypes

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The subtype CRF01_AE is most prevalence in Vietnam

Global distribution of HIV-1 by subtypes

Region
N. America, Caribbean, latin America and West Europe East Europe, Central Asia N. America, Mid East Southeast Asia Sub-Saharan Africa East Asia Subtypes B A, B B, C B, AE A, C, D, F, G, H, J, K, CRF B, C, BC, CRF 01

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Source: Lancet 2007; 368:489

Transmission and Mechanism of Immunological Response

Antigen Anti body

IgM

IgG

Time of Immune response

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Potential Antigen Targets for HIV Testing

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What do HIV Tests Detect?

Antibody
ELISA/EIA RAPID Immunoassays WB IFA RIPA

Antigen
P24 Ag Immunoassays RAPID Combo Immunoassays

HIV DNA or RNA

NAAT (Nucleic Acid Amplification Test for HIV DNA or RNA) PCR (Polymerase Chain Reaction) Plasma or DBS

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Classification of Rapid HIV tests

First Generation test
Detect IgG antibody Unacceptable rate of false positives Contamination issues

Second Generation test

Detect /IgG antibody Improved sensitivity and specificity False positives and contamination continued to be an issue

Third Generation test

Detect IgM/IgG antibody Sandwich technique employing conjugated antigen Improved sensitivity and specificity

Fourth Generation test

Detect IgM/ IgG antibody and P24 antigen 10-14 day window to detect Acute HIV infection (AHI) Sensitivity of p24 testing is still questionable in AHI May increase indeterminate results

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Source: Future Microbiol. 2009;4(8):963-982.

Evolution of Rapid HIV tests

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Source: Future Microbiol. 2009;4(8):963-982.

HIV Transmission, Eclipse, and Window Period

Window period

IgG

Eclipse Phase

IgM

1st generation EIA

2nd generation EIA

3rd generation EIA 4th-generation Ag/Ab Early HIV infection

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Rapid tests: short timing of detection

Results in ten minutes to 2 hours using blood, urine or saliva. Extremely useful in immediate situations. Many different tests are now available, all with excellent sensitivity and specificity. Negative test can be reported as negative Positive results must be confirmed with additional testing

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RESULT OF DETERMINE HIV 1/2

Test is dameged

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Criteria for WB confirmation

Western blot negative: there is no specific color band. Western blot positive: there are at least 2 color bands correspond to the envelop gene. Western blot suspect (in determinate): one or more color bands does not fix with the standard Western blot positive. _ +

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Example of Confirmatory test Western blot test (WB)

Used as a confirmatory test. Very specific for HIV antibodies Indeterminate tests must be repeated Samples that give a negative result are reported as negative Resource intensive and require high level of external quality assurance

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Sensitivity and specificity and predictive value

Test result Positive HIV status
HIV infections True Positive a No HIV infections False Positive b

(a + b) (c + d)

Negative

False Negative c

True Negative d

(a + c)
Sensitivity Specificity Positive predictive value (PPV) Negative predictive value (NPV)

(b + d) = a/(a+c) = d/(b+d) = a/(a+b) = d/(c+d)

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The Sensitivity and Specificity of Different Tests

HIV test

Sensitivity

Specificity

Determine HIV-1/2 Elisa Genscreen ultra HIV Ag/Ab Elisa Murex HIV Ag/Ab combination ARCHITECT HIV Ag/Ab Combo WB

99.9 100 100 100 98

99.7 99.87 99.80 98 99.9

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Objectives of the San Francisco Study

To assess how new tests might influence the performance of HIV testing programs in San Francisco. To determine how use of these new tests might perform given their variable ability to detect acute infections.

Source: Pilcher et al. PLOS, Volume 8, Issue 12, e80629. December 2013
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Methods
Analyzed 21,234 consecutive HIV tests with venous blood obtained from 2003 to 2008. Using an HIV antibody-plus-RNA test algorithm. New tests and re-testing all specimens that had negative/discrepant antibody results on initial screening Separate analysis of oral HIV test on 127 oral samples from HIV+ patients

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Process of study

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Ability of Tests to Detect Acute HIV Cases, and All HIV Cases San Francisco Targeted Testing Programs, 20032008.
Test Name Type Format Detection of HIV infection among Ab-/RNA+specimens (n = 66 cases)
Ab Screening Assay-, WB-/ind Acute Specimens (n = 58)
Test+ %

Estimate of potential for case finding by each test

Numerator includes 695 Ab screening test+, WB+specimens

Ab Screening Assaybut WB+Specimens (n = 8)

