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Zhou S, Long N, Moeser M, Hill CS, Samoff E, Mobley V, Frost S, Bayer C, Kelly E, Greifinger A, Shone S, Glover W, Clark M, Eron J, Cohen M, Swanstrom R, Dennis AM. Use of Next-Generation Sequencing in a State-Wide Strategy of HIV-1 Surveillance: Impact of the SARS-COV-2 Pandemic on HIV-1 Diagnosis and Transmission. J Infect Dis 2023; 228:1758-1765. [PMID: 37283544 PMCID: PMC10733719 DOI: 10.1093/infdis/jiad211] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2023] [Revised: 05/24/2023] [Accepted: 06/05/2023] [Indexed: 06/08/2023] Open
Abstract
BACKGROUND The ongoing severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic posed an unpreceded threat to the management of other pandemics such as human immunodeficiency virus-1 (HIV-1) in the United States. The full impact of the SARS-CoV-2 pandemic on the HIV-1 pandemic needs to be evaluated. METHODS All individuals with newly reported HIV-1 diagnoses from NC State Laboratory of Public Health were enrolled in this prospective observational study, 2018-2021. We used a sequencing-based recency assay to identify recent HIV-1 infections and to determine the days postinfection (DPI) for each person at the time of diagnosis. RESULTS Sequencing used diagnostic serum samples from 814 individuals with new HIV-1 diagnoses spanning this 4-year period. Characteristics of individuals diagnosed in 2020 differed from those in other years. People of color diagnosed in 2021 were on average 6 months delayed in their diagnosis compared to those diagnosed in 2020. There was a trend that genetic networks were more known for individuals diagnosed in 2021. We observed no major integrase resistance mutations over the course of the study. CONCLUSIONS SARS-CoV-2 pandemic may contribute to the spread of HIV-1. Public health resources need to focus on restoring HIV-1 testing and interrupting active, ongoing, transmission.
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Affiliation(s)
- Shuntai Zhou
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
- Department of Microbiology and Immunology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Nathan Long
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Matt Moeser
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Collin S Hill
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Erika Samoff
- North Carolina Department of Health and Human Services, Raleigh, North Carolina, USA
| | - Victoria Mobley
- North Carolina Department of Health and Human Services, Raleigh, North Carolina, USA
| | - Simon Frost
- Microsoft Health Futures, Microsoft Corporation, Redmond, Washington, USA
- Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Cara Bayer
- Department of Epidemiology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Elizabeth Kelly
- Division of Infectious Diseases, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Annalea Greifinger
- Division of Infectious Diseases, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Scott Shone
- North Carolina Department of Health and Human Services, Raleigh, North Carolina, USA
| | - William Glover
- North Carolina Department of Health and Human Services, Raleigh, North Carolina, USA
| | - Michael Clark
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Joseph Eron
- Division of Infectious Diseases, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Myron Cohen
- Division of Infectious Diseases, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Ronald Swanstrom
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
- Department of Biochemistry and Biophysics, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Ann M Dennis
- Division of Infectious Diseases, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
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Kin-On Lau J, Murdock N, Murray J, Justman J, Parkin N, Miller V. A systematic review of limiting antigen avidity enzyme immunoassay for detection of recent HIV-1 infection to expand supported applications. J Virus Erad 2022; 8:100085. [PMID: 36124229 PMCID: PMC9482108 DOI: 10.1016/j.jve.2022.100085] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2022] [Accepted: 09/01/2022] [Indexed: 11/18/2022] Open
Abstract
Introduction The need for detection of new and recent HIV infections is essential for surveillance and assessing interventions in controlling the epidemic. HIV recency assays are one way of providing reliable incidence estimates by determining recent versus non-recent infection. The objective of this study was to review the current body of knowledge of the limiting antigen avidity enzyme immunoassay to expand supported applications through an assessment of what is known and the gaps. Methods A search for peer-reviewed literature in PubMed, Embase, and Web of Science Core Collection was conducted using the search term “human immunodeficiency virus and avidity”. Non-peer reviewed published reports from the Population-based HIV Impact Assessment Project were also included. These were limited to literature published in English between January 2010 and August 2021. Results This search resulted in 2080 publications and 14 reports, with 137 peer-reviewed studies and 14 non-peer reviewed reports that met the inclusion criteria, yielding a total of 151 studies for the final review. There were similar findings among studies that compared the performances of assay manufacturers and sample types. Studies that evaluated various assay algorithms and thresholds were heterogeneous, illustrating the need for context-specific test characteristics for classifying recent infections. Most studies estimated subtype-specific test characteristics for HIV subtypes A, B, C, and D. This was further illustrated when looking only at studies that compared HIV incidence estimates from recency assay algorithms and longitudinal cohorts. Conclusions These findings suggest that the current body of knowledge provides important information that contributes towards distinguishing recent and non-recent infection and incidence estimation. However, there are knowledge gaps with respect to factors that influence the test characteristics (e.g., HIV-1 subtype, population characteristics, assay algorithms and thresholds). Further studies are needed to estimate and establish context-specific test characteristics that consider these influencing factors to improve and expand the use of this assay for detection of recent HIV infection.
