1. Managing Acute HIV Infection Nucleic Acid Amplification Testing January 26, 2009
Nick Curry, MD, MPH
Infectious Diseases Prevention Section
Texas Department of State Health Services

2. Setting the Stage
In Texas, >25% of those initially diagnosed as HIV-infected, receive a diagnosis of AIDS within one month of the HIV diagnosis.
Several studies have demonstrated that fifty percent or more of HIV transmission is due to acutely infected sources.
Period of acute infection associated with high viral load.

3. Setting the Stage ~ 4,600 new cases of HIV reported in Texas in 2006.
Black females are nineteen times more likely to be diagnosed with HIV when compared to white females today.
Black males are five times more likely to be diagnosed with HIV when compared to white males.

4. Definition of Acute HIV Infection
Time period following infection with HIV during which HIV can be detected in blood but antibodies to HIV are not detected OR
Window period when routine HIV antibody tests (EIAs) are negative but HIV can be detected in blood

5. What is the Rationale for Detecting Acute Infection?
Interruption of HIV Transmission From Highly Infectious Individuals using NAAT and rapid DIS response
Improved HIV Infection Diagnosis
Earlier and Appropriate Clinical Management of Acutely Infected Persons
Enhanced HIV Surveillance
Improved Assessment of Epidemiologic Trends

6. What is a nucleic acid amplification test?
It is a test for the presence of HIV, not antibodies to HIV.
It detects HIV infection before any antibody test can do so.
It identifies the presence of HIV RNA, the nucleic acid which caries the HIV genetic information.
It amplifies the HIV RNA for enhanced detection.
It is highly sensitive and specific.
It requires plasma (or serum) specimens.
It is approved as a diagnostic test, and can thus replace the Western Blot for confirmation.

7. Clinical Genetic Amplification for HIV
Nucleic Acid Amplified Test (NAAT) Examples
Only one FDA approved diagnostic test
Transcription Mediated Amplification (TMA) - APTIMA® HIV-1 RNA Qualitative Assay by GenProbe (2006)
Specificity and sensitivity 100% in high-risk 100 copies/ml
Earliest possible detection of infection
Detects all major groups of HIV-1
Turnaround 3-7 days

8. Diagnostic Nucleic Acid Amplification for HIV
Transcription Mediated Amplification (TMA) – Uses RNA Polymerase and Reverse Transcriptase; can amplify RNA or DNA targets; isothermal

9. Clinical Sensitivity and Specificity of the APTIMA HIV-1 Assay in a High Risk Population
Gen-Probe

10. Jay Epstein, M.D., Director, Office of Blood Research and Review, Center for Biologics Evaluation and Research (CBER), FDA
"This test also can detect infection with HIV- 1 earlier than HIV antibody tests when used to detect primary HIV-1 infection.“
“This test has important implications for medical diagnostic use because it could be a potential alternative to the traditional Western blot test now used for confirmation of HIV-1 infection when screening tests for HIV-1 antibodies are positive.”

11. Intended Use
It is intended for use as an aid in the diagnosis of HIV-1 infection, including acute or primary infection. Presence of HIV-1 RNA in plasma of patients without antibodies to HIV-1 is indicative of acute or primary HIV-1 infections
May also be used as an additional test, when it is reactive, to confirm HIV-1 infection in an individual whose specimen is repeatedly reactive for HIV-1 antibodies
Gen-Probe

12. Established Infection
Acute HIV
Established Infection
RNA NAAT
p24
4th gen EIA
2nd & 3rd gen EIA
Western Blot
Less Sensitive EIA
ARS*
CD4
HIV Abs
Viremia
Genital Shedding 2 7 14 3 4 5 24
*Acute Retroviral Syndrome
Days
Weeks
After Pilcher, 2008

13. Detection Range of HIV Tests
ACUTE
SYMPTOMS
HIV-1 RNA NAAT (2006)
HIV EIA 1ST (1985) & 2ND ( ) Generation
HIV EIA 3RD (~ ) Generation
Western Blot (1985) 1 2 3 4 5 6 7
Weeks After Infection

14. NAAT Testing of Pooled Sera to Identify Acute HIV Infection (seronegative, NAAT positive)
After Leone, from International Society for Sexually Transmitted Disease Research, 2007 14

15. May 5, 2005

16. Pooling and HIV RNA testing
A B C D E F G H I
90 individual HIV antibody negative or WB indeterminate specimens
9 intermediate pools (10 specimens)
1 master pool (90 specimens)

17. North Carolina New NAAT Assay and Pooling Algorithm
GenProbe APTIMA HIV-1 RNA NAAT assay
Hamilton STARlet robotic pipetting instrument
Reduced pool size (80 samples/pool)
Increased sensitivity for HIV-1 NAAT
Myra Brinson - North Carolina Laboratory of Public Health, 2008

18. Who performs HIV RNA NAAT in Texas?
Various private reference labs^
Dallas County Department of Health and Human Services*
Houston Department of Health and Human Services*
DSHS Laboratory**
Blood banks and organ donation
^Perform both screening and diagnostic assays
*Will begin diagnostic assays in 2009
**Will request funding to begin diagnostic assay in 2009.
@Perform screening assays

19. A sexual network presented by Lisa Hightow at CROI in 2006
A sexual network presented by Lisa Hightow at CROI in This demonstrates the large numbers of sexual partners an acute case may have and the increasing use of the Internet to acquire new sexual partners. Identifying acutely infected individuals, counseling them, enrolling them in medical care, and interrupting disease transmission are key objectives associated with the use of Nucleic Acid Amplification Testing.

20. HIV-1 NAAT Summary
HIV-1 RNA NAAT can contribute to eliminating the chain of HIV transmission.
HIV-1 RNA NAAT provides an option for early clinical management of cases.
HIV-1 RNA NAAT will identify at least 2-3 acute infections for every 10,000 specimens tested in high prevalence geographic areas.
HIV-1 RNA NAAT expected to become a standard for HIV diagnosis within the next 2-3 years.
HIV-1 RNA NAAT can replace the Western Blot as the confirmatory assay.