Test+ %

Test+

ARCHITECT HIV Ag/Ab Combo(4thgeneration) Determine HIV-1/2 Ag/Ab Combo Genetic Systems HIV-1/2 Plus O (3rd generation ) Oraquick Advance (on blood plasma)* Genetic Systems HIV WB (any bands positive)

Ag-Ab

Rapid lab IA

48/55

87.3

6/6

100.0

754/761

99.1

Ag-Ab
Ab

POC RT
Lab IA

31/57
20/58

54.4
34.5

8/8
8/8

100.0
100.0

735/761
723/761

96.6
95.0

Ab
Ab

POC RT

3/58

5.2
27.6

8/8
8/8

100.0
100.0

706/761
719/761

92.8
94.4
20

Western 16/58 blot

Detecting Acute HIV Infection

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Findings and Conclusions of the study

Some rapid antibody blood tests will give similar case detection to laboratory antibody tests. Oral fluid testing has limited ability to detect Acute HIV infection. New 4th-generation combo tests can increase detection of acute infections detectable by HIV RNA and could be used for high risk population groups with active transmission.

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HIV cascade in Vietnam

OUTREACH & LINKING TO TESTING

CONFIRMATION OF HIV(+) TEST

EFFECTIVE REFERRAL TO CARE

Most at risk

ART ELIGIBLE

RETAINED IN CARE & ART INITIATION

HIV Testing

ADHERENCE

HIV Diagnosed

Care
ART Initiation

Sustained on ART

Viral Load Suppression

CONTINUM OF PREVENTION TO CARE (CoPC)

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The HIV testing in Vietnam

Adults and Children>18 months: HIV tests (screening rapid and confirmation with 2 ELISA + 1 Rapid) used popularly to confirm HIV positive. Delays from time of first positive rapid test to confirmation (3-5 days). PCR HIV tests are used to detect HIV DNA applied in HIV exposed children <18 months old with HIV Ab (+)) . Recently, the 4th Generation testing (detect both antigen-antibody combo HIV tests ) have used but role unclear

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Current HTC testing in HCM city

HIV test Reactive Transfer the sample to the PMC laboratory to confirm

1/Determine HIV 1/2

HTC site
Determine HIV 1/2

HIV test No Reactive

HIV test Reactive

2/ELISA Genscreen Ultra HIV Ag/Ab 3/ELISA MUREX HIV Ag/Ab combination
HIV test No Reactive
2(-),3(-)

Confirm HIV(-), but counselling about the windows period

2(+), 3(-) 2(-), 3(+)

2(+), 3(+)

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Undetermined, counselling HIV testing again after 14 days

Confirm HIV (+)

Mountainous Model: The HIV testing pilot

Pilot new HIV testing approach in mountainous areas three sequential rapid tests at districts after one positive rapid at commune Likely some overlap in antigen/antibodies tested but still acceptable PPV. Avoids specimen transportation in high-heat conditions to provinces for confirmation Still requires EQAs at district level

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Mountainous Model Confirmatory Tests

Screening Test Used

Sensitivity

Specificity

Determine HIV-1/2

100 100 100

99.7 99.87 99.80

SD Bioline 1/2 3.0

Double CheckGold Ultra HIV 1&2

Source: NIHE, manufacturer inserts, FHI360 lab team

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Mountainous Model Algorithm

Approach testing in phase done parallel for comparison

SP Determine HIV Ab

Reactive with screening test? Yes START ART, Confrim with SP SD Bioline HIV 1/2 3.0 & Double CheckGold HIV 1&2 Whole Blood Transfer the sample to the PAC laboratory to confirm and comparison (preservation of samples for comparison?)
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No

Confirm HIV(-) and return the test result and counselling

01test or both tests are not reactive

Both tests are reactive

Reply suspect results undetermined ", appointment to tested again after 14 days

Counselling on suspected results and support the patient register into OPC for treatment immediately, while waiting to confirm test results and inform with the clients their test result will be returned in OPC

What are the advantages of opt-out screening?

More persons with HIV can be identified earlier with routine HIV screening (opt-out screening). Reduction of risky behaviors has been observed following detection of HIV infection and subsequent patient education. Effective care can decrease morbidity, mortality, and community viral load.

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Potential Application of 4th Generation Tests in Vietnam Use only makes sense if prevention and care and treatment resources can be mobilized quickly to reduce transmission. Follow-up confirmation on p24 positive and indeterminate results still requires confirmation. New 4th-generation combo tests could be used in highrisk HIV testing programs, especially MSM. Should be used as initial test in mountainous test and treat strategy. EQAs is critical otherwise acute cases will be missed

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Thanks

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