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Affiliation(s)
- Joseph Kin-On Lau
- Forum for Collaborative Research, 1608 Rhode Island Avenue NW, Suite 212, Washington, DC, 20036, USA
| | - Nicholas Murdock
- Forum for Collaborative Research, 1608 Rhode Island Avenue NW, Suite 212, Washington, DC, 20036, USA
| | - Jeffrey Murray
- Forum for Collaborative Research, 1608 Rhode Island Avenue NW, Suite 212, Washington, DC, 20036, USA
| | - Jessica Justman
- ICAP Columbia University Mailman School of Public Health, 722 West 168 Street, New York, NY, 10032, USA
| | - Neil Parkin
- Data First Consulting, Inc, Sebastopol, CA, USA
| | - Veronica Miller
- Forum for Collaborative Research, 1608 Rhode Island Avenue NW, Suite 212, Washington, DC, 20036, USA
- Corresponding author.
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Facente SN, Grebe E, Maher AD, Fox D, Scheer S, Mahy M, Dalal S, Lowrance D, Marsh K. Use of HIV Recency Assays for HIV Incidence Estimation and Other Surveillance Use Cases: Systematic Review. JMIR Public Health Surveill 2022; 8:e34410. [PMID: 35275085 PMCID: PMC8956992 DOI: 10.2196/34410] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2021] [Revised: 01/16/2022] [Accepted: 02/02/2022] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND HIV assays designed to detect recent infection, also known as "recency assays," are often used to estimate HIV incidence in a specific country, region, or subpopulation, alone or as part of recent infection testing algorithms (RITAs). Recently, many countries and organizations have become interested in using recency assays within case surveillance systems and routine HIV testing services to measure other indicators beyond incidence, generally referred to as "non-incidence surveillance use cases." OBJECTIVE This review aims to identify published evidence that can be used to validate methodological approaches to recency-based incidence estimation and non-incidence use cases. The evidence identified through this review will be used in the forthcoming technical guidance by the World Health Organization (WHO) and United Nations Programme on HIV/AIDS (UNAIDS) on the use of HIV recency assays for identification of epidemic trends, whether for HIV incidence estimation or non-incidence indicators of recency. METHODS To identify the best methodological and field implementation practices for the use of recency assays to estimate HIV incidence and trends in recent infections for specific populations or geographic areas, we conducted a systematic review of the literature to (1) understand the use of recency testing for surveillance in programmatic and laboratory settings, (2) review methodologies for implementing recency testing for both incidence estimation and non-incidence use cases, and (3) assess the field performance characteristics of commercially available recency assays. RESULTS Among the 167 documents included in the final review, 91 (54.5%) focused on assay or algorithm performance or methodological descriptions, with high-quality evidence of accurate age- and sex-disaggregated HIV incidence estimation at national or regional levels in general population settings, but not at finer geographic levels for prevention prioritization. The remaining 76 (45.5%) described the field use of incidence assays including field-derived incidence (n=45), non-incidence (n=25), and both incidence and non-incidence use cases (n=6). The field use of incidence assays included integrating RITAs into routine surveillance and assisting with molecular genetic analyses, but evidence was generally weaker or only reported on what was done, without validation data or findings related to effectiveness of using non-incidence indicators calculated through the use of recency assays as a proxy for HIV incidence. CONCLUSIONS HIV recency assays have been widely validated for estimating HIV incidence in age- and sex-specific populations at national and subnational regional levels; however, there is a lack of evidence validating the accuracy and effectiveness of using recency assays to identify epidemic trends in non-incidence surveillance use cases. More research is needed to validate the use of recency assays within HIV testing services, to ensure findings can be accurately interpreted to guide prioritization of public health programming.
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Affiliation(s)
- Shelley N Facente
- Department of Laboratory Medicine, University of California San Francisco, San Francisco, CA, United States.,Facente Consulting, Richmond, CA, United States.,Vitalant Research Institute, San Francisco, CA, United States
| | - Eduard Grebe
- Department of Laboratory Medicine, University of California San Francisco, San Francisco, CA, United States.,Vitalant Research Institute, San Francisco, CA, United States.,South African Centre for Epidemiological Modeling and Analysis (SACEMA), Stellenbosch University, Stellenbosch, South Africa
| | - Andrew D Maher
- South African Centre for Epidemiological Modeling and Analysis (SACEMA), Stellenbosch University, Stellenbosch, South Africa.,Institute for Global Health Sciences, University of California San Francisco, San Francisco, CA, United States
| | - Douglas Fox
- Facente Consulting, Richmond, CA, United States
| | | | - Mary Mahy
- Strategic Information Department, The Joint United Nations Programme on HIV/AIDS (UNAIDS), Geneva, Switzerland
| | - Shona Dalal
- Global HIV, Hepatitis and Sexually Transmitted Infections Programmes, World Health Organisation, Geneva, Switzerland
| | - David Lowrance
- Global HIV, Hepatitis and Sexually Transmitted Infections Programmes, World Health Organisation, Geneva, Switzerland
| | - Kimberly Marsh
- Strategic Information Department, The Joint United Nations Programme on HIV/AIDS (UNAIDS), Geneva, Switzerland
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de Wit MM, Rice B, Risher K, Welty S, Waruiru W, Magutshwa S, Motoku J, Kwaro D, Ochieng B, Reniers G, Cowan F, Rutherford G, Hargreaves JR, Murphy G. Experiences and lessons learned from the real-world implementation of an HIV recent infection testing algorithm in three routine service-delivery settings in Kenya and Zimbabwe. BMC Health Serv Res 2021; 21:596. [PMID: 34158047 PMCID: PMC8220670 DOI: 10.1186/s12913-021-06619-6] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2021] [Accepted: 06/04/2021] [Indexed: 11/10/2022] Open
Abstract
