Diagnoses of HIV-1 and HIV-2 in England, Wales, and Northern Ireland associated with west Africa

OBJECTIVES

To describe HIV diagnoses, including those of HIV-2 infection, made in England, Wales, and Northern Ireland (E,W&NI) among those probably infected in west Africa, and to consider whether there is evidence for ongoing heterosexual transmission within the United Kingdom.

METHODS

Reports of new HIV diagnoses received at the Communicable Disease Surveillance Centre were analysed. Individuals probably infected in west Africa and those infected through heterosexual intercourse within the United Kingdom by a heterosexual partner infected in west Africa were included.

RESULTS

Between 1985 and 2003 inclusive, 1324 individuals diagnosed and reported with HIV had probably been infected in west Africa, with 222 diagnoses made in 2003. 917 (69%) were HIV-1 infected and 52 (6%) HIV-2 or HIV-1/HIV-2 co-infected. For 355 (27%) the HIV type was not reported. The proportion of HIV-2 and HIV-1/HIV-2 infections varied by country of infection (p<0.001): ranging from the Gambia (11.7%-15.2%) to Nigeria (0.7%-1.0%). A further 130 individuals were probably infected through heterosexual intercourse within the United Kingdom by a heterosexual partner infected in west Africa. 89 (68%) were HIV-1 infected and three (2%) HIV-2 infected or HIV-1/HIV-2 co-infected. For 38 (29%) HIV type was not reported.

CONCLUSION

The number of people infected with HIV in west Africa and diagnosed in E,W&NI has increased in recent years, and there is evidence of heterosexual transmission within the United Kingdom from people infected in west Africa. While numbers of HIV-2 diagnoses remain relatively low, an appreciable proportion of people infected in some west African countries and diagnosed in the United Kingdom may be HIV-2 positive, with implications for prognosis and treatment.

Prospective study of HTLV-I infection in an initially asymptomatic cohort

A prospective clinical study of 20 initially asymptomatic HTLV-I-seropositive carriers was commenced in 1991 to determine the natural history of the infection in relation to HTLV-I proviral load, immune responses, and lymphocyte phenotype. Proviral load varied widely between carriers but was relatively constant within an individual over time. The lymphocyte phenotype and prevalence of activated lymphocytes were not predictive of disease and the magnitude of the cytotoxic T-lymphocyte response to HTLV-I was independent of proviral load. Incident conditions, some related to HTLV-I infection, including a case of HTLV-I-associated myelopathy (HAM), were documented in 9 carriers. Development of myelopathy and uveitis was associated with high peripheral blood HTLV-I proviral load that predated symptoms. Persistently high proviral load appears to predate the development of HTLV-I-associated inflammation in neuro-ophthalmic tissue.

Quantification of proviral DNA load in human T-cell leukaemia virus type I infections

A nested PCR was designed using primers from the pol and tax genes of human T-cell leukaemia virus type I (HTLV-I). The assay reliably detected a single copy of HTLV-I proviral genome in DNA from 1 x 10(5) Peripheral blood mononuclear cells (PBMCs). Using serial dilutions of sample DNA, the assay was applied prospectively to study proviral load in patients with HTLV-associated disease and carriers. The median proviral load expressed as number of copies/100 PBMCs was found to be 14.0 copies in patients with HAM and 1.55 copies in initially asymptomatic carriers. The assay was used to test for low proviral load in subjects who may have HTLV-I infection, and to monitor response to therapy.

Performance of the Amplicor human immunodeficiency virus type 1 PCR and analysis of specimens with false-negative results

Over a 4-year period, the Roche Amplicor kit was used in a United Kingdom reference laboratory for the detection or confirmation of human immunodeficiency virus (HIV) type 1 infection, particularly in infants born to HIV-infected mothers. Of 408 specimens from adults and older children tested, the 122 seronegative specimens were all Amplicor negative. Of the 286 seropositive specimens, 268 were Amplicor positive. On the basis of these results, the Amplicor assay has a specificity of 100% and a sensitivity of 93.7%. In addition, for 247 specimens from infants and young children, serological results may not have been diagnostic because of placental transfer of maternal antibodies. Forty-eight were Amplicor positive, and of the 199 Amplicor-negative specimens, 19 were assumed to be false negative on the basis of clinical data, serological markers (including p24 antigen), and/or results for previous or follow-up specimens. This represents a sensitivity of 75% for the Amplicor test for specimens from patients under 2 years of age. Of these 37 false-negative specimens plus 2 specimens from other laboratories, 31 could be characterized by amplifying extracted material from them by an in-house nested gag PCR spanning the Amplicor target region. The amplicons were sequenced and found to represent subtypes A (35.5%), B (22.6%), C (22.6%), D (16.1%), and G (3.2%). False-negative results by the Amplicor assay may be ascribed to low-target copy number, the physical behavior of one primer (SK462), and sequence variation in the target region of the other primer (SK431).

