HIV Testing Algorithms

1

• HIV Testing Algorithms
• A Long Journey
• Eugene G. Martin, Ph.D.
• Professor Pathology Laboratory Medicine
• UMDNJ Robert Wood Johnson Medical School
• Co-Director, NJ HIV

2
AGENDA

• Background HIV Testing 1985 -2013
• Overview of Current  HIV Testing Algorithms
• Testing performed at public sites LICENSURE
  DETERMINES OPTIONS
• Testing preformed in hospital laboratories
  MIXTURE OF LAB-BASED POCT-BASE
• Testing performed in national laboratories
  GAMUT with use of reflex testing driven by
  results
• CDC updates and revisions over the past few
  years
• CDC/APHL DIAGNOSTIC CONFERENCES 2004-2012
• CDC TASKFORCES HIV LAB POCT TESTING, AHI DEFN
• DRAFT HIV DIAGNOSTIC GUIDELINES 2013
• Testing Results
• Result and Interpretation.    
• THE connection
• Linkage to Care

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BACKGROUND

• THE CONTEXT

4
CDC estimates

• 1.2 million people (US) are living with HIV
• One in five (20) are unaware of their infection
• While relatively stable for several years the
  rate of new HIV infection rate is substantial ?
• About 50,000 become infected each year
• Prevalence is increasing because of
  anti-retroviral therapy.
• The problem infectivity is largely a function of
  viral load and risk encounters

5

• Gardner et al. Clin Infect Dis 201152 Marks et
  al. AIDS 201024

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Why Rapid Testing Algorithms are Need in Public
Health?

• Problem
• Preliminary Positive clients fail to return for
  results (25.2)
• NAP succeeds ONLY 20 of the time in locating
  these clients
• Solution
• Confirmatory testing on-site, same day
• In use, high prevalence areas worldwide

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Key Questions

1. What strategies will get more people to learn
   their HIV status?
2. How do we get more infected individuals into care
   AND encourage earlier treatment?
3. How does improved ART impact efforts to reduce
   transmission?

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• Recently Large Change in Focus. Why?
• 40 of HIV infections occur in the earliest
  stages of the disease
• New 4th generation HIV Tests are allowing us to
  identify infected individuals when they are most
  infectious!
• Earlier treatment preserves immune function and
  improves morbidity
• LINKAGE TO CARE Underpins prevention
  treatment ...
• Test to Treat
• Treatment as Prevention

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Transmission is a function of viral load!
5
Risk of Transmission Male to Female -
Blue Reflects Genital Viral Burden
Yellow Effect of ART Theoretical - Red
Evolving Opportunity!
HIV RNA in Semen (Log10 copies/ml)
4
(1/100- 1/1000)
(1/30-1/200)
3
(1/500 - 1/2000)
(1/1000 1/10,000)
HIV Screening before 2012
2
Acute Infection
Asymptomatic Infection
HIV Progression
AIDS
Cohen and Pilcher, JID 1911391, 2005
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AHI Acute HIV Infection

• SYMPTOMS - ACUTE HIV INFECTION
• Rash /or fever(s), possibly in combination with
• Malaise
• Loss of Appetite
• Weight loss
• Sore Throat
• Mouth Sores
• Joint Pain
• Muscle Pain
• Swollen lymph nodes
• Diarrhea
• Fatigue
• Night sweats
• Nausea/vomiting
• Headache
• Genital Sores

• 70-80 symptomatic, 3-12 weeks after exposure
• Surge in viral RNA copies to gt1 million
• Recently we had one 10 million copies!!
• CD4 count drop to 300-400 w/ rebound
• Recovery in 7-14 days
• Because individuals with AHI are highly
  infectious, have engaged in high risk behaviors,
  and are often unaware of their status they
  contribute substantially to the spread of HIV.
• Although AHI is short (typically 3-4 weeks),
  studies have consistently shown that 40-50 of
  new HIV transmissions are caused by onward
  transmission from an individual with AHI.