INTRODUCTION Testing for recent HIV infection can distinguish recently acquired infection from long-standing infections. Given current interest in the implementation of recent infection testing algorithms (RITA), we report our experiences in implementing a RITA in three pilot studies and highlight important issues to consider when conducting recency testing in routine settings. METHODS We applied a RITA, incorporating a limited antigen (LAg) avidity assay, in different routine HIV service-delivery settings in 2018: antenatal care clinics in Siaya County, Kenya, HIV testing and counselling facilities in Nairobi, Kenya, and female sex workers clinics in Zimbabwe. Discussions were conducted with study coordinators, laboratory leads, and facility-based stakeholders to evaluate experiences and lessons learned in relation to implementing recency testing. RESULTS In Siaya County 10/426 (2.3%) of women testing HIV positive were classified as recent, compared to 46/530 (8.7%) of women and men in Nairobi and 33/313 (10.5%) of female sex workers in Zimbabwe. Across the study setting, we observed differences in acceptance, transport and storage of dried blood spot (DBS) or venous blood samples. For example, the acceptance rate when testing venous blood was 11% lower than when using DBS. Integrating our study into existing services ensured a quick start of the study and kept the amount of additional resources required low. From a laboratory perspective, the LAg avidity assay was initially difficult to operationalise, but developing a network of laboratories and experts to work together helped to improve this. A challenge that was not overcome was the returning of RITA test results to clients. This was due to delays in laboratory testing, the need for multiple test results to satisfy the RITA, difficulties in aligning clinic visits, and participants opting not to return for test results. CONCLUSION We completed three pilot studies using HIV recency testing based on a RITA in Kenya and Zimbabwe. The main lessons we learned were related to sample collection and handling, LAg avidity assay performance, integration into existing services and returning of test results to participants. Our real-world experience could provide helpful guidance to people currently working on the implementation of HIV recency testing in sub-Saharan Africa.
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Affiliation(s)
| | - Brian Rice
- London School of Hygiene and Tropical Medicine, London, UK
| | - Kathryn Risher
- London School of Hygiene and Tropical Medicine, London, UK
| | - Susie Welty
- University of California, San Francisco, USA
| | | | | | - John Motoku
- Eastern Deanery AIDS Relief Programme, Nairobi, Kenya
| | | | | | | | - Frances Cowan
- Centre for Sexual Health and HIV/AIDS Research, Harare, Zimbabwe
- Liverpool School of Tropical Medicine, Liverpool, UK
| | | | | | - Gary Murphy
- Independent consultant in HIV laboratory diagnostics, London, UK
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Mustanski B, Ryan DT, Newcomb ME, D'Aquila RT, Matson M. Very High HIV Incidence and Associated Risk Factors in a Longitudinal Cohort Study of Diverse Adolescent and Young Adult Men Who Have Sex with Men and Transgender Women. AIDS Behav 2020; 24:1966-1975. [PMID: 31858300 DOI: 10.1007/s10461-019-02766-4] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
To report HIV incidence and associated factors among young men who have sex with men (YMSM) and transgender women (TW). Data were collected February 2015 to July 2018 in the RADAR longitudinal cohort study of YMSM/TW aged 16-29 years (N = 1093). Data included tests for HIV and rectal STIs and self-reported sexual behaviors and networks characteristics. HIV incidence rates were 2.91 per 100 person years (44 seroconversions among 1513 person years). Incidence was significantly higher in Black participants than white (IRR 8.81; 95% CI 2.72-45.26) and Latinx (IRR 3.15; 1.49-7.28) participants, but no significant differences by gender identity were found. Testing positive for rectal STIs (HR 2.50; 95% CI 1.27-4.92) and sex with a partner from a high HIV incidence community area (HR 2.46; 95% CI 1.19-5.07) were associated with higher incidence. HIV incidence was very high and Black YMSM/TW experienced higher HIV incidence attributable to partner race and geographic residence. Rectal STIs were associated with increased HIV incidence.
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Affiliation(s)
- Brian Mustanski
- Institute for Sexual and Gender Minority Health and Wellbeing, Northwestern University, Chicago, IL, USA.
- Department of Medical Social Sciences, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA.
- Northwestern Institute for Sexual and Gender Minority Health and Wellbeing, 625 N Michigan Ave, Suite 1400, Chicago, IL, 60611, USA.
| | - Daniel T Ryan
- Institute for Sexual and Gender Minority Health and Wellbeing, Northwestern University, Chicago, IL, USA
- Department of Medical Social Sciences, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Michael E Newcomb
- Institute for Sexual and Gender Minority Health and Wellbeing, Northwestern University, Chicago, IL, USA
- Department of Medical Social Sciences, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Richard T D'Aquila
- Institute for Sexual and Gender Minority Health and Wellbeing, Northwestern University, Chicago, IL, USA
- Division of Infectious Diseases, Department of Medicine, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Margaret Matson
- Institute for Sexual and Gender Minority Health and Wellbeing, Northwestern University, Chicago, IL, USA
- Department of Medical Social Sciences, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
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Verhofstede C, Mortier V, Dauwe K, Callens S, Deblonde J, Dessilly G, Delforge ML, Fransen K, Sasse A, Stoffels K, Van Beckhoven D, Vanroye F, Vaira D, Vancutsem E, Van Laethem K. Exploring HIV-1 Transmission Dynamics by Combining Phylogenetic Analysis and Infection Timing. Viruses 2019; 11:v11121096. [PMID: 31779195 PMCID: PMC6950120 DOI: 10.3390/v11121096] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2019] [Revised: 11/21/2019] [Accepted: 11/22/2019] [Indexed: 12/12/2022] Open
Abstract
HIV-1 pol sequences obtained through baseline drug resistance testing of patients newly diagnosed between 2013 and 2017 were analyzed for genetic similarity. For 927 patients the information on genetic similarity was combined with demographic data and with information on the recency of infection. Overall, 48.3% of the patients were genetically linked with 11.4% belonging to a pair and 36.9% involved in a cluster of ≥3 members. The percentage of early diagnosed (≤4 months after infection) was 28.6%. Patients of Belgian origin were more frequently involved in transmission clusters (49.7% compared to 15.3%) and diagnosed earlier (37.4% compared to 12.2%) than patients of Sub-Saharan African origin. Of the infections reported to be locally acquired, 69.5% were linked (14.1% paired and 55.4% in a cluster). Equal parts of early and late diagnosed individuals (59.9% and 52.4%, respectively) were involved in clusters. The identification of a genetically linked individual for the majority of locally infected patients suggests a high rate of diagnosis in this population. Diagnosis however is often delayed for >4 months after infection increasing the opportunities for onward transmission. Prevention of local infection should focus on earlier diagnosis and protection of the still uninfected members of sexual networks with human immunodeficiency virus (HIV)-infected members.
