HIV testing updates and challenges: when regulatory caution and public health imperatives collide

Viral infection and its impact on fertility, medically assisted reproduction and early pregnancy - a narrative review

Viral infections can significantly affect the physiopathology of reproductive organs, leading to fertility problems, reducing the success rates of assisted reproductive technologies, and negatively impacting pregnancy. This review aims to summarize the current evidence on viral pathogens that are either suspected or confirmed to play a role in reproductive medicine and their effects on early pregnancy. For instance, viral hepatitis and human immunodeficiency virus can decrease sperm quality. Human papilloma virus infection in men appears to cause infertility, while herpesviruses pose a greater risk to fetuses rather than to fertility. The Zika virus disrupts early embryo development, necessitating a delay in conception for those suspected or confirmed to be infected. The effects of SARS-CoV-2 on reproduction are still unclear. Rubella and cytomegalovirus can cause serious congenital defects, making pre-conception screening essential, and a Rubella vaccine is recommended. More rigorous studies are needed to clarify the roles of various infectious agents, enhance fertility treatments, and improve pregnancy outcomes while reducing complications.

HIV Self-Testing: A Discussion on the Benefits, Limitations, and Implications for Public Health with a Focus on Poland

BACKGROUND/OBJECTIVES

A late HIV diagnosis represents a significant public health concern in Poland, with approximately 50% of patients being identified as late presenters (LPs), resulting in the delayed initiation of treatment. This study assesses the potential of HIV self-testing (HIVST) to enhance early detection, particularly among heterosexual individuals, and evaluates its advantages and limitations within the Polish context.

METHODS

This study examines the advantages and disadvantages of HIVST by analyzing data from various studies. It focuses on the acceptability, sensitivity, and specificity of HIVST, comparing blood-based and oral fluid-based tests. Moreover, the economic impact and potential public health benefits of HIVST in Poland are evaluated.

RESULTS

HIVST is well-accepted, especially among key populations; it can reduce stigma and enhance privacy. The results of studies conducted in Poland indicate that heterosexuals are more inclined to use self-testing methods than traditional diagnostic procedures. On the other hand, HIVST has the potential for false-negative results due to the serological window and the possibility of missed diagnoses of other sexually transmitted infections (STIs). Moreover, the cost of HIVST remains a significant barrier, as it is not publicly funded in Poland.

CONCLUSIONS

Despite its limitations, HIVST offers a number of significant benefits, including increased rates of testing and earlier detection, which could prove vital in reducing the transmission of HIV in Poland. This study proposes that increased funding, the integration of HIVST into public health strategies, and further research to enhance its implementation, alongside education and support for its effective use, should be prioritized.

Highlighting and addressing barriers to widespread adaptation of HIV self-testing in the United States

INTRODUCTION

HIV self-testing (HIVST), whereby an individual performs and interprets their own rapid screening test at home, is another tool to increase the proportion of at-risk individuals who know their status. Globally, HIVST has rapidly been adopted through global partnerships to ensure equitable access to tests in low- and middle-income countries (LMIC).

AREA COVERED

This review discusses the regulatory burdens of HIV self-testing within the United States while examining the use of HIV self-tests on a global scale. While the United States only has one approved HIV self-test, numerous tests have been prequalified by the WHO.

EXPERT OPINION

Despite the US Food and Drug Administration (FDA) clearance of the first and only self-test in 2012, there have been no other tests that have undergone FDA consideration due to regulatory barriers. This, in turn, has stifled market competition. Despite existing evidence that such programs are an innovative approach to testing hesitant or hard-to-reach populations, high individual test cost and bulky packaging make large-scale, mail-out, and HIV self-testing programs expensive. COVID-19 pandemic has accelerated the public demand for self-testing - HIV self-test programs should capitalize on this to increase the proportion of at-risk people who know their status and are linked to care to contribute to ending the HIV epidemic.

Molecular epidemiology in the HIV and SARS-CoV-2 pandemics

PURPOSE OF REVIEW

The aim of this review was to compare and contrast the application of molecular epidemiology approaches for the improved management and understanding of the HIV versus SARS-CoV-2 epidemics.

