HCV, HIV AND HBV rapid test diagnosis in non-clinical outreach settings can be as accurate as conventional laboratory tests

Point of care rapid diagnostic tests (POC-RDT) for Hepatitis C virus (HCV), Human Immunodeficiency virus (HIV) and Hepatitis B virus (HBV), are ideal for screening in non-clinical outreach settings as they can provide immediate results and facilitate diagnosis, allowing high risk population screening. The aim of this study was to compare POC-RDT with laboratory conventional tests. A total of 301 vulnerable evaluable subjects (drug users, migrants and homeless population) were recruited at a mobile screening unit in outreach settings in Madrid. Fingerprick whole blood capillary samples were tested using the SD BIOLINE HCV POC-RDT, Determine HIV Early Detect and Determine HBsAg 2, and the results were assessed against the LIAISON XL HCV, HIV and Murex-HBsAg-Quant, reference assays, respectively. The feasibility and user satisfaction of the POC-RDT were evaluated through a questionnaire. The resolved sensitivity and resolved specificity and their 95% confidence intervals (95% CI) were as follows, respectively: SD-BIOLINE-HCV: 98.8% (95% CI 93.4, 100.0) and 100.0% (95% CI 98.3, 100.0); Determine HIV Early Detect: 100% (95% CI 85.2, 100.0) and 100% (95% CI 98.7, 100); and Determine HBsAg 2: 66.7% (95% CI 9.4, 99.2) and 100.0% (95% CI 98.7, 100.0). As expected, the number of subjects with a confirmed positive result for HBsAg was very low (n = 4). Therefore, the analytical sensitivity has been evaluated in addition: The Determine HBsAg 2 test demonstrated 100% sensitivity for standard concentrations ≥ 0.125 IU/mL. The subject questionnaire yielded positive feedback for most subjects. The POC-RDT fingerprick blood collection method was well received, and the tests demonstrated a comparable clinical performance with conventional tests in outreach settings and vulnerable high-risk populations.

Canadian and international recommendations on the frequency of HIV screening and testing: A systematic review

Background

In 2014, the Public Health Agency of Canada estimated that 21% of the people living with HIV in Canada were unaware of their infection. Increased screening and testing for HIV is crucial to reducing the number of undiagnosed infections. To ensure the best use of available resources, it is important to determine the optimal intervals for HIV screening and testing.

Objective

To conduct a systematic review of the recommendations for the frequency of HIV screening and testing in different populations.

Methods

To identify eligible guidelines, a comprehensive two-tiered search strategy of journals and websites of governments and non-governmental organizations and a three-tiered screening strategy (title, abstract and full content screen) were used. Guidelines were eligible for inclusion if they, a) were published between 2000 and 2015 in English or French, and b) provided guidance on HIV screening/testing intervals for at least one population.

Results

Of the 609 documents retrieved from the search, 34 guidelines met the eligibility criteria. The most frequently mentioned populations were pregnant women, men who have sex with men (MSM) and the general population. Overall, there was consensus on at least annual testing for MSM, intravenous drug users, individuals with HIV-positive sex partners, individuals with multiple partners, sex workers and their clients, migrants from HIV-endemic countries and indigenous peoples. Of the 20 guidelines that provided recommendations for pregnant women, the most common recommendation (n=9) was to test as early as possible during each pregnancy; four guidelines recommended screening during the first prenatal visit; three recommended routine HIV testing; and four suggested retesting in the third trimester regardless of maternal risk of HIV infection. Consensus on HIV testing of the general public, incarcerated people and individuals diagnosed with other sexually transmitted infections (STIs) was lacking. Four guidelines cited a lack of data for not providing specific recommendations in the general population.

Conclusions

Additional evidence is needed to refine the recommendations for pregnant women and inform the optimal timing of HIV testing, especially in the general population, individuals diagnosed with other STIs and incarcerated people.