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Affiliation(s)
- Chris Verhofstede
- Aids Reference Laboratory, Department of Diagnostic Sciences, Ghent University, 9000 Ghent, Belgium; (V.M.); (K.D.)
- Correspondence:
| | - Virginie Mortier
- Aids Reference Laboratory, Department of Diagnostic Sciences, Ghent University, 9000 Ghent, Belgium; (V.M.); (K.D.)
| | - Kenny Dauwe
- Aids Reference Laboratory, Department of Diagnostic Sciences, Ghent University, 9000 Ghent, Belgium; (V.M.); (K.D.)
| | - Steven Callens
- Aids Reference Center, Department of Internal Medicine, Ghent University Hospital, 9000 Ghent, Belgium;
| | - Jessika Deblonde
- Epidemiology of Infectious Diseases Unit, Scientific Institute of Public Health Sciensano, 1050 Brussels, Belgium; (J.D.); (A.S.); (D.V.B.)
| | - Géraldine Dessilly
- Aids Reference Laboratory, Medical Microbiology Unit, Université Catholique de Louvain, 1200 Brussels, Belgium;
| | - Marie-Luce Delforge
- Aids Reference Laboratory, Université Libre de Bruxelles, 1050 Brussels, Belgium;
| | - Katrien Fransen
- HIV/STD Reference Laboratory, Department of Clinical Sciences, Institute of Tropical Medicine, 2000 Antwerp, Belgium; (K.F.); (F.V.)
| | - André Sasse
- Epidemiology of Infectious Diseases Unit, Scientific Institute of Public Health Sciensano, 1050 Brussels, Belgium; (J.D.); (A.S.); (D.V.B.)
| | - Karolien Stoffels
- Aids Reference Laboratory, Centre Hospitalier Universitaire St. Pierre, 1000 Brussels, Belgium;
| | - Dominique Van Beckhoven
- Epidemiology of Infectious Diseases Unit, Scientific Institute of Public Health Sciensano, 1050 Brussels, Belgium; (J.D.); (A.S.); (D.V.B.)
| | - Fien Vanroye
- HIV/STD Reference Laboratory, Department of Clinical Sciences, Institute of Tropical Medicine, 2000 Antwerp, Belgium; (K.F.); (F.V.)
| | - Dolores Vaira
- Aids Reference Laboratory, Centre Hospitalier Universitaire de Liège, 4000 Liège, Belgium;
| | - Ellen Vancutsem
- Aids Reference Laboratory, Vrije Universiteit Brussel VUB, 1090 Brussels, Belgium;
| | - Kristel Van Laethem
- Aids Reference Laboratory, University Hospital Leuven, 3000 Leuven, Belgium;
- Rega Institute for Medical Research, Department of Microbiology, Immunology and Transplantation, KU Leuven, 3000 Leuven, Belgium
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Abstract
Purpose Identifying infectious pathogens by collecting intravenous blood (IVB) is a well-established procedure, however, the collection of IVB in field epidemiological study is challenging. The dried blood spot (DBS) as an alternative to IVB has been introduced, although, there is a limited study to demonstrate the utility of DBS stored at various storage conditions and transported at different periods. This is an observational study, which evaluates the effectiveness of DBS in field epidemiological studies to identify infectious pathogens. Materials and Methods A total of 264 paired DBS samples prepared from IVB, stored at 4°C, -20°C after period 24, 48 and 72 h. Serologically, enzyme-linked immunosorbent assay [ELISA] IgG antibody detected against Helicobacter pylori infection from DBS and compared with IVB. Results Quantitatively, IgG antibody reactivity showed >87% correlation between IVB and DBS samples stored at 4°C or -20°C within 48 h of transport duration. DBS stored at 4°C shows, equal sensitivity 87.5% and specificity 95% before 48 h of transport duration, while at -20°C storage similar sensitivity 87.5% observed but slightly less specificity 86.36% observed as compared to 24 h of transport duration. One-way analysis of variance showed, nonsignificant difference at both (-20°C and 4°C) the stored condition with P value (P > 0.851) and (P > 0.477). Kappa values showed good inter-rater reliability between DBS and IVB in a range (0.77-0.81). Conclusion No significant difference was observed in detecting H. pylori when ELISA was conducted using IVB or DBS stored at 4°C and transported even after 48 h. This confirms that DBS collected even in compromised conditions in the field can be used for detecting infection.
