HIV Diagnostics and A New Testing Algorithm Lorna Seybolt, M.D., M.P.H. Louisiana State University Health Sciences Center Children’s Hospital New Orleans June 23, 2012

Objectives Describe the evolution of HIV testing from the beginning of the epidemic to the currently available tests Delineate the proposed new testing algorithm Review recent studies supporting the use of the new algorithm

Considerations ~half of US adults have been tested Not much change since 2004 ~20% of 1 million infected don’t know ~1/3 have AIDS diagnosis within 1 year of testing positive 40,000 new infections/yr 25% unaware  54% new infections 75% aware  46% new infections

www.kff.org

FDA Timeline 1985 1987 1989 ELISA test kit for antibodies Western Blot Virus antigens (HIV-1)

FDA Timeline 1990 1991 Recombigen HIV-1 EIA antibody detection For high volume sites Novopath HIV-1 immunoblot test for detection of antibody to individual proteins 1991 Combo test to detect HIV 1 and 2 antibodies

FDA Timeline 1992 1994 SUDS HIV-1 Non blood-based collection kit 10 minute diagnostic test kit 1994 Non blood-based collection kit Utilizes oral fluid for detection of HIV-1 antibody

FDA Timeline 1996 March May Coulter HIV-1 (p24 antigen) Confide HIV Testing System Can be used at home, purchased OTC 3 components OTC home blood collection kit HIV antibody testing at certified lab Results, counseling, referral

FDA Timeline 1996 June August AMPLICOR HIV-1 Monitor Test NAAT for quantitation HIV-1 RNA in plasma HIV-1 WB confirmatory test for oral collection system August Urine-based test (ELISA)

FDA Timeline 1998 1999 WB for urine specimen testing Supplement to AMPLICOR HIV-1 Monitor Extend LLQ from 400 50 copies/ml

FDA Timeline 2001 September November First NAT systems to screen plasma donors for HIV and HCV TrueGene HIV-1 Genotyping Kit Open Gene DNA Sequencing System Identification of drug resistance November NucliSens HIV-1 QT For prognostic assessment and monitoring

FDA Timeline 2002 September November VERSANT HIV-1 RNA 3.0 Assay bDNA (quantitation) November OraQuick Rapid HIV-1 Antibody Test First rapid diagnostic test kit Results in 20 min, drop of blood No specialized equipment In 2003 test CLIA waived

ORA-What?

ORA-What? OraQuick Rapid HIV 1/2 Antibody Oral fluid, plasma, whole blood (fingerstick, venipuncture) CLIA waived for all but plasma OraSure HIV-1 Oral Specimen Collection Device Collects oral fluid for lab-based EIA screening tests OraSure HIV-1 WB Kit Confirmatory assay for specimens collected with oral collection device

FDA Timeline 2004 March June December OraSure Rapid Test approved for detection of HIV-2 Oral fluid samples, results in 20 min OraQuick Rapid HIV-1 Antibody Test (plasma for HIV-1/2) June CLIA waiver OraQuick ADVANCE Rapid HIV-1/2 Antibody Test (oral fluid) December Multispot HIV-1/HIV-2 Rapid Test Discriminatory test

FDA Timeline 2005 2006 Meeting to discuss home-use rapid HIV test kits OraQuick ADVANCE Rapid HIV-1/2 Antibody Test, oral fluid 2006 APTIMA HIV-1 RNA Qualitative Assay To detect primary HIV infection Can also be used for confirmation ADVIA Centaur 3rd generation format

FDA Timeline May 2007 Abbott Real Time HIV-1 Assay RT-PCR for quantitation 40-10 million copies/ml AmpliPrep/COBAS TaqMan HIV-1Test Automated PCR for quantitation Procleix Ultrio Assay Qualitative NAT to screen blood

FDA Timeline 2008 March December VITROS Anti-HIV-1/2 (3rd gen) Donor screening December COBAS TaqScreen MPX Test First to detect HIV-2 and HIV-1 group O Donated plasma

FDA Timeline 2009 2010 2011 Avioq HIV-1 Microelisa Oral fluid, DBS 2010 Rapid INSTI HIV-1 60 sec antibody test Abbott Architect 4th gen Ag/Ab Combo 2011 Bio-Rad GS HIV Ag/Ab Combo

Where Do Your Specimens Go?

What Happens When They Get There? ???

Generations?

Generations? 1927-1945 - Silent Generation or Traditionalists 1946-1964 - Baby Boomers 1965-1983 - Gen X or the Busters 1984- 2002 - Gen Y or the Millennials 2003- Current Gen Z or the Digital Generation

Arch Intern Med. 2010;170(1):66-74

Who Is This Girl? And Why Is She Famous?

Available Tests Conventional blood test Conventional oral fluid test 1st, 2nd, 3rd, 4th generation EIA Conventional oral fluid test OraSure (collection device) Avioq (used with specimens collected with OraSure device)

Available Tests Rapid tests OraQuick Advance Rapid HIV-1/2 Antibody Test Reveal Rapid HIV-1 Antibody Test Uni-Gold Recombigen HIV Test Multispot HIV-1/HIV-2 Rapid Test Clearview HIV 1/2 Stat Pak Clearview Complete HIV 1/2

Available Tests Home tests HomeAccess HIV-1 Test System

Available Tests Urine test Calypte ???