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HIV Testing 1983 ? Present Day

• 1980s -T-cell assays
• 1985 HIV Antibody testing Lab-based
• Enzyme Immunoassays 1st Gen
• 1987 HIV Western Blot criteria Why?
• 1991 Improved EIA 2nd Gen
• 1996 Oral mucosal transudate testing- OraSure
• 2003 Rapid testing (blood and then oral
  transudate)
• Current Rapid 3rd gen assays and laboratory 4th
  gen assays with available nucleic acid
  amplification testing (NAAT)
• Current Rapid 4th gen assays with both antibody
  and antigen p24 testing (Determine, FDA approved)
• Future Rapid CD4/CD8 assays and rapid viral load
  assays

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HIV Infection
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Serologic markers DURING HIV-1 infection

• THE CONTEXT

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Assay Reactivity during Early HIV
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Typical HIV Serologic Profile
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Viremia During Early HIV Infection

• Ramp-up Viremia Doubling Time 21.5 hrs
• Peak Viremia106 108 gEq/mL
• Viral set-point102 105 gEq/mL
• WINDOW
• Antibody 22 Days
• Antigen 16 Days
• Pooled NAT 14 Days
• Individual NAT 11 Days

HIV Antibody 3rd Generation 22 Days
P24 Ag 16 Days
Pooled NAAT 14 Days
Individual NAAT 11 Days
0 10
16 22 DAYS
ANTIBODY WINDOW
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HIV Tests are NOT all equal
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BACKGROUND

• Testing 1985-2003
• CLIA - Waived Rapid HIV antibody tests
• Orasure
• Oral
• Fingerstick
• Clearview
• Trinity
• Insti (2011) 1 Minute to Read
• 2010 ? 4th generation testing
• Laboratory-based (CLIA MOD. COMPLEXITY)
• Abbott Architect Combo HIV1/2 Ag/Ab
• Biorad
• Rapid HIV Antigen/Antibody tests (2013) (PENDING
  CLIA WAIVER)
• Alere Determine (HIV1/2 Ag/Ab)

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Whats it all about?

• SCREENING versus DIAGNOSIS
• SCREENING FOR HIV ? Focus on LINKAGE TO CARE
• Orthogonal Confirmation
• Presumptive Diagnosis Pending additional
  testing
• CD4
• NAAT Testing Aptima
• LAB-BASED DIAGNOSIS
• Manufacturers Package Insert couple with a
  confirmatory step

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MMWR September 22, 2006 / 55(RR14)1-17
Revised Recommendations for HIV Testing of
Adults, Adolescents, and Pregnant Women in
Health-Care SettingsBernard M. Branson, MD1 H.
Hunter Handsfield, MD2 Margaret A. Lampe,
MPH1Robert S. Janssen, MD1 Allan W. Taylor,
MD1Sheryl B. Lyss, MD1Jill E. Clark, MPH3
1Division of HIV/AIDS Prevention, National
Center for HIV/AIDS, Viral Hepatitis, STD, and TB
Prevention (proposed) 2Division of STD
Prevention, National Center for HIV/AIDS, Viral
Hepatitis, STD, and TB Prevention (proposed) and
University of Washington, Seattle, Washington
3Northrup Grumman Information Technology
(contractor with CDC)

• Routine HIV testing for adolescents and adults in
  health-care settings
• Test everybody unless specifically denied
• Screen for HIV regardless of prevalence (as
  effective in very low prevalence as in high
  prevalence areas).
• High-risk individuals at least annually,
  recommended every 6 months
• Drug users are by definition high-risk
• Addiction treatment centers
• Methadone programs
• Needle exchange programs
• strange advantage patients keep returning to
  the center, so counseling, linkage to care or
  additional tests can be performed

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4th gen. Lab Based Assays

• To Date FDA Has Approved 2

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FDA Approval 4th gen. Lab Based Assays

