1. © 2010 Baylor College of Medicine Post-18 month confirmatory HIV testing in HIV DNA PCR positive children: retrospective descriptive analysis from an operational setting in Lesotho Anthony J. Garcia-Prats, Heather R. Draper, Jill Sanders, Anu Agrawal, Edith Q. Mohapi, Gordon E. Schutze

2. © 2010 Baylor College of Medicine Background Non-resource-limited settings  2 virologic tests used to diagnose HIV in children <18 months of age Resource-limited settings  HIV DNA PCR (PCR) is still unavailable in some places, necessitating presumptive diagnosis  Resource constraints may preclude the use of 2 virologic tests for children <18 months  For these cases, the WHO recommends that these children have HIV-antibody testing after 18 months to confirm HIV infection  Little published data on field implementation of this guideline

3. © 2010 Baylor College of Medicine Case Age (mos) Visit NotesTime on ART (mos) CD4 count and % Rapid tests Other tests (PCR, ELISA) 1.6First visit---1342/19%Pos/NegPCR - Positive 2.6ART initiation0 6.0Stopped BF3.4 9.56.91858/30% 14.812.21494/29% 18.716.11316/30% 18.9Conf testing16.3Neg/NegPCR - Negative 20.5ART stopped17.9Neg/Neg 23.5Returned to clinic---1633/15%Pos/PosPCR - Positive 26.9ART reinitiated---ELISA - Positive

4. © 2010 Baylor College of Medicine Purpose Describe results of confirmatory rapid HIV antibody tests, as well as confirmatory HIV DNA PCR and HIV ELISA Describe factors associated with any falsely negative results

5. © 2010 Baylor College of Medicine Methods 1 Retrospectively reviewed routine program data Patient population  Baylor College of Medicine Bristol-Myers Squibb Children’s Clinical Center of Excellence, in Maseru, Lesotho  Pediatric and family HIV clinic Inclusion criteria  Enrolled in the clinic between Dec-01-2005 through Feb-01-2009  Positive HIV DNA PCR at <18 months of age  Documented post-18 month rapid test results Patient characteristics and post-18 month confirmatory test results were reviewed

6. © 2010 Baylor College of Medicine Methods 2 All HIV testing was done according to Lesotho Ministry of Health and Social Welfare (MOHSW) guidelines Parallel rapid testing with…  Determine TM HIV-1/2 (Inverness Medical Innovations, Inc./Abbot Laboratories)  Double-Check Gold TM HIV1&2 (Inverness Medical Innovations, Inc./Orgenics, Ltd.) HIV DNA PCR using Dried Blood Spot  Processed through Lesotho MOHSW  National Institute for Communicable Diseases laboratory in South Africa using the Amplicor® HIV-1 Test (Roche). HIV ELISA testing  Done at the national laboratory at Queen Elizabeth II Hospital in Maseru or a private lab in South Africa

7. © 2010 Baylor College of Medicine Results 1 Post-18 month Confirmatory Rapid Antibody Test Results [n=109] Positive [N=60 (55%)] Discordant [N=27 (25%)] Negative [N=22 (20%)] On ARVs53 (88%)27 (100%)20 (91%) Post-18 month PCR results (%) Positive---7 (78%)5 (36%) Negative---2 (22%)9 (64%) Post-18 month ELISA results (%) Positive---1 (100%)6 (86%) Negative---00 Equivocal---01 (14%) Ultimate HIV status Positive - Definitive60 (100%)10 (37%)17 (77%) Positive - Probably17 (63%)0 Negative02 (9%) Unsure03 (14%)

8. © 2010 Baylor College of Medicine Results 2 Univariate analysis, significant predictors of the combined outcome of discordant or negative confirmatory rapid tests were:  Age at ART initiation <9 months (OR 4.25, p=.002)  Duration on ART ≥9 months (OR 4.96, p<.001) Other factors were not significant predictors  Gender  PMTCT status  Baseline immunologic status  Acute malnutrition

9. © 2010 Baylor College of Medicine Conclusions 1 Study limitations Falsely negative post-18 month confirmatory rapid HIV antibody tests in ART treated children were not a rare phenomenon A considerable number of post-18 month confirmatory HIV DNA PCRs using DBS were falsely- negative in this operational setting

10. © 2010 Baylor College of Medicine Conclusion 2 2/109 children had an initial positive DNA PCR documented in their record, but were ultimately determined to be HIV negative  Importance of not relying on a single PCR to establish the diagnosis Implications for frontline clinicians and for Early Infant Diagnosis program planning WHO 2010 recommendations Additional study is needed to replicate and further elucidate this in more detail

11. © 2010 Baylor College of Medicine Acknowledgements Baylor International Pediatric AIDS Initiative (BIPAI) Physicians, staff, and patients of the Baylor College of Medicine Bristol- Myers Squibb Children’s Clinical Center of Excellence – Lesotho Lesotho Ministry of Health and Social Welfare