RECENT FINDINGS

Molecular biology approaches, including PCR and whole genome sequencing (WGS), have become powerful tools for epidemiological investigation. PCR approaches form the basis for many high-sensitivity diagnostic tests and can supplement traditional contact tracing and surveillance strategies to define risk networks and transmission patterns. WGS approaches can further define the causative agents of disease, trace the origins of the pathogen, and clarify routes of transmission. When coupled with clinical datasets, such as electronic medical record data, these approaches can investigate co-correlates of disease and pathogenesis. In the ongoing HIV epidemic, these approaches have been effectively deployed to identify treatment gaps, transmission clusters and risk factors, though significant barriers to rapid or real-time implementation remain critical to overcome. Likewise, these approaches have been successful in addressing some questions of SARS-CoV-2 transmission and pathogenesis, but the nature and rapid spread of the virus have posed additional challenges.

SUMMARY

Overall, molecular epidemiology approaches offer unique advantages and challenges that complement traditional epidemiological tools for the improved understanding and management of epidemics.

Pattern and Frequency of Seroreactivity to Routinely Used Serologic Tests in Early-Treated Infants With HIV

BACKGROUND

Previous studies have shown low frequencies of seroreactivity to HIV diagnostic assays for infected infants treated with antiretroviral therapy (ART) early in infection.

METHODS

Fifty-eight HIV-infected infants treated with ART at a median age of 1.9 months (range: 0.2-5.4) for up to 4 years of life were assessed for seroreactivity to 4 routinely used HIV clinical immunoassays (IA): Second-generation (2ndG) IA and 2 rapid diagnostic tests (RDT), based on third-generation principles, measuring antibody only and a fourth-generation (4thG) antigen/antibody IA. HIV Western blot assay was also performed to assess HIV-specific antibodies.

RESULTS

The 2ndG IA demonstrated the highest frequency of seroreactivity in children (69%) followed by the 4thG IA (40%) and the RDT (26%) after one year of ART. Infants initiating ART during ages 3-6 months (N = 15) showed a greater frequency (range: 53%-93%) and breadth (median and range: 3 [1-4]) of reactivity across the assays compared with those treated within 3 months (N = 43):16%-61% and breadth (1 [0-4]). The 4thG IA showed significantly reduced reactivity relative to the 2ndG IA at one (P = 0.016) and 3 (P = 0.004) years of ART. Western blot profiles following 3 years of ART showed the highest frequency of reactivity to HIV Gag p24 (76%) and lowest reactivity to Env gp120 and gp41, with only 24% of children confirmed positive by the assay.

CONCLUSIONS

These results suggest that the use of 4thG IA and RDT test combination algorithms with limited HIV antigen breadth may not be adequate for diagnosis of HIV-infected children following early treatment.

Update on the Diagnosis of Sexually Transmitted Infections

Sexually transmitted infections (STIs) are one of the most frequent and universal Public Health problems. Health professionals should be aware of the possibility of STIs due to their high morbidity and the presence of sequelae. The delay in the diagnosis is one of the factors that justifies the difficulty to infections control. Diagnostic tests allow the introduction of aetiological treatment and also lead to treating symptomatic and asymptomatic patients more effectively, as well as to interrupt the epidemiological transmission chain without delay. In this review we have made an update of the main existing diagnostic methods for the more important STIs.

Reduction of anti-HIV antibody responses in subjects receiving antiretroviral therapy during chronic HIV-1 infection

OBJECTIVE

Antiretroviral therapy (ART) can lead to a decline or absence of anti-HIV antibodies in HIV-infected children or acutely HIV-infected (AHI) subjects. However, the characteristics of anti-HIV antibody response in the subjects who are treated during chronic HIV-1 infection (CHI) have not yet been fully investigated.

METHODS

Different anti-HIV antibodies were longitudinally quantified and analyzed in 81 CHI adults under ART. The factors associated with antibody decline were evaluated by binary logistic regression analysis.

RESULTS

ART led to 36.0% (27/75) and 52.1% (38/73) of the patients whose anti-HIV levels reduced by more than 75% of the baseline levels at 12 and 24 months post-ART, respectively. The reduction of anti-HIV antibodies correlated with the decline of HIV-1 viral load with correlation coefficients in the range 0.556-0.848 or R2 value of 0.576-0.873 (P < 0.001). However, no negative detection of anti-HIV antibody was observed at 24 months post-ART. The time from HIV-1 diagnosis to ART initiation and the baseline anti-HIV levels were the key factors associated with quick decline of anti-HIV antibodies during ART.