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Affiliation(s)
- Abhinendra Kumar
- Centre for Cancer Epidemiology, Advanced Centre for Treatment Research and Education in Cancer, Tata Memorial Centre; Homi Bhabha National Institute (HBNI), Training School Complex, Anushaktinagar, Mumbai, Maharashtra, India
| | - Sharayu Mhatre
- Centre for Cancer Epidemiology, Advanced Centre for Treatment Research and Education in Cancer, Tata Memorial Centre; Homi Bhabha National Institute (HBNI), Training School Complex, Anushaktinagar, Mumbai, Maharashtra, India
| | - Rajesh Dikshit
- Centre for Cancer Epidemiology, Advanced Centre for Treatment Research and Education in Cancer, Tata Memorial Centre; Homi Bhabha National Institute (HBNI), Training School Complex, Anushaktinagar, Mumbai, Maharashtra, India
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Sempa JB, Welte A, Busch MP, Hall J, Hampton D, Facente SN, Keating SM, Marson K, Parkin N, Pilcher CD, Murphy G, Grebe E. Performance comparison of the Maxim and Sedia Limiting Antigen Avidity assays for HIV incidence surveillance. PLoS One 2019; 14:e0220345. [PMID: 31348809 PMCID: PMC6660077 DOI: 10.1371/journal.pone.0220345] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2019] [Accepted: 07/13/2019] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Two manufacturers, Maxim Biomedical and Sedia Biosciences Corporation, supply CDC-approved versions of the HIV-1 Limiting Antigen Avidity EIA (LAg) for detecting 'recent' HIV infection in cross-sectional incidence estimation. This study assesses and compares the performance of the two assays for incidence surveillance. METHODS We ran both assays on a panel of 2,500 well-characterized HIV-1-infected specimens. We analysed concordance of assay results, assessed reproducibility using repeat testing and estimated mean durations of recent infection (MDRIs) and false-recent rates (FRRs) for a range of normalized optical density (ODn) thresholds, alone and in combination with viral load thresholds. We defined three hypothetical surveillance scenarios, similar to the Kenyan and South African epidemics, and a concentrated epidemic. These scenarios allowed us to evaluate the precision of incidence estimates obtained by means of various recent infection testing algorithms (RITAs) based on each of the two assays. RESULTS The Maxim assay produced lower ODn values than the Sedia assay on average, largely as a result of higher calibrator readings (mean OD of 0.749 vs. 0.643), with correlation of normalized readings lower (R2 = 0.908 vs. R2 = 0.938). Reproducibility on blinded control specimens was slightly better for Maxim. The MDRI of a Maxim-based algorithm at the 'standard' threshold (ODn ≤1.5 & VL >1,000) was 201 days (95% CI: 180,223) and for Sedia 171 (152,191). The difference Differences in MDRI were estimated at 32.7 (22.9,42.8) and 30.9 days (21.7,40.7) for the two algorithms, respectively. Commensurately, the Maxim algorithm had a higher FRR in treatment-naive subjects (1.7% vs. 1.1%). The two assays produced similar precision of incidence estimates in the three surveillance scenarios. CONCLUSIONS Differences between the assays can be primarily attributed to the calibrators supplied by the manufacturers. Performance for surveillance was extremely similar, although different thresholds were optimal (i.e. produced the lowest variance of incidence estimates) and at any given ODn threshold, different estimates of MDRI and FRR were obtained. The two assays cannot be treated as interchangeable: assay and algorithm-specific performance characteristic estimates must be used for survey planning and incidence estimation.
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Affiliation(s)
- Joseph B. Sempa
- DST-NRF Centre of Excellence in Epidemiological Modelling and Analysis (SACEMA), Stellenbosch University, Stellenbosch, South Africa
| | - Alex Welte
- DST-NRF Centre of Excellence in Epidemiological Modelling and Analysis (SACEMA), Stellenbosch University, Stellenbosch, South Africa
| | - Michael P. Busch
- Vitalant Research Institute, San Francisco, CA, United States of America
- University of California San Francisco, San Francisco, CA, United States of America
| | - Jake Hall
- Public Health England, London, United Kingdom
| | - Dylan Hampton
- Vitalant Research Institute, San Francisco, CA, United States of America
| | - Shelley N. Facente
- Vitalant Research Institute, San Francisco, CA, United States of America
- University of California San Francisco, San Francisco, CA, United States of America
- Facente Consulting, Richmond, CA, United States of America
| | - Sheila M. Keating
- Vitalant Research Institute, San Francisco, CA, United States of America
- University of California San Francisco, San Francisco, CA, United States of America
| | - Kara Marson
- University of California San Francisco, San Francisco, CA, United States of America
| | - Neil Parkin
- Data First Consulting, Belmont, CA, United States of America
| | | | - Gary Murphy
- Public Health England, London, United Kingdom
| | - Eduard Grebe
- DST-NRF Centre of Excellence in Epidemiological Modelling and Analysis (SACEMA), Stellenbosch University, Stellenbosch, South Africa
- Vitalant Research Institute, San Francisco, CA, United States of America
- University of California San Francisco, San Francisco, CA, United States of America
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Facente SN, Busch MP, Grebe E, Pilcher CD, Welte A, Rice B, Murphy G. Challenges to the performance of current HIV diagnostic assays and the need for centralized specimen archives: a review of the Consortium for the Evaluation and Performance of HIV Incidence Assays (CEPHIA) repository. Gates Open Res 2019; 3:1511. [PMID: 31460496 PMCID: PMC6706958 DOI: 10.12688/gatesopenres.13048.1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/17/2019] [Indexed: 11/20/2022] Open
Abstract
Background: New challenges for diagnosis of HIV infection abound, including the impact on key viral and immunological markers of HIV vaccine studies, pre-exposure prophylaxis usage and breakthrough infections, and very early initiation of anti-retroviral treatment. These challenges impact the performance of current diagnostic assays, and require suitable specimens for development and evaluation. In this article we review and describe an archive developed by the Consortium for the Evaluation and Performance of HIV Incidence Assays (CEPHIA), in order to identify the critical features required to create a centralized specimen archive to support these current and future developments. Review and Findings: We review and describe the CEPHIA repository, a large, consolidated repository comprised of over 31,000 highly-selected plasma samples and other body fluid specimen types, with over 50 purposely designed specimen panels distributed to 19 groups since 2012. The CEPHIA repository provided financial return on investment, supported the standardization of HIV incidence assays, and informed guidance and standards set by the World Health Organization and UNAIDS. Unified data from extensively characterized specimens has allowed this resource to support biomarker discovery, assay optimization, and development of new strategies for estimating duration of HIV infection. Critical features of a high-value repository include 1) extensively-characterized samples, 2) high-quality clinical background data, 3) multiple collaborations facilitating ongoing sample replenishment, and 4) sustained history of high-level specimen utilization. Conclusion: With strong governance and leadership, a large consolidated archive of samples from multiple studies provides investigators and assay developers with easy access to diverse samples designed to address challenges associated with HIV diagnosis, helping to enable improvements to HIV diagnostic assays and ultimately elimination of HIV. Its creation and ongoing utilization should compel funders, institutions and researchers to address and improve upon current approaches to sharing specimens.