• 18 June 2010 Abbott Architect HIV Ag/Ab Combo
  Assay
• First diagnostic test approved by FDA for use in
  children as young as 2 years of age, and pregnant
  women.
• Specific for the detection of the HIV-1 p24
  antigen , as well as antibodies to HIV-1 groups M
  and O, and as antibodies to HIV-2.
• 22 July 2011 - GS HIV Combo Ag/Ab EIA, (Bio-Rad
  Laboratories)
• Neither test distinguishes between HIV-1 p24
  antigen, HIV-1 antibody, or HIV-2 antibody in a
  sample, but they are sensitive to the presence of
  p24Ag.
• Patients who identify a specific risk
  occurring more that 4 weeks previously, should
  not be made to wait three months (12 weeks)
  before HIV testing. They should be offered a 4th
  generation laboratory HIV test and advised that a
  negative result at 4 weeks post exposure is very
  reassuring/highly likely to exclude HIV
  infection. An additional HIV test should be
  offered to all persons at three months (12 weeks)
  to definitively exclude HIV infection. Patients
  at lower risk may opt to wait until three months
  to avoid the need for HIV testing twice.

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• Study design
• 9150 samples at four U.S. clinical trial sites,
  using three kit lots. Unlinked samples were from
  routine testing, repositories or purchased from
  vendors.
• Results
• GS HIV Combo Ag/Ab EIA detection in samples from
  individuals in two separate populations with
  acute HIV infection was 95.2 (20/21) and 86.4
  (38/44). Sensitivity was 100 (1603/1603) in
  known antibody positive HIV-1 Groups M and O,
  and HIV-2 samples.
• HIV-1 seroconversion panel detection improved by
  a range of 020 days compared to a 3rd generation
  HIV test. Specificity was 99.9 (5989/5996) in
  low risk, 99.9 (959/960) in high risk and 100
  (100/100) in pediatric populations.

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NJ Facilities with 4th Gen. HIV testing Oct.
2013

• CentraState Medical Center
• 901 West Main Street,
• Freehold TWP NJ 07728
•  
• Jersey Shore University Medical Center
• 1945 New Jersey 33
• Neptune, NJ
•  
• St. Barnabas Medical Center
• 94 Old Short Hills Rd.
• Livingston, NJ 07039
•  
• Newark Beth Israel Medical Center
• 201 Lyons Ave.
• Newark, NJ 07112
•  
• St. Peters Medical Center
• 254 Easton Ave.
• New Brunswick. NJ 08901

• Our Lady Of Lourdes Medical Center
• 1600 Haddon Ave.
• Camden NJ
•  
• Shore Memorial Hospital
• 1 E New York Ave.
• Somers Point, NJ 08244
•  
• RWJ Hamilton
• 1440 Lower Ferry Rd.
• Ewing twp, Nj
•  
• St, Josephs regional Medical center
• 703 Main Street.
• Paterson, NJ 07503
•  
• UMDNJ
• 150 Bergen stHackettstown Medical Center
• 651 Willow Grove St.

VA East Orange 385 Tremont Ave. East Orange
NJ   Hackensack University Medical Center 30
prospect ave. Hackensack, NJ 07601   Manhattan
Labs 25 riverside Dr. Pine Brook NJ
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HIV Rapid Screening Tests
CLIA-waived Complexity
Clearview StatPak
Clearview HIV1/2 Complete
Trinity Uni-Gold
Oraquick Rapid
MedMira Reveal
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(No Transcript)
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Test develops in 20-40 minutes
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Rapid HIV Testing Results
Trinity Unigold
Orasure Oraquick
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3.5 ? 4th Gen Point-of-Care Test
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• All 7 false positive p24 Ag sera were correctly
  identified by the Determine Combo test as
  negative.
• 5/14 of the p24 Ag true positive sera (early
  seroconversion) were missed by the Determine
  Combo test and tested negative for both p24 Ag
  and antibodies

• Even though there is a 64 improvement over a
  third generation (Ab only) POCT, health care
  professionals should still be aware that the
  Determine HIV-1/2 Ag/Ab Combo is not as sensitive
  as 4th generation Lab-based EIAs in diagnosing
  primary HIV-1 infections!!

