• hiv & aids
• international health services
• paediatric infectious disease & immunisation
• public health

• Early Diagnosis
• Feasibility Studies
• Female
• HIV Infections/diagnosis
• HIV Infections/drug therapy
• HIV Infections/transmission
• Humans
• Infant
• Infectious Disease Transmission, Vertical/prevention & control
• Myanmar
• Papua New Guinea
• Point-of-Care Systems

• Characterization
• Human immunodeficiency virus
• Nucleic acid testing
• Qualitative nucleic acid assays
• Quantitative nucleic assays

• CD4
• HIV incidence
• HIV rapid tests
• dried blood spots
• drug resistance
• early infant diagnosis
• enzyme immunoassay
• point-of-care testing
• quality assurance
• viral load

This study evaluated a National External Quality Scheme Program for early infant diagnosis of HIV. Fourteen laboratory technicians participated and nine testing panel cycles were sent between 2011 and 2014. The response rate was 100% for the first eight panels, and the number of technicians with a test score of 100% increased during the first three panels. Based on the evaluations of the technicians, the quality of testing for early infant diagnosis of HIV improved over time in the laboratories.

• D43 TW009753 FIC NIH HHS

• Adult
• Anti-HIV Agents/therapeutic use
• Child
• Cross-Sectional Studies
• Dried Blood Spot Testing/methods
• Drug Resistance, Viral/genetics
• Epidemiological Monitoring
• Female
• HIV Infections/drug therapy
• HIV Infections/epidemiology
• HIV Infections/virology
• HIV-1/drug effects
• HIV-1/genetics
• Humans
• Kenya/epidemiology
• Male
• Tanzania/epidemiology
• Viral Load

• PEPFAR

• HIV/AIDS
• children
• implementation
• monitoring
• paediatrics
• viral load

Early diagnosis of HIV infection in infants and children remains a challenge in resource-limited settings, with approximately half of all HIV-exposed infants receiving virological testing for HIV by the recommended age of 2 months in 2015. To reduce morbidity and mortality among HIV-infected children and close the treatment gap for HIV-infected children, there is an urgent need to evaluate existing programmatic and laboratory practices for early infant diagnosis and introduce strategies to improve identification of HIV-exposed infants and ensure access to systematic, early HIV testing, with early linkage to treatment for HIV-infected infants. This article describes progress made in follow-up of HIV-exposed infants since 2006, including remaining unmet laboratory and programmatic needs, and recommends strategies for improvement, especially those related to the implementation of point-of-care technology for early infant diagnosis.

• HIV
• early infant diagnosis
• near point-of-care
• point-of-care

• Anti-HIV Agents/therapeutic use
• Child, Preschool
• Cross-Sectional Studies
• Early Diagnosis
• Female
• HIV Core Protein p24/immunology
• HIV Infections/diagnosis
• HIV Infections/drug therapy
• HIV Infections/epidemiology
• HIV Infections/immunology
• HIV-1/immunology
• Humans
• Infant
• Infant, Newborn
• Male
• Mozambique/epidemiology
• Point-of-Care Testing/standards
• Reproducibility of Results
• Sensitivity and Specificity
• Standard of Care
• Workflow

• Unitaid
• Government of Flanders

• Africa South of the Sahara
• Caribbean Region
• Early Diagnosis
• Female
• HIV Infections/diagnosis
• HIV Infections/transmission
• Humans
• Infant
• Infectious Disease Transmission, Vertical
• Mass Screening/statistics & numerical data
• Pregnancy

AIM: To study the impact of rejection at different levels of health care by retrospectively reviewing records of dried blood spot samples received at the molecular laboratory for human immunodeficiency virus (HIV) early infant diagnosis (EID) between January 2008 and December 2012.

METHODS: The specimen rejection rate, reasons for rejection and the impact of rejection at different levels of health care was examined. The extracted data were cleaned and checked for consistency and then de-duplicated using the unique patient and clinic identifiers. The cleaned data were ciphered and exported to SPSS version 19 (SPSS 2010 IBM Corp, New York, United States) for statistical analyses.