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Affiliation(s)
- Shelley N. Facente
- University of California, San Francisco, San Francisco, CA, 94110, USA
- Vitalant Research Institute (formerly Blood Systems Research Institute), San Francisco, CA, 94118, USA
- Facente Consulting, Richmond, CA, 94804, USA
| | - Michael P. Busch
- University of California, San Francisco, San Francisco, CA, 94110, USA
- Vitalant Research Institute (formerly Blood Systems Research Institute), San Francisco, CA, 94118, USA
| | - Eduard Grebe
- University of California, San Francisco, San Francisco, CA, 94110, USA
- Vitalant Research Institute (formerly Blood Systems Research Institute), San Francisco, CA, 94118, USA
- The South African DST-NRF Centre of Excellence in Epidemiological Modelling and Analysis (SACEMA), Stellenbosch University, Stellenbosch, South Africa
| | | | - Alex Welte
- The South African DST-NRF Centre of Excellence in Epidemiological Modelling and Analysis (SACEMA), Stellenbosch University, Stellenbosch, South Africa
| | - Brian Rice
- London School of Hygiene and Tropical Medicine, London, UK
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10
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Laeyendecker O, Konikoff J, Morrison DE, Brookmeyer R, Wang J, Celum C, Morrison CS, Abdool Karim Q, Pettifor AE, Eshleman SH. Identification and validation of a multi-assay algorithm for cross-sectional HIV incidence estimation in populations with subtype C infection. J Int AIDS Soc 2019; 21. [PMID: 29489059 PMCID: PMC5829581 DOI: 10.1002/jia2.25082] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2017] [Accepted: 01/29/2018] [Indexed: 12/02/2022] Open
Abstract
Introduction Cross‐sectional methods can be used to estimate HIV incidence for surveillance and prevention studies. We evaluated assays and multi‐assay algorithms (MAAs) for incidence estimation in subtype C settings. Methods We analysed samples from individuals with subtype C infection with known duration of infection (2442 samples from 278 adults; 0.1 to 9.9 years after seroconversion). MAAs included 1‐4 of the following assays: Limiting Antigen Avidity assay (LAg‐Avidity), BioRad‐Avidity assay, CD4 cell count and viral load (VL). We evaluated 23,400 MAAs with different assays and assay cutoffs. We identified the MAA with the largest mean window period, where the upper 95% confidence interval (CI) of the shadow was <1 year. This MAA was compared to the LAg‐Avidity and BioRad‐Avidity assays alone, a widely used LAg algorithm (LAg‐Avidity <1.5 OD‐n + VL >1000 copies/mL), and two MAAs previously optimized for subtype B settings. We compared these cross‐sectional incidence estimates to observed incidence in an independent longitudinal cohort. Results The optimal MAA was LAg‐Avidity <2.8 OD‐n + BioRad‐Avidity <95% + VL >400 copies/mL. This MAA had a mean window period of 248 days (95% CI: 218, 284), a shadow of 306 days (95% CI: 255, 359), and provided the most accurate and precise incidence estimate for the independent cohort. The widely used LAg algorithm had a shorter mean window period (142 days, 95% CI: 118, 167), a longer shadow (410 days, 95% CI; 318, 491), and a less accurate and precise incidence estimate for the independent cohort. Conclusions An optimal MAA was identified for cross‐sectional HIV incidence in subtype C settings. The performance of this MAA is superior to a testing algorithm currently used for global HIV surveillance.