Evaluation of two HIV antibody confirmatory assays: Geenius™ HIV1/2 Confirmatory Assay and the recomLine HIV-1 & HIV-2 IgG Line Immunoassay

The laboratory diagnosis of an HIV infection mainly depends on the detection of HIV-specific antibodies/HIV p24 antigen whereby different algorithms for the confirmation of reactive screening assays exist. The objective of the present study was to compare the performance of two supplemental HIV antibody confirmatory assays: the Geenius™ HIV1/2 Confirmatory Assay and the recomLine HIV-1 & HIV-2 IgG Line Immunoassay. Therefore 279 serum samples previously analyzed for HIV during routine diagnostics at the Institute for Medical Virology, National Reference Center for Retroviruses, University Hospital Frankfurt, were analyzed retrospectively. 96.8% samples had concordant results in both HIV confirmatory assays, whereby the Geenius Assay showed a discrimination rate of 100% while two HIV-1 samples were not typeable with the recomLine Assay. Overall assay sensitivity was 100% in both assays and specificity was 99.0% (recomLine Assay) and 93.4% (Geenius Assay), respectively. The κ-values for both assays indicated high agreement. Overall nine samples had discordant results from which four were from acutely EBV/CMV-infected patients and one from a patient with primary HIV-1 infection during seroconversion. In conclusion, both assays are well suited for the detection, confirmation and discrimination of HIV-1- and -2-specific antibodies.

HIV pre-test information, discussion or counselling? A review of guidance relevant to the WHO European Region

In the context of a shift from exceptionalism to normalisation, this study examines recommendations/evidence in current pan-European/global guidelines regarding pre-test HIV testing and counselling practices in health care settings. It also reviews new research not yet included in guidelines. There is consensus that verbal informed consent must be gained prior to testing, individually, in private, confidentially, in the presence of a health care provider. All guidelines recommend pre-test information/discussion delivered verbally or via other methods (information sheet). There is agreement about a minimum standard of information to be provided before a test, but guidelines differ regarding discussion about issues encouraging patients to think about implications of the result. There is heavy reliance on expert consultation in guideline development. Referenced scientific evidence is often more than ten years old and based on US/UK research. Eight new papers are reviewed. Current HIV testing and counselling guidelines have inconsistencies regarding the extent and type of information that is recommended during pre-test discussions. The lack of new research underscores a need for new evidence from a range of European settings to support the process of expert consultation in guideline development.

2014 European Guideline on HIV testing

Testing for HIV is one of the cornerstones in the fight against HIV spread. The 2014 European Guideline on HIV Testing provides advice on testing for HIV infection in individuals aged 16 years and older who present to sexually transmitted infection, genito-urinary or dermato-venereology clinics across Europe. It may also be applied in other clinical settings where HIV testing is required, particularly in primary care settings. The aim of the guideline is to provide practical guidance to clinicians and laboratories that within these settings undertake HIV testing, and to indicate standards for best practice.

Attitudes to rapid HIV testing among Spanish General Practitioners

OBJECTIVES

The objectives of this study were to investigate the acceptability of rapid HIV testing among general practitioners in Spain and to identify perceived barriers and needs in order to implement rapid testing in primary care settings.

METHODS

An anonymous questionnaire was distributed online to all members of the two largest Spanish scientific medical societies for family and community medicine. The study took place between 15th June and 31st October 2010.

RESULTS

Completed questionnaires were returned by 1308 participants. The majority (90.8%) of respondents were General Practitioners (GP). Among all respondents, 70.4% were aware of the existence of rapid tests for the diagnosis of HIV but they did not know how to use them. Nearly 80% of participants would be willing to offer rapid HIV testing in their practices and 74.7% would be confident of the results obtained by these tests. The barriers most commonly identified by respondents were a lack of time and a need for training, both in the use of rapid tests (44.3% and 56.4%, respectively) and required pre- and post-test counselling (59.2% and 34.5%, respectively).

CONCLUSIONS

This study reveals a high level of acceptance and willingness on the part of GPs to offer rapid HIV testing in their practices. Nevertheless, the implementation of rapid HIV testing in primary care will not be possible without moving from comprehensive pre-test counselling towards brief pre-test information and improving training in the use of rapid tests.

Guidance and practice on frequency of HIV and sexually transmitted infection testing in men who have sex with men - what is the European situation?

Men who have sex with men (MSM) are at particular risk for HIV/sexually transmitted infections (STI). To investigate the European guidance used for MSM STI and HIV screening, risk level profiling and how this translated to practice, we conducted a questionnaire survey of leading physicians in the European branch of the International Union against Sexually Transmitted Infections (IUSTI). We identified that most European countries have limited guidance on screening intervals for MSM. Where risk profiling is advised, it is often left to clinicians to weight different behaviours and decide on screening frequency. Our results suggest that European MSM STI and HIV testing guidelines be developed with clear and specific recommendations around screening intervals and risk profiling. These guidelines will be particularly helpful due to rapidly evolving models of sexual healthcare, and the emergence of new providers who may benefit from guidelines that require less interpretation.