Available Tests Urine test Maxim HIV-1 Urine EIA Cambridge Biotech Urine HIV-1 WB

Laboratory Based Tests

Bio-Rad GS HIV Combo Ag/Ab EIA 2011 4th generation

Abbott Architect Ag/Ab Combo Assay 2010 4th Generation

Avioq HIV-1 Microelisa 2009 1st Generation Oral fluid, DBS, Serum, Plasma

VITROS HIV 1/2 2008 3rd Generation

ADVIA Centaur HIV 1/O/2 2006 3rd Generation

Rapid Test Kits

CDC

OraQuick Advance 2002

Reveal G3

Uni-Gold

Multispot HIV-1/HIV-2 Rapid Test

Clearview Stat Pak Clearview Complete

Current Testing Algorithm

Limitations of Current Algorithm Newer screening tests are more sensitive than WB for detecting early infection New 4th generation Ag/Ab tests detect infection during early, antibody negative, highly infectious stage Misdiagnosis of HIV-2 infections as HIV-1 (60%)

Arch Intern Med. 2010;170(1):66-74

J Acquir Immune Defic Syndr 2010;55:S102–S105

J Acquir Immune Defic Syndr 2010;55:S102–S105

False Positive OR False Negative ???

Paradigm Shift ???

Proposed New Diagnostic Algorithm

J Acquir Immune Defic Syndr 2010;55:S102–S105

Evidence for New Algorithm

Comparison of multi IA’s and rapid tests with NAAT vs WB Performance of an alternative laboratory-based algorithm for HIV diagnosis in a high-risk population High risk persons Comparison of multi IA’s and rapid tests with NAAT vs WB Correct classification of all with few needing NAAT Journal of Clinical Virology 52S (2011) S5– S10

Journal of Clinical Virology 52S (2011) S5– S10

Acute and established infections Evaluation of an alternative HIV diagnostic algorithm using specimens from seroconversion panels and persons with established HIV infections Acute and established infections 3rd and 4th gen IA’s, rapid tests, NAAT, and WB Improved sensitivity for detecting acute infection while maintaining ability to detect established infection Journal of Clinical Virology 52S (2011) S17– S22

Journal of Clinical Virology 52S (2011) S17– S22

Journal of Clinical Virology 52S (2011) S17– S22

Retrospective analysis of test results to compare algorithms Evaluation of an alternative supplemental testing strategy for HIV diagnosis by retrospective analysis of clinical HIV testing data Retrospective analysis of test results to compare algorithms 38,257 specimens Proposed algorithm outperformed current More sensitive for detecting HIV-1 infection, greater number definitive results, detected HIV-2 more efficiently Journal of Clinical Virology 52S (2011) S35– S40

Comparison of 3rd gen IA followed by Multispot vs WB 8,760 specimens Comparison of Multispot EIA with Western blot for confirmatory serodiagnosis of HIV Comparison of 3rd gen IA followed by Multispot vs WB 8,760 specimens Detected additional 14 HIV-1 infections, differentiated 26 HIV-1 WB positives as HIV-2, detected additional 12 HIV-2 infections Journal of Clinical Virology 52S (2011) S41– S44

HIV infected, not on therapy HIV uninfected blood donors Performance of an alternative laboratory-based algorithm for diagnosis of HIV infection utilizing a third generation immunoassay, a rapid HIV-1/HIV-2 differentiation test and a DNA or RNA-based nucleic acid amplification test in persons with established HIV-1 infection and blood donors Evaluation of 3rd gen IA and Multispot followed by NAAT for IA positive/MS negative HIV infected, not on therapy HIV uninfected blood donors Algorithm had high sensitivity and specificity in specimens from HIV infected and uninfected (blood donors) Journal of Clinical Virology 52S (2011) S45– S49

Proposed Algorithm With current HIV-1/2 differentiation tests turnaround time is less than that with WB Resolve most positive specimens with only 2 tests RNA test only for those antibody negative specimens likely to represent acute infection

Proposed Algorithm Decrease cost Decrease turn around time Increase detection of acute infections Increase sensitivity for detecting acute infections while maintaining ability to detect established infections Reduce or eliminate misclassification of HIV-2 infections

What’s Next? Revision of HIV surveillance case definition Feb 2012—consultation convened by CDC Recommendations regarding testing algorithms, HIV-2, ‘Stage 0’ infection To be presented to CSTE at annual meeting June 2012 Anticipate MMWR later in 2012

What’s Next? Rapid 4th generation test HIV 1/2 rapid line assay POC fingerstick rapid test Viral load CD4

Ability to Detect Infection Earlier More Detected Earlier

Ability to Detect Infection Earlier More Detected Earlier

Selected References Journal of Clinical Virology : 2011 Supplement www.journalofclinicalvirology.com MMWR July 21,1989 Volume 38, Supplement No. 7 Henry J. Kaiser Family Foundation HIV/AIDS Policy www.kff.org J Acquir Immune Defic Syndr 2010;55:S102-S105 The Future of HIV Testing, Bernard M. Branson Expert Rev Anti Infect Ther 2010;8(6):631-633 2010 HIV Diagnostics Conference Summary of the 2012 Consultation of Revision of the HIV Surveillance Case Definition http://www.cdc.gov/hiv/resources/reports/pdf/HIV_Case_Def_Consult_Summary.pdf CDC http://www.cdc.gov/hiv/topics/testing/index.htm