Analysis and genotyping of PCR products of the Amplicor HIV-1 kit

The Roche Amplicor PCR kit was used to detect HIV-1 DNA in UK patients of known serostatus. Four false-negative and/or equivocal results were obtained from patients who were known to be anti HIV seropositive (Tosswill et al., 1994). Cells from the blood of these patients were shown to contain HIV DNA after extraction, concentration and amplification by nested PCR using primers flanking those in the kit. To determine whether DNA sequence divergence was the cause of these discrepancies, the gag region targeted by the primers in the kit was sequenced for specimens giving positive, equivocal and false-negative results. No greater degree of sequence divergence was found within the primer and probe target regions among the equivocals and false-negatives than among the positive control specimens. The few misleading results were probably attributable to low copy numbers of proviral DNA in these specimens. Sequences obtained from the target and flanking regions of the kit were sufficient to allow the genotype of the virus to be determined.

Surveillance of HTLV infection in England and Wales: 1986-1992

The epidemiology of infection with human T cell leukaemia/lymphoma virus (HTLV) types I and II in England and Wales between 1986 and 1992 has been studied. Two sources of data have been reviewed: reports of cases of infection received by the PHLS Communicable Disease Surveillance Centre, and information about people infected with HTLV-I and II provided on laboratory request forms sent to the Virus Reference Division of the PHLS Central Public Health Laboratory. Most patients were of Caribbean origin. The age and sex distribution of people with disease associated with HTLV-I and II in England and Wales resembles that previously recorded in the Caribbean. The data suggest that the prevalence of disease associated with HTLV infection is low in England and Wales, but case ascertainment may be incomplete.

Prevalence of antibodies to human T cell leukaemia/lymphoma virus in blood donors in north London

OBJECTIVES

To determine the prevalence of antibodies to the human T cell leukaemia/lymphoma viruses (HTLV-I and HTLV-II) in blood donors in north London in order to assess the economic impact and the logistic effects that routine screening would have on the blood supply.

DESIGN

All donations collected by the north London blood transfusion centre between January 1991 and June 1991 were screened for antibodies to HTLV-I and HTLV-II by modified, improved Fujirebio gel particle agglutination test. Positive samples were titrated and retested as necessary.

SUBJECTS

96,720 unpaid volunteers, who gave 105,730 consecutive donations of blood and plasma.

SETTING

North London blood transfusion centre.

MAIN OUTCOME MEASURE

Observed numbers of donors confirmed to be seropositive for HTLV by reference laboratories.

RESULTS

Of 2622 (2.5%) initially reactive samples, 414 (0.4% of all samples) gave a titre of > or = 1 in 16 on the modified agglutination test. Thirty five of the 414 serum samples yielded positive results on one of two enzyme linked immunosorbent assays (ELISA (Cambridge Biotech and Abbot)), and none of these results were confirmed by either reference laboratory. Five samples yielded positive results on both ELISAs and all five of these were confirmed to contain antibodies to HTLV. One of the five contained antibodies to HTLV-II and the others antibodies to HTLV-I. Four seropositive donors were white women whose only risk factor for infection was sexual contact. The fifth (positive for antibodies to HTLV-II) was an Anglo-Caribbean man who admitted to previous misuse of intravenous drugs.

CONCLUSION

The prevalence of antibodies to HTLV in blood donors in north London was one in 19,344 (0.005%). Up to 100 donors a year might be identified in the United Kingdom as being infected with HTLV, although prevalence in different regions may vary considerably.

Serological speciation of human T-cell leukaemia virus infections using synthetic peptide antigens

In order to assess the specificity and sensitivity of two peptide-based assays (Synth HTLV-I and HTLV-II enzyme-linked immunoassay [EIA] [UBI] and Select-HTLV EIA [IAF]) in discriminating between antibody to HTLV-I and HTLV-II infection, a panel of 186 well-characterised serum/plasma samples was tested by the two assays. The panel comprised 160 samples that by Western blot were confirmed to contain antibodies to HTLV-I/II and 26 samples that showed reactivity with gag but not env gene products. Both assays were found to be specific in that they did not misclassify any of the 80 specimens from cases of tropical spastic paraparesis or adult T-cell leukaemia/lymphoma, diseases believed to be HTLV-I associated, as anti-HTLV-II positive. Of the 160 specimens confirmed as anti-HTLV-I/II positive by Western blot, 6.2% were negative or untypable in the Synth EIA compared with 13.7% in the Select EIA. Of the 26 Western blot indeterminate samples, 16 were negative by both assays. Five were typed as anti-HTLV-I by both assays and 5 as anti HTLV-II by Select EIA only. The peptide based EIAs offer an economical and, in most cases, reliable means of discriminating between anti-HTLV-I and anti-HTLV-II. However, they should only be applied to sera that have been confirmed by Western blot or other methods as anti-HTLV-I/II positive. Even then they may fail to speciate sera from non-Japanese, non-Afrocaribbean populations.