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ALGORITHMS

• Laboratory-based
• Point-of-Care based

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NJ RAPID TESTING ALGORITHM
ORTHOGONAL
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PRESUMPTIVE DIAGNOSIS

• When Rapid HIV Tests are used as a part of an
  RTA, a diagnosis can be made with a CONFIRMATORY
  Western blot OR by a second (but different
  manufacturers) rapid test.
• If the diagnosis is made by a second rapid
• Presumptive Diagnosis and requires further
  testing at the treatment site as a part of
  staging the infection.

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November, 2011RTA MEETS CDC HIV CASE DEFINITION

• Dear ColleaguesThank you for joining us on
  last weeks HICSB Quarterly Call.  Attached is
  the letter discussed during the call regarding
  the new HIV testing algorithms guidance issued by
  the Clinical Laboratory and Standards Institute
  (CLSI).  The letter affirms that these new
  algorithms meet the current HIV case definition
  and provides instructions for recording a case
  diagnosed using the new algorithms in eHARS.We
  recognize these new algorithms represent a shift
  in surveillance practices.  To help states
  address these changes, HICSB is creating a list
  of Frequently Asked Questions (FAQs).  Please
  send your questions to Adria Prosser at
  ahp8_at_cdc.gov and cc your surveillance programs
  CDC epidemiology consultant.Best regards,H
  Irene Hall, PhD, FACE

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• Review of HIV-1 Confirmation testing WB/Aptima
• While Western blot (WB) is still widely
  considered a gold standard
• No longer suitable, more sensitive assays in use
  already
• Issue aggravated by potential availability of
  Ag/Ab Combo rapid assays
• Cost. Also, cost dependent on TAT requirements
  i.e. if rapid TAT, cost increases (kit-based
  assay)
• Serum sample
• Aptima
• approved for diagnosis of HIV-1 (early AHI/
  primary HIV, no antibodies yet)
• Approved for confirmation of HIV-1 if antibody
  screen is positive
• Lab based method, sensitivity similar to FDA
  approved viral load assays
• Plasma sample (or conversely, Whole Blood if spun
  adequately)

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• Possible HIV CONFIRMATORY pathways
• On-site RAPID3 with On-site RAPID3 verification
  (current RR algorithm)
• On-site RAPID3 with remote EIA3 or EIA4
• EIA can serve as an orthogonal assay
• On-site RAPID3 with remote RAPID3
• On-site RAPID4 Antigen ONLY with remote Aptima
• On-site RAPID4 Antibody/Antigen (Lab-based or
  POCT) with an ON-SITE RAPID3
• Discordant results will be handled by same
  procedures by NJHIV staff/ docs
• Still need sample collected for discordant
  resolution
• If remote EIA/ rapid, need to get client back to
  site
• Delay referral
• Delay entry into care
• Refuse confirmation possible for all remote tests
• If on-site verification, referral to care faster,
  eliminates non-returners, blood draw refuse

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• Summary of Interpretation of HIV-1 Specimen
  Results
• The individual should be referred for medical
  follow-up and additional testing.
• Antibody results should be confirmed with
  Western blot or IFA.
• A nonreactive test result does not preclude
  the possibility of exposure to or infection with
  HIV-1.
• Sample requirements for Aptima (studies with
  alternative specimens, good results available)

APTIMA HIV-1 RNA HIV-1 Antibody Result Interpretation
A Reactive Repeatedly Reactive Confirmed HIV-1 infection
B Repeatedly Reactive Nonreactive Possible acute/ primary HIV-1 infection
C Nonreactive Repeatedly Reactive Unconfirmed HIV-1 Positive
D Nonreactive Nonreactive or Not Done HIV-1 RNA not detected
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But an important question remains

• How often do we miss an early infection?
• How often do we screen an individual and tell
  them theyre negative, when, in fact, they are
  most likely to infect others?