Validation of the Elecsys® HIV combi PT assay for screening and reliable early detection of HIV-1 infection in Asia

BACKGROUND

The Elecsys® HIV combi PT assay was developed to allow earlier detection of HIV infection with increased sensitivity and specificity.

OBJECTIVES

To validate the assay for screening and reliable early detection of HIV-1 infection in Asia.

STUDY DESIGN

Samples tested reflected those routinely screened in Asia and comprised: HIV-1 antigen lysate (25 samples) and antibody (20 samples) dilutions; seven HIV-1 seroconversion panels (46 samples); 39 patient samples from early infection; 183 known-positive sera; HIV-1 p24 antigen sensitivity panel (seven samples); >500 routine clinical samples per center. The Elecsys® HIV combi PT assay was compared with fourth- (ADVIA Centaur® HIV combo, ARCHITECT® HIV combo, Elecsys® HIV combi) and third-generation (VIRONOSTIKA® HIV Uni-Form II Plus O, Zhuhai Livzon Anti-HIV EIA, Serodia® Particle Agglutination) assays commonly used in the region.

RESULTS

Overall, the Elecsys® HIV combi PT showed superior or similar sensitivity to the comparators for detecting all subtypes. The assay correctly identified all positive samples, including those taken soon after infection, and detected seroconversion at a similar or shorter time interval than the comparators. The analytical sensitivity of Elecsys® HIV combi PT for HIV-1 p24 antigen was 0.90 IU/mL, which was lower than reported previously. The assay showed good specificity (99.86%) that was superior or equivalent to the other fourth-generation assays tested.

CONCLUSIONS

These robust data demonstrate the good subtype inclusivity of the Elecsys® HIV combi PT assay and its suitability for screening and reliable early detection of HIV infection in Asia.

Current assays for HIV-1 diagnostics and antiretroviral therapy monitoring: challenges and possibilities

In 2011, there were over 34 million people living with HIV infections, placing a heavy burden on public health sectors. HIV infection is a lifelong threat that cannot be prevented by vaccination or cured by antiretroviral drugs. The infected patients rely on daily antiretroviral therapy to suppress HIV viral replication. Hence, it is important to diagnose HIV infections as early as possible and to monitor the efficacy of antiretroviral therapy every 3–6 months. Different immunoassays detecting HIV antigens and antibodies have been modified to offer better sensitivity and more rapid diagnosis. Several clinical and virological parameters, including CD4+ cell counts, viral load and drug resistance mutations, are also used for treatment monitoring. Many molecular assay optimizations are now being utilized to improve patient care. This review will focus on the most updated HIV diagnostic assays, as well as discussing the upcoming possibilities of other advanced technologies.

Associations between mode of HIV testing and consent, confidentiality, and referral: a comparative analysis in four African countries

BACKGROUND

Recommendations about scaling up HIV testing and counseling highlight the need to provide key services and to protect clients' rights, but it is unclear to what extent different modes of testing differ in this respect. This paper examines whether practices regarding consent, confidentiality, and referral vary depending on whether testing is provided through voluntary counseling and testing (VCT) or provider-initiated testing.

METHODS AND FINDINGS

The MATCH (Multi-Country African Testing and Counseling for HIV) study was carried out in Burkina Faso, Kenya, Malawi, and Uganda. Surveys were conducted at selected facilities. We defined eight outcome measures related to pre- and post-test counseling, consent, confidentiality, satisfactory interactions with providers, and (for HIV-positive respondents) referral for care. These were compared across three types of facilities: integrated facilities, where testing is provided along with medical care; stand-alone VCT facilities; and prevention of mother-to-child transmission (PMTCT) facilities, where testing is part of PMTCT services. Tests of bivariate associations and modified Poisson regression were used to assess significance and estimate the unadjusted and adjusted associations between modes of testing and outcome measures. In total, 2,116 respondents tested in 2007 or later reported on their testing experience. High percentages of clients across countries and modes of testing reported receiving recommended services and being satisfied. In the unadjusted analyses, integrated testers were less likely to meet with a counselor before testing (83% compared with 95% of VCT testers; p<0.001), but those who had a pre-test meeting were more likely to have completed consent procedures (89% compared with 83% among VCT testers; p<0.001) and pre-test counseling (78% compared with 73% among VCT testers; p = 0.015). Both integrated and PMTCT testers were more likely to receive complete post-test counseling than were VCT testers (59% among both PMTCT and integrated testers compared with 36% among VCT testers; p<0.001). Adjusted analyses by country show few significant differences by mode of testing: only lower satisfaction among integrated testers in Burkina Faso and Uganda, and lower frequency of referral among PMTCT testers in Malawi. Adjusted analyses of pooled data across countries show a higher likelihood of pre-test meeting for those testing at VCT facilities (adjusted prevalence ratio: 1.22, 95% CI: 1.07-1.38) and higher satisfaction for stand-alone VCT facilities (adjusted prevalence ratio: 1.15; 95% CI: 1.06-1.25), compared to integrated testing, but no other associations were statistically significant.