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Affiliation(s)
- Oliver Laeyendecker
- Laboratory of Immunoregulation, NIAID, NIH, Baltimore, MD, USA.,Division of Infectious Diseases, Department of Medicine, School of Medicine, Johns Hopkins University, Baltimore, MD, USA.,Department of Epidemiology, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA
| | - Jacob Konikoff
- Department of Biostatistics, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA
| | - Douglas E Morrison
- Department of Biostatistics, UCLA School of Public Health, Los Angeles, CA, USA
| | - Ronald Brookmeyer
- Department of Biostatistics, UCLA School of Public Health, Los Angeles, CA, USA
| | - Jing Wang
- Vaccine and Infectious Disease Division, SCHARP-FHCRC, Seattle, WA, USA
| | - Connie Celum
- Departments of Global Health, Medicine, and Epidemiology, University of Washington, Seattle, WA, USA
| | | | - Quarraisha Abdool Karim
- Centre for the AIDS Programme of Research in South Africa (CAPRISA), University of KwaZulu-Natal, Durban, South Africa.,Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, NY, USA
| | - Audrey E Pettifor
- Department of Epidemiology, University of North Carolina, Chapel Hill, NC, USA.,Carolina Population Center, University of North Carolina, Chapel Hill, NC, USA.,Medical Research Council/Wits Rural Public Health and Health Transitions Research Unit, School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa.,Wits Reproductive Health and HIV Institute, University of the Witwatersrand, Johannesburg, South Africa
| | - Susan H Eshleman
- Department of Pathology, School of Medicine, Johns Hopkins University, Baltimore, MD, USA
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11
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Carmona S, Seiverth B, Magubane D, Hans L, Hoppler M. Separation of Plasma from Whole Blood by Use of the cobas Plasma Separation Card: a Compelling Alternative to Dried Blood Spots for Quantification of HIV-1 Viral Load. J Clin Microbiol 2019; 57:e01336-18. [PMID: 30728197 DOI: 10.1128/JCM.01336-18] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2018] [Accepted: 01/23/2019] [Indexed: 12/21/2022] Open
Abstract
Plasma HIV viral load testing is the preferred means of monitoring antiretroviral treatment response. Dried blood spots (DBSs) hold considerable logistical advantages over EDTA samples, but they more frequently misclassify virological failure and have higher limits of detection (LoD). Plasma separation cards (PSCs) may overcome these limitations. Health workers collected EDTA whole blood by venipuncture and 140 μl of finger-prick blood by capillary tube from 53 HIV-infected adults. Capillary blood was immediately transferred to PSCs. Additionally, 432 EDTA samples from HIV-infected adults were spotted onto PSCs and analyzed together with the finger-prick samples. Specificity and sensitivity of PSC with paired EDTA-PSC samples tested on a cobas 6800/8800 system with the cobas HIV-1 test (cobas HIV) was determined. LoD (3rd HIV-1 WHO International Standard) and stability at a range of temperatures and storage durations was determined using cobas HIV and cobas AmpliPrep/cobas TaqMan HIV-1 test v2.0 (CAP/CTM). Of 132 specimens with quantitative values for paired EDTA-PSC samples, the mean log10 difference between samples was 0.05 copies/ml (95% confidence interval [CI], -0.01 to 0.11). The LoD for cobas HIV was 790.2 copies/ml and for CAP/CTM was 737.9 copies/ml. At 1,000 copies/ml, PSC sensitivity was 97.0% (128/132) and specificity was 97.2% (343/353). Results correlated well with those from EDTA samples (Deming R 2 = 0.90). PSC results were unaffected by temperature and storage conditions. PSC samples correlate well with plasma viral load and have adequate sensitivity and specificity. The improved performance may be as a result of a reduction in contribution from cell-associated viral nucleic acids. The card provides an alternative sample collection technology to DBSs.
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12
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Eisenberg AL, Patel EU, Packman ZR, Fernandez RE, Piwowar-Manning E, Hamilton EL, MacPhail C, Hughes J, Pettifor A, Kallas EG, Busch MP, Murphy G, Quinn TC, Eshleman SH, Laeyendecker O, Agyei Y, Wang J, Kahn K, Selin A, Gomez-Olive FX, Pilcher FCEPHIAC, Santos BR, Deeks SG, Facente S, Keating SM, Welte A. Short Communication: Dried Blood Spots Stored at Room Temperature Should Not Be Used for HIV Incidence Testing. AIDS Res Hum Retroviruses 2018; 34:1013-1016. [PMID: 30215267 DOI: 10.1089/aid.2018.0138] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
The limiting antigen (LAg)-avidity assay is a serologic assay used for cross-sectional HIV incidence testing. We compared the results obtained with the LAg-avidity assay using dried blood spot (DBS) samples stored at room temperature (18°C-25°C) or stored frozen at -80°C with results obtained from matched plasma samples. Matched DBS and plasma samples (306 paired samples) were collected in the HIV Prevention Trials Network (HPTN) 068 trial in South Africa (2012-2014). The DBS were stored at room temperature before testing. Matched DBS and plasma samples (100 paired samples) from the Consortium for the Evaluation and Performance of HIV Incidence Assays (CEPHIA) were collected in 2016 and were stored at -80°C. All DBS testing was performed in 2017. Differences in normalized optical density (ODn) were compared between matched DBS and plasma samples. For DBS samples stored at room temperature (HPTN 068), the average difference in ODn values for plasma versus DBS was 1.49 (95% confidence intervals [CI]: 1.36-1.62). In contrast, when DBS samples were stored at -80°C (CEPHIA), the average difference in ODn values for plasma versus DBS was -0.22 (95% CI: -0.32 to -0.13). DBS samples stored at room temperature should not be used for cross-sectional HIV incidence testing with the LAg-avidity assay.