CONCLUSIONS

ART-induced kinetics of anti-HIV antibody response was different among the subjects with AHI and CHI. Misdiagnosis of HIV-1 infection may not be a serious issue in HIV-1 chronically infected subjects under ART, and could ideally be avoided by using multiple HIV-1 antigens for screening purposes.

Selecting an HIV Test: A Narrative Review for Clinicians and Researchers

Given the many options available, selecting an HIV test for a particular clinical or research setting can be daunting. Making an informed decision requires an assessment of the likelihood of acute infection in the test population and an understanding of key aspects of the tests themselves. The ability of individual tests to reliably detect HIV infection depends on the target(s) being detected, when they can be expected to be present after infection, and the concentration of stable target in test specimens, all of which are explained by the virologic and serologic events after infection. The purpose of this article is to review the timeline of HIV infection, nomenclature, and characteristics of different tests; compare point-of-care and laboratory-based tests; discuss the impact of different specimens on test performance; and provide practical advice to help clinicians and researchers new to the field select a test that best suits their needs.

A mixed methods study of HIV-related services in buprenorphine treatment

BACKGROUND

Opioid use disorder (OUD) is a major risk factor in the acquisition and transmission of HIV. Clinical practice guidelines call for the integration of HIV services in OUD treatment. This mixed methods study describes the integration of HIV services in buprenorphine treatment and examines whether HIV services vary by prescribers' medical specialty and across practice settings.

METHODS

Data were obtained via qualitative interviews with buprenorphine experts (n = 21) and mailed surveys from US buprenorphine prescribers (n = 1174). Survey measures asked about screening for HIV risk behaviors at intake, offering HIV education, recommending all new patients receive HIV testing, and availability of on-site HIV testing. Prescribers' medical specialty, practice settings, caseload demographics, and physician demographics were measured. Multivariate models of HIV services were estimated, while accounting for the nesting of physicians within states.

RESULTS

Qualitative interviews revealed that physicians often use injection behaviors as the primary indicator for whether a patient should be tested for HIV. Interviews revealed that HIV-related services were often viewed as beyond the scope of practice among general psychiatrists. Surveys indicated that prescribers screened for an average of 3.2 of 5 HIV risk behaviors (SD = 1.6) at intake. About 62.0% of prescribers delivered HIV education to patients and 53.2% recommended HIV testing to all new patients, but only 32.3% offered on-site HIV testing. Addiction specialists and psychiatrists screened for significantly more HIV risk behaviors than physicians in other specialties. Addiction specialists and psychiatrists were significantly less likely than other physicians to offer on-site testing. Physicians in individual medical practice were significantly less likely to recommend HIV testing and to offer onsite testing than physicians in other settings.

CONCLUSIONS

Buprenorphine treatment providers have not uniformly integrated HIV-related screening, education, and testing services for patients. Differences by medical specialty and practice setting suggest an opportunity for targeting efforts to increase implementation.

Human Immunodeficiency Virus

In this chapter we will discuss the diagnosis and monitoring of individuals with HIV infection. The application and interpretation of these tests does not change dramatically when used in the immunocompromised host. The principal approach to the diagnosis of HIV infection involves serologic testing, although nucleic acid amplification tests play an important role in the diagnosis of acute HIV infection. The algorithm for diagnosis of HIV continues to evolve with newer assays that are able to detect infection within an earlier timeframe after HIV transmission. Viral load testing for HIV-1 is the cornerstone for monitoring patients on antiretroviral therapy. Genotypic and phenotypic resistance tests are employed when antiretroviral resistance is suspected and results help guide therapy. The tropism assay must be performed to determine the efficacy of CCR5 chemokine receptor antagonists. Next-generation sequencing methods are an innovative approach to assessing archived antiretroviral resistance in patients with virologic suppression. The success of antiretroviral therapy with improved long-term outcomes has made transplantation in HIV-infected patients a reality.