Evaluation of an enzyme immunoassay for the combined detection of antibodies to HIV-1, HIV-2, HTLV-I and HTLV-II

OBJECTIVE

To assess the sensitivity and specificity of a newly-developed assay (Bioelisa HIV-1 + 2, HTLV-1 + 2) for the simultaneous detection of HIV-1, HIV-2, HTLV-I and HTLV-II antibodies in human serum or plasma specimens.

METHODS

A panel of 775 well characterized serum or plasma samples was studied. This included samples confirmed to contain antibodies to HIV-1 (n = 46), HIV-2 (n = 19), HTLV-I (n = 49) and HTLV-II (n = 12), samples containing low titres of anti-HIV antibody (n = 14) and samples collected during HIV seroconversion (n = 36). Eighty-three sera samples which were reactive in one or more HIV or HTLV screening assays, but which could not be confirmed to contain anti-HIV-1/2 or anti-HTLV-I/II antibodies, were also examined.

RESULTS

Excluding the seroconversion samples and those selected on the basis of false reactivity in other screening assays, the Bioelisa kit had a sensitivity of 100% for antibody to all four viruses and a specificity of 98.8%. The ability of the kit to detect anti-HIV during seroconversion was similar to that of several other synthetic HIV-antigen-based screening kits currently in use.

CONCLUSIONS

Our findings indicate that the Bioelisa kit is sufficiently accurate to screen for both HIV and HTLV infections and that it warrants larger scale trials. Its use might allow blood donor screening for HTLV infection to be introduced more widely at modest extra cost [corrected].

Application of screening and confirmatory assays for anti-HTLV-I/II in U.K. populations

During an epidemiological study of a low risk U.K. population diverse screening and confirmatory assays for the detection of anti-HTLV-I/II were assessed. Sera from 2,900 antenatal patients were tested for anti-HTLV-I/II by gelatin particle agglutination assay (GPA). All reactive sera, and 133 randomly selected unreactive sera, were further tested by Abbott and DuPont ELISAs, "in house" competitive and IgG capture radioimmunoassays (RIAs), and Western blot (WB). Sera which reacted with any HTLV-I proteins by WB were tested by radio immunoprecipitation assays (RIPA). The two ELISAs detected all the GPA reactive specimens that were subsequently confirmed as anti-HTLV-I/II positive. Confirmation of positive screening results required the use of both WB and RIPA. Serological diagnosis of HTLV infection involves access to specialised assays that are not commercially available.

An evaluation of the ELISA for schistosomiasis in a hospital population

In order to evaluate the ELISA for schistosomiasis under the conditions of clinical practice, 1576 hospital patients were tested using a crude soluble Schistosoma mansoni egg antigen. Test sensitivity in detection of S. mansoni was found to be 96.2% and in S. haematobium 92.3%. The predictive value of positive results was high, reaching 88% at antibody levels three or more times the screening level. The test was considered by clinicians to be valuable for diagnosis and patient management, though it did not distinguish active from recently treated infections. Of 37 apparently false positive schistosome ELISA results only seven could be attributed to other helminth infections. Another nine patients had hepatitis. It is suggested that the antigens and antibodies of the two diseases are mutually cross-reactive, since reports have suggested a high increase of HBsAg patients with schistosomiasis.

The cryopreservation of standard sera

To determine the storage temperature needed for the preservation of standard sera for serodiagnostic tests, groups of sera were tested before and after storage at -70 degrees C and -20 degrees C for periods of up to five years. The temperature required depended on the nature of the test, but no definite advantage was found in storage at -70 degrees C. For complement fixation this temperature was inadequate and greatly inferior to liquid nitrogen. For immunofluorescence it had no apparent advantage over a temperature of -20 degrees C, and for some other tests it was no more than marginally superior.

Counter immunoelectrophoresis as a rapid screening test for amoebic liver abscess

Counter immunoelectrophoresis using cellulose acetate as the supporting medium was used as a rapid screening test for amoebic abscess. All the sera from 40 cases gave positive results. No false positives were obtained, but the results in intestinal amoebiasis were less reliable. An attempt was made to account for discrepancies in previous reports.