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NAAT TESTING

• Screening for Acute HIV Infection in Newark, NJ
• Eugene Martin1, Debbie Mohammed2, Gratian
  Salaru1, Joanne Corbo1, Michael Jaker2, Joan
  Dragavon4, Robert Coombs4, Sindy Paul3, and Evan
  Cadoff1
• 1 UMDNJ Robert Wood Johnson Medical School,
  Somerset, NJ 088732 UMDNJ New Jersey
  Medical School3 New Jersey State Department
  of Health and Senior Services, Trenton, NJ 4
  University of Washington, Seattle, WA
• Use of rapid HIV in conjunction with pooled NAAT
  allows assessment of the burden of acute HIV
  infection (AHI) in a particular locale.
• Clients offered NAAT testing after rapid HIV
  testing. Of those accepted (50), specimens
  collected shipped to Univ. of Washington where
  NAAT was performed.
• 8 AHIs identified in 6785 specimens tested.
  Approximately 6.9 increase in yield over AB
  only

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Reminder 10 -14 Days Ramp-Up Phase Rapid Viral
Replication
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NAAT Testing of Antibody Negative Blood
Results Nationwide
Program Dates Description Rapid Tested NAAT Tested AHI HIV Ab HIV Ab Inc in Yield Yield AHI
Maryland 6/06-3/08 HIV Ab neg adults seen at two STD clinics (6/06--3/08) multiple venues 7/07-3/08)   58925 7 1709 2.90 0.41 0.01
North Carolina 11/02-10/03 HIV Ab neg persons in North Carolina seeking HIV testing at 110 publicly funded sites (n 109,250)   108667 23 583 0.54 3.95 0.02
Los Angeles 2/04-4/04 HIV Ab neg men seeking HIV testing at three STD clinics (n 1712)   1698 1 14 0.82 7.14 0.06
NEWARK, NJ 2/10 to 1/12 HIV Ab neg adults receiving testing and counseling at two high risk urban hospitals in Newark, NJ 12390 6785 8 116 0.94 6.90 0.12
Seattle King County 9/03-1/05 HIV Ab neg MSM seeking HIV testing through Seattle-King County (n 3525)   3439 5 81 2.36 6.17 0.15
Atlanta 10/02-1/04 2202 adults receiving HIV testing and counseling at three high risk urban sites in Atlanta, Georgia   2136 4 66 3.09 6.06 0.19
San Francisco 10/03-7/04 HIV Ab neg persons seeking HIV testing at San Francisco Municipal STD clinic (n 3075)   2722 11 105 3.86 10.48 0.40
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HIV Tests have come a long ways
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Conclusions

• NAAT tells us were missing of 6-8 of those
  infected when we screen for antibodies!
• Those with the highest risk of infecting others
  are the ones being missed!!
• The same issues with patient return and process
  completion occur with NAAT that occur with
  traditional testing!!!
• Solution EIAs that pickup p24 Ag COULD pickup
  a substantial proportion of the same population.
  A POCT device could increase the pickup without
  losing the ability to link patients to care.

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Recommendations 2013 - CDC Diagnostics

• Recommendations
• Initiate screening with a 4th generation Ag/Ab
  combination immunoassay (IA)
• Reactive (repeatedly reactive) specimens should
  be tested with a 2nd generation Ab IA that
  differentiates HIV-1 from HIV-2 antibodies.
  (MULTISPOT)
• Persons whose specimens are positive on the
  initial IA and antibody differentiation IA should
  be considered positive for HIV-1 or HIV-2
  antibodies and initiate medical care that
  includes laboratory tests such as viral load,
  CD4, and antiretroviral resistance assays.
• Specimens reactive on the initial IA and negative
  on the HIV-1/HIV-2 Ab differentiation IA should
  be tested for HIV-1 RNA. A reactive result
  indicates Acute HIV-1 infection.
• Follow this same testing algorithm (beginning
  with 4th generation IA) for specimens with a
  previous reactive rapid HIV test result.

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• Alternatives
• If 3rd gen HIV-1/2 IA as initial test perform
  subsequent testing specified in the algorithm.
• If alternative 2nd Ab test is used (e.g., WB or
  IFA) If negative or indeterminate, perform HIV-1
  NAT if HIV-1 NAT is negative, perform Ab IA for
  HIV-2
• HIV-1 NAT as 2nd test if positive, HIV-1
  infection if negative, perform HIV-1/HIV-2 Ab
  differentiation assay.