Highlights from the 2016 HIV diagnostics conference: The new landscape of HIV testing in laboratories, public health programs and clinical practice

The 2016 HIV Diagnostics Conference, held in Atlanta, Georgia, was attended by public health officials, laboratorians, HIV testing program managers, surveillance coordinators and industry representatives. The conference addressed test performance data, the implementation of new testing algorithms, quality assurance, and the application of new tests in a variety of settings. With regard to the recommended Centers for Disease Control and Prevention/Association of Public Health Laboratories HIV laboratory testing algorithm, the conference featured performance data, implementation challenges such as a lack of test options for the second and third steps, as well as data needs for new tests that may be used as part of the algorithm. There are delays when nucleic acid testing is needed with the algorithm. Novel tests such as point of care nucleic acid tests are needed on the U.S. market to readily identify acute infection. Multiplex tests are being developed which allow for the simultaneous detection of multiple pathogens. CDC staff highlighted new guidance for testing in non-clinical settings. Innovative approaches to linking testing and care in some settings have led to identification of early infections, improved receipt of test results and expedited initiation of therapy. Work continues to optimize testing so that infections are accurately identified as early as possible and time to treatment is minimized to improve health outcomes and prevent transmission.

Human immunodeficiency virus: Diagnostic approach

First descriptions of acquired immunodeficiency syndrome appeared in 1981. Four years later the causative agent was cultured which lead to development and production of tests that helped healthcare providers to identify persons living with HIV. Currently, diagnosis of HIV is performed with fourth generation immunoassays (those that detect p24 antigen together with IgM and IgG antibodies to HIV-1 and -2) which if positive need to be followed by an assay that can differentiate between HIV-1 and HIV-2 viruses. The Western blot is no longer used to confirm HIV infections per CDC guidelines. In case there is a positive fourth generation assay but negative differentiation assay, nucleic acid testing for HIV-1 should be performed. This algorithm allows for detection of acute infections. Alternatively, the World Health Organization has algorithms that use rapid testing for diagnosis of HIV infections. This review will describe the evolution of tests and diagnostic algorithms from the 1980s to the current state. Special situations regarding diagnosis will also be discussed.

Initiation of Antiretroviral Therapy During Acute HIV-1 Infection Leads to a High Rate of Nonreactive HIV Serology

BACKGROUND

Third- and fourth-generation immunoassays (IAs) are widely used in the diagnosis of human immunodeficiency virus (HIV) infection. Antiretroviral therapy (ART) during acute HIV infection (AHI) may impact HIV-specific antibodies, with failure to develop antibody or seroreversion. We report on the ability of diagnostic tests to detect HIV-specific antibodies in Thai participants initiating ART during AHI.

METHODS

Participants with detectable plasma HIV RNA but nonreactive HIV-specific immunoglobulin G, enrolled in an AHI study, were offered immediate initiation of ART. Participants were tested at initiation and at 12 and 24 weeks following treatment using standard second-, third-, and fourth-generation IAs and Western blot (WB).

RESULTS

Participants (N = 234) initiating ART at a median of 19 days (range, 1-62 days) from HIV exposure demonstrated different frequencies of reactivity prior to and following 24 weeks of ART depending on the IA. Third-generation IA nonreactivity prior to ART was 48%, which decreased to 4% following ART (P < .001). Fourth-generation IA nonreactivity was 18% prior to ART and 17% following ART (P = .720). Negative WB results were observed in 89% and 12% of participants prior to and following 24 weeks of ART, respectively (P < .001). Seroreversion to nonreactivity during ART was observed to at least one of the tests in 20% of participants, with fourth-generation IA demonstrating the highest frequency (11%) of seroreversion.

CONCLUSIONS

HIV-specific antibodies may fail to develop and, when detected, may decline when ART is initiated during AHI. Although fourth-generation IA was the most sensitive at detecting AHI prior to ART, third-generation IA was the most sensitive during treatment.

CLINICAL TRIALS REGISTRATION

NCT00796146 and NCT00796263.

On-site bundled rapid HIV/HCV testing in substance use disorder treatment programs: study protocol for a hybrid design randomized controlled trial

BACKGROUND

More than 1.2 million people in the United States are living with human immunodeficiency virus (HIV), and 3.2 million are living with hepatitis C virus (HCV). An estimated 25 % of persons living with HIV also have HCV. It is therefore of great public health importance to ensure the prompt diagnosis of both HIV and HCV in populations that have the highest prevalence of both infections, including individuals with substance use disorders (SUD).