CONCLUSIONS

Overall, in this study most respondents reported favorable outcomes for consent, confidentiality, and referral. Provider-initiated ways of delivering testing and counseling do not appear to be associated with less favorable outcomes for clients than traditional, client-initiated VCT, suggesting that testing can be scaled up through multiple modes without detriment to clients' rights. Please see later in the article for the Editors' Summary.

Acceptability of rapid HIV diagnosis technology among primary healthcare practitioners in Spain

This study investigated the acceptability of rapid HIV testing among general practitioners (GP) and aimed to identify perceived barriers and needs in order to implement rapid testing in primary care settings. An anonymous questionnaire was distributed online to all members of the two largest Spanish scientific medical societies for family and community medicine. The study took place between 15 June 2012 and 31 October 2010. Completed questionnaires were returned by 1308 participants. The majority (90.8%) of respondents were GP. Among all respondents, 70.4% were aware of the existence of rapid tests for the diagnosis of HIV but they did not know how to use them. Nearly 80% of participants would be willing to offer rapid HIV testing in their practices and 74.7% would be confident of the result obtained by these tests. The barriers most commonly identified by respondents were a lack of time and a need for training, both in the use of rapid tests (44.3% and 56.4%, respectively) and required pre- and post-test counselling (59.2% and 34.5%, respectively). This study reveals a high level of acceptance and willingness on the part of GPs to offer rapid HIV testing in their practices. Nevertheless, the implementation of rapid HIV testing in primary care will not be possible without moving from comprehensive pre-test counselling towards brief pre-test information and improving training in the use of rapid tests.

Diagnosing acute HIV infection

Individuals with acute HIV infection (AHI) pose a greater transmission risk than most chronically HIV-infected patients and prevention efforts targeting these individuals are important for reducing the spread of HIV infection. Rapid and accurate diagnosis of AHI is crucial. Since symptoms of AHI are nonspecific, its diagnosis requires a high index of suspicion and appropriate HIV laboratory tests. However, even 30 years after the start of the HIV epidemic, laboratory tools remain imperfect and only a few individuals with AHI are identified. We review the clinical presentation of the acute retroviral syndrome, the laboratory markers and their detection methods, and propose an algorithm for the laboratory diagnosis of AHI.

Women's views on consent, counseling and confidentiality in PMTCT: a mixed-methods study in four African countries

BACKGROUND

Ambitious UN goals to reduce the mother-to-child transmission of HIV have not been met in much of Sub-Saharan Africa. This paper focuses on the quality of information provision and counseling and disclosure patterns in Burkina Faso, Kenya, Malawi and Uganda to identify how services can be improved to enable better PMTCT outcomes.

METHODS

Our mixed-methods study draws on data obtained through: (1) the MATCH (Multi-country African Testing and Counseling for HIV) study's main survey, conducted in 2008-09 among clients (N = 408) and providers at health facilities offering HIV Testing and Counseling (HTC) services; 2) semi-structured interviews with a sub-set of 63 HIV-positive women on their experiences of stigma, disclosure, post-test counseling and access to follow-up psycho-social support; (3) in-depth interviews with key informants and PMTCT healthcare workers; and (4) document study of national PMTCT policies and guidelines. We quantitatively examined differences in the quality of counseling by country and by HIV status using Fisher's exact tests.