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Affiliation(s)
- Anna L. Eisenberg
- Division of Intramural Research, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Baltimore, Maryland
| | - Eshan U. Patel
- School of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Zoe R. Packman
- School of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Reinaldo E. Fernandez
- School of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | | | | | - Catherine MacPhail
- School of Health and Society, University of Wollongong, Wollongong, Australia
| | - James Hughes
- Fred Hutchinson Cancer Research Center, Seattle, Washington
- Department of Biostatistics, University of Washington, Seattle, Washington
| | - Audrey Pettifor
- Department of Epidemiology, University of North Carolina, Chapel Hill, North Carolina
- Carolina Population Center, University of North Carolina, Chapel Hill, North Carolina
- Medical Research Council/Wits Rural Public Health and Health Transitions Research Unit, Faculty of Health Sciences, School of Public Health, University of the Witwatersrand, Johannesburg, South Africa
- Wits Reproductive Health and HIV Institute, University of the Witwatersrand, Johannesburg, South Africa
| | | | - Michael P. Busch
- Blood Systems Research Institute, San Francisco, California
- Department of Medicine, School of Medicine, University of California at San Francisco, San Francisco, California
| | - Gary Murphy
- Public Health England, London, United Kingdom
| | - Thomas C. Quinn
- Division of Intramural Research, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Baltimore, Maryland
| | - Susan H. Eshleman
- School of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Oliver Laeyendecker
- Division of Intramural Research, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Baltimore, Maryland
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13
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Parekh BS, Ou CY, Fonjungo PN, Kalou MB, Rottinghaus E, Puren A, Alexander H, Hurlston Cox M, Nkengasong JN. Diagnosis of Human Immunodeficiency Virus Infection. Clin Microbiol Rev 2019; 32:e00064-18. [PMID: 30487166 DOI: 10.1128/CMR.00064-18] [Citation(s) in RCA: 39] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
HIV diagnostics have played a central role in the remarkable progress in identifying, staging, initiating, and monitoring infected individuals on life-saving antiretroviral therapy. They are also useful in surveillance and outbreak responses, allowing for assessment of disease burden and identification of vulnerable populations and transmission "hot spots," thus enabling planning, appropriate interventions, and allocation of appropriate funding. HIV diagnostics are critical in achieving epidemic control and require a hybrid of conventional laboratory-based diagnostic tests and new technologies, including point-of-care (POC) testing, to expand coverage, increase access, and positively impact patient management. In this review, we provide (i) a historical perspective on the evolution of HIV diagnostics (serologic and molecular) and their interplay with WHO normative guidelines, (ii) a description of the role of conventional and POC testing within the tiered laboratory diagnostic network, (iii) information on the evaluations and selection of appropriate diagnostics, (iv) a description of the quality management systems needed to ensure reliability of testing, and (v) strategies to increase access while reducing the time to return results to patients. Maintaining the central role of HIV diagnostics in programs requires periodic monitoring and optimization with quality assurance in order to inform adjustments or alignment to achieve epidemic control.
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14
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Abstract
There is increasing interest in using dried blood spot (DBS) cards to extend the reach of global health and disease surveillance programs to hard-to-reach populations. Conceptually, DBS offers a cost-effective solution for multiple use cases by simplifying logistics for collecting, preserving, and transporting blood specimens in settings with minimal infrastructure. This review describes methods to determine both the reliability of DBS-based bioanalysis for a defined use case and the optimal conditions that minimize pre-analytical sources of data variability. Examples by the newborn screening, drug development, and global health communities are provided in this review of published literature. Sources of variability are linked in most cases, emphasizing the importance of field-to-laboratory standard operating procedures that are evidence based and consider both stability and efficiency of recovery for a specified analyte in defining the type of DBS card, accessories, handling procedures, and storage conditions. Also included in this review are reports where DBS was determined to not be feasible because of technology limitations or physiological properties of a targeted analyte.
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Affiliation(s)
- Mark D. Lim
- Global Health Division, Bill & Melinda Gates Foundation, Seattle, Washington
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15
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Joseph J, Kent N, Bowen A, Hart J, Sheel M, Wardrop R, Abbs S, Bazely S, Rybak M. Immuno-nephelometric determination of group streptococcal anti-streptolysin O titres (ASOT) from dried blood spots: Method for validating a new assay. J Immunol Methods 2017; 448:59-65. [PMID: 28554544 DOI: 10.1016/j.jim.2017.05.009] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2017] [Accepted: 05/23/2017] [Indexed: 11/24/2022]
Abstract
This study was designed to determine the sensitivity and reproducibility of recovering anti-streptolysin O titres (ASOT) from dried blood spot (DBS) samples, a methodologic subcomponent of the penicillin pharmacokinetic studies in children receiving secondary prophylaxis with intramuscular benzathine penicillin for acute rheumatic fever.
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Affiliation(s)
- John Joseph
- PathWest Laboratory Medicine, QE2 Medical Centre Redevelopment, Australia.
| | - Neil Kent
- PathWest Laboratory Medicine, QE2 Medical Centre Redevelopment, Australia
| | - Asha Bowen
- Menzies School of Health Research, Charles Darwin University, Australia; Wesfarmers Centre for Vaccines and Infectious Diseases, Telethon Kids Institute, University of Western Australia, Australia; Princess Margaret Hospital for Children, Australia; University of Western Australia, Australia
| | - Julie Hart
- PathWest Laboratory Medicine, QE2 Medical Centre Redevelopment, Australia
| | - Meru Sheel
- Wesfarmers Centre for Vaccines and Infectious Diseases, Telethon Kids Institute, University of Western Australia, Australia
| | | | - Sam Abbs
- PathWest Laboratory Medicine, QE2 Medical Centre Redevelopment, Australia
| | | | - Monika Rybak
- PathWest Laboratory Medicine, QE2 Medical Centre Redevelopment, Australia
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