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• Supersedes
• Recommendations for Use of Western Blot (1989)
• Recommendations for HIV-2 Antibody Testing (1992)
• Protocols for confirmation of reactive rapid
  tests (2004)
• Screens for both virologic and serologic markers
  of HIV infection
• Incorporates NAT to resolve discordant IA results
  
• Identifies acute HIV-1 infection
• Reduces indeterminate test results
• All IA-positive specimens tested for HIV-2
• Emphasizes sensitivity
• For initial testing
• During supplemental testing
• Rare false-positive antibody test results might
  occur
• False-positive results would be discovered during
  subsequent laboratory testing recommended as part
  of initial clinical evaluation

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THE END
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NJHIV WHO WE ARE

• Rapid HIV testing support group
• Composed of laboratorians
• MD, PhD, MT, RN
• Department of Pathology and Laboratory Medicine
  at Rutgers Robert Wood Johnson Medical School
• Built upon an existing Rutgers Robert Wood
  Johnson Medical School, multi-facility,
  point-of-care-testing program
• Develop a centralized quality assurance process
• Management by board certified Pathologists,
  experienced laboratory professionals, RNs and
  medical technologists
• Supervisory control through site coordinators

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New Jersey Rapid Testing

• RWJ Sites 97 Non RWJ Sites 64

Rapid HIV Testing NJ Rapid HIV Testing NJ
RWJ sites  
  60 Primary
  24 satellites
  13 mobile
Non RWJ site  
  64 sites including 12 ERS
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Sites, laboratories and point-of-care locations
supervised by the Department of Pathology at
RWJMS
NJHIV AtlantiCare Mission Health-Atlanitc County
Corrections Atlantic City Health
Department Bergen County Health
Department Burlington County Health
Department Camden AHEC Camden County Health
Department Catholic Charities-Hudson Union
County Corrections Check-Mate City of
Trenton City of Vineland Complete Health
Care Cumberland County Health Department Dooley
House East Orange Health Department Eric B.
Chandler Health Center FamCare Hamilton Township
STD Clinic HiTops Inc. Henry J. Austin Health
Center Horizon Health Center Hunterdon County
Health Department Hyacinth Foundation John Brooks
Recovery (IHD) Jersey Shore Addiction Services
(JSAS) Kean University La Casa Don
Pedro Liberation In Truth Drop In
Center Middlesex County Department of
Health NAP Neighborhood Health Centers Newark
Community Health Centers Newark STD Clinic NJCRI
NJHIV N. Hudson Community Action Corporation
Health Ctrs. Oasis Drop In Center Ocean County
Health Department Paterson Health
Department Proceed Saint James Social
Services Robert Wood Johnson Medical
School Visiting Nurse Association of Central
NJ Well of Hope William Paterson College
Hospitals /Laboratories State Public Health
Laboratories Bayshore Community
Hospital Childrens Specialized Hospital, New
Brunswick Childrens Specialized Hospital,
Mountainside Robert Wood Johnson University
Hospital Robert Wood Johnson University Hospital
at Hamilton Southern Ocean County
Hospital University Behavioral Healthcare,
Piscataway
Medical offices POCT New Brunswick/Piscataway
Chandler Health Center Clinical Academic
Building Clinical Research Center Cancer
Institute of New Jersey Medical Education
Building Monument SquareIcon Laboratories CRC
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Thanks To

• NJ DMHAS
• Adam Bucon
• Nancy Hopkins, MAS
• Mollie Greene

• RWJMS
• Evan Cadoff, MD
• Eugene Martin, Ph.D.
• Gratian Salaru, MD
• Joanne Corbo, MBA, MT
• Mooen Ahmed, MT
• Claudia Carron, RN
• Aida Gilanchi, MT
• Nisha Intwala, MT
• Franchesca Jackson, BS
• Lisa May
• Karen Williams

Site coordinators and counselors throughout New
Jersey