METHODS/DESIGN

In this theory-driven, efficacy-effectiveness-implementation hybrid study, we will develop and test an on-site bundled rapid HIV/HCV testing intervention for SUD treatment programs. Its aim is to increase the receipt of HIV and HCV test results among SUD treatment patients. Using a rigorous process involving patients, providers, and program managers, we will incorporate rapid HCV testing into evidence-based HIV testing and linkage to care interventions. We will then test, in a randomized controlled trial, the extent to which this bundled rapid HIV/HCV testing approach increases receipt of HIV and HCV test results. Lastly, we will conduct formative research to understand the barriers to, and facilitators of, the adoption, implementation, and sustainability of the bundled rapid testing strategy in SUD treatment programs.

DISCUSSION

Novel approaches that effectively integrate on-site rapid HIV and rapid HCV testing are needed to address both the HIV and HCV epidemics. If feasible and efficacious, bundled rapid HIV/HCV testing may offer a scalable, potentially cost-effective approach to testing high-risk populations, such as patients of SUD treatment programs. It may ultimately lead to improved linkage to care and progress through the HIV and HCV care and treatment cascades.

TRIAL REGISTRATION

ClinicalTrials.gov: NCT02355080 . (30 January 2015).

Low Rates of Adoption and Implementation of Rapid HIV Testing in Substance Use Disorder Treatment Programs

INTRODUCTION

Rapid HIV testing (RHT) greatly increases the proportion of clients who learn their test results. However, existing studies have not examined the adoption and implementation of RHT in programs treating persons with substance use disorders, one of the population groups at higher risk for HIV infection.

METHODS

We examined 196 opioid treatment programs (OTPs) using data from the 2011 National Drug Abuse Treatment System Survey (NDATSS). We used logistic regressions to identify client and organizational characteristics of OTPs associated with availability of on-site RHT. We then used zero-inflated negative binomial regressions to measure the association between the availability of RHT on-site and the number of clients tested for HIV.

RESULTS

Only 31.6% of OTPs offered on-site rapid HIV testing to their clients. Rapid HIV testing was more commonly available on-site in larger, publicly owned and better-staffed OTPs. On the other hand, on-site rapid HIV testing was less common in OTPs that prescribed only buprenorphine as a method of opioid dependence treatment. The availability of rapid HIV testing on-site reduced the likelihood that an OTP did not test any of its clients during the prior year. But on-site availability rapid HIV testing was not otherwise associated with an increased number of clients tested for HIV at an OTP.

CONCLUSIONS

New strategies are needed to a) promote the adoption of rapid HIV testing on-site in substance use disorder treatment programs and b) encourage substance use disorder treatment providers to offer rapid HIV testing to their clients when it is available.

Acute Infections, Cost per Infection and Turnaround Time in Three United States Hospital Laboratories Using Fourth-Generation Antigen-Antibody Human Immunodeficiency Virus Immunoassays

Background. To improve clinical and public health outcomes through early human immunodeficiency virus (HIV) detection, fourth-generation antigen/antibody immunoassay (4IA) and supplemental testing results must be returned rapidly.

Methods. We examined HIV testing data at Harborview Medical Center (HMC), Massachusetts General Hospital (MGH), and the Medical University of South Carolina (MUSC), which used 4IA and supplemental antibody and nucleic acid tests (NATs). At MGH and MUSC, HIV-1 Western blot (WB) and HIV-2 testing were conducted at a reference laboratory. We compared time from specimen collection to laboratory result for established (positive WB) and acute infections (reactive 4IA, negative/indeterminate WB, detectable NAT), and we calculated testing cost per positive-test result.

Results. From 3731 (MUSC) to 19 774 (MGH) tests were conducted; 0.01% (MGH) to 0.05% (HMC) were acute infections. Each laboratory had reactive 4IA, WB-negative, or indeterminate specimens without NAT (ie, potential acute infections). Time to result was 1.5 (HMC) to 5.2 days (MGH) for acute and 1.0 (HMC) to 5.2 days (MGH) for established infections. Costs were $1054 (MGH) to $1521 (MUSC).

Conclusions. Conducting supplemental testing in-house lowered turnaround times, which may be further reduced with rapid HIV-1/HIV-2 differentiation tests. Hospitals may benefit from quantitative NATs not requiring physician orders, so all potential acute infections receive NAT.