RESULTS

The majority of pregnant women attending antenatal care (80-90%) report that they were explained the meaning of the tests, explained how HIV can be transmitted, given advice on prevention, encouraged to refer their partners for testing, and given time to ask questions. Our qualitative findings reveal that some women found testing regimes to be coercive, while disclosure remains highly problematic. 79% of HIV-positive pregnant women reported that they generally keep their status secret; only 37% had disclosed to their husband.

CONCLUSION

To achieve better PMTCT outcomes, the strategy of testing women in antenatal care (perceived as an exclusively female domain) when they are already pregnant needs to be rethought. When scaling up HIV testing programs, it is particularly important that issues of partner disclosure are taken seriously.

HIV testing in Europe: mapping policies

OBJECTIVES

In the absence of treatment and in the context of discrimination, HIV testing was embedded within exceptional procedures. With increasing treatment effectiveness, early HIV diagnosis became important, calling for the normalization of testing. National HIV testing policies were mapped to explore the characteristics and variations across European countries.

METHODS

Key informants within the health authorities of all EU/EEA countries were questioned on HIV testing policies, which were assessed within a conceptual framework and the level of exceptionalism and normalization was scored based on defined attributes.

RESULTS

Twenty-four out of 31 countries participated in the survey. Policies tended to support confidential voluntary testing, informed consent, and counselling. In the majority of countries, specific groups were targeted for provider-initiated testing. Taking together all attributes of HIV testing, 14 countries obtained a high score for exceptionalism, while only 3 achieved a high score on normalization. Italy, Lithuania and Romania had primarily exceptional procedures; Norway leant more towards normalization; Netherlands, the United Kingdom, and Denmark scored high in both.

CONCLUSIONS

In most EU/EEA countries, policies are integrating HIV testing in health care settings, through voluntary and targeted testing strategies. Current HIV testing policies exhibited a high level of exceptionalism with varying degrees of normalization. Further research should compare HIV testing policies with practices.

HIV testing strategies: test performance is important, but not sufficient

Minimum accuracy of HIV diagnostic tests is considered the pillar on which testing strategies for all settings must be based. Systematic reviews and meta-analyses have shown that performance of the same test in different settings may vary according to several factors, resulting in different confidence intervals for sensitivity and specificity. Prevalence of HIV infection may influence observed test accuracy. The purpose of this article is to use the knowledge from meta-analyses of general diagnostic tests to inform the specific field of HIV diagnostic strategies. We propose the 'Bayesian' thinking: considering the pretest probability (i.e., prevalence, risk factors) and understanding test limitations to estimate a post-test probability of HIV diagnosis. Cost-effectiveness analysis, patient preferences and ethical issues must also be considered in HIV testing strategies.

Feasibility and acceptability of point of care HIV testing in community outreach and GUM drop-in services in the North West of England: a programmatic evaluation

Background

In Liverpool, injecting drug users (IDUs), men-who-have-sex-with-men (MSM) and UK Africans experience a disproportionate burden of HIV, yet services do not reach out to these groups and late presentations continue. We set out to: increase testing uptake in targeted marginalized groups through a community and genitourinary medicine (GUM)-based point of care testing (POCT) programme; and conduct a process evaluation to examine service provider inputs and document service user perceptions of the programme.

Methods

Mixed quantitative, qualitative and process evaluation methods were used. Service providers were trained to use fourth generation rapid antibody/antigen HIV tests. Existing outreach services incorporated POCT into routine practice. Clients completed a semi-structured questionnaire and focus group discussions (FGDs) were held with service providers.

Results

Between September 2009 and June 2010, 953 individuals underwent POCT (GUM: 556 [59%]; community-based sites: 397 [42%]). Participants in the community were more likely to be male (p = 0.028), older (p < 0.001), of UK African origin (p < 0.001) and IDUs (p < 0.001) than participants from the GUM clinic. Seventeen new HIV diagnoses were confirmed (prevalence = 1.8%), 16 of whom were in risk exposure categories (prevalence: 16/517, 3.1%). Questionnaires and FGDs showed that clients and service providers were supportive of POCT, highlighting benefits of reaching out to marginalised communities and incorporating HIV prevention messages.

Conclusions

Community and GUM clinic-based POCT for HIV was feasible and acceptable to clients and service providers in a low prevalence setting. It successfully reached target groups, many of whom would not have otherwise tested. We recommend POCT be considered among strategies to increase the uptake of HIV testing among groups who are currently underserved.