RESULTS: Sample rejection rate of 2.4% (n = 786/32552) and repeat rate of 8.8% (n = 69/786) were established. The mean age of infants presenting for first HIV molecular test among accepted valid samples was 17.83 wk (95%CI: 17.65-18.01) vs 20.30 wk (95%CI: 16.53-24.06) for repeated samples. HIV infection rate was 9.8% vs 15.9% for accepted and repeated samples. Compared to tertiary healthcare clinics, secondary and primary clinics had two-fold and three-fold higher likelihood of sample rejection, respectively (P < 0.05). We observed a significant increase in sample rejection rate with increasing number of EID clinics (r = 0.893, P = 0.041). The major reasons for rejection were improper sample collection (26.3%), improper labeling (16.4%) and insufficient blood (14.8%).

CONCLUSION: Programs should monitor pre-analytical variables and incorporate continuous quality improvement interventions to reduce errors associated with sample rejection and improve patient retention.

• Human immunodeficiency virus
• Prevention of mother-to-child transmission
• Early infant diagnosis
• Dried blood spot
• Pre-analytical error
• Sample rejection

• U2G GH000925 CGH CDC HHS

• Early infant diagnosis
• HIV-1
• POC tests
• Viral load

Mothers infected with human immunodeficiency virus (HIV) can transmit the virus to their babies in utero, intrapartum or postpartum through breastfeeding. Maternal to child transmission can be prevented through administration of antiretroviral drugs to mother and child, and through restriction of breastfeeding. This study evaluated the effectiveness of prevention of mother-to-child transmission (PMTCT) activities in reducing the incidence of HIV infection among exposed babies at the National Hospital Abuja, Nigeria.

Early infant diagnosis laboratory records of 515 exposed babies aged below 18 months who had polymerase chain reaction (PCR) test between January 1^st 2011 and December 31^st 2012 were reviewed. The details of antiretroviral (ARV) therapy commencement for mother and baby, infant feeding choices, mode of delivery and HIV test results were analysed.

Of the 515 samples tested, 36 (7.0%) were found to be positive. The mean age of exposed children tested was 4 months. Highest prevalence was among children in the age group 6-18 months (16.1%). There was statistically significant association between HIV positive results and age. (P = 0.0000). If the mother and child pairs received ARVs, the prevalence was 1.3%, whereas if the mother only received ARV, then the prevalence was 4.6%, and when only the child received ARV the prevalence was 20.0%. When neither the mother nor the child received ARVs, the prevalence was 66.7%.

There was a high prevalence of HIV among exposed children in our setting, especially if the mother and child pairs did not receive any form of antiretroviral prophylaxis. This further emphasises the usefulness of ARVs as the single most important intervention in PMTCT. Therefore, there is need to expand antiretroviral coverage, ensure access of the PMTCT program, and provide effective services to support infected children.

• Abuja
• HIV
• early infant diagnosis
• prevention of mother-to-child transmission

• democratic republic of congo
• hiv-exposed infant
• mother-infant pair
• pediatric hiv
• prevention of mother-to-child hiv transmission/vertical transmission

• Adult
• Anti-Retroviral Agents/therapeutic use
• Cohort Studies
• Democratic Republic of the Congo/epidemiology
• Female
• HIV Infections/epidemiology
• HIV Infections/mortality
• HIV Infections/prevention & control
• HIV Infections/transmission
• Humans
• Incidence
• Infant
• Infant, Newborn
• Infectious Disease Transmission, Vertical/prevention & control
• Male
• Pregnancy
• Treatment Outcome

• P30 AI050410 NIAID NIH HHS
• T32 AI070114 NIAID NIH HHS
• 5T32AI070114-07 NIAID NIH HHS
• 2T32AI070114-06 NIAID NIH HHS

In China, 1.1% of people living with HIV were transmitted vertically, causing a heavy burden on families and society. Early infant diagnosis (EID) is critical for improving neonatal survival. The purpose of this study is to suggest improvement in antibody testing strategies with dried blood spots (DBSs) for EID in China through analysis of anti-HIV seroreversion of infants.

A total of 280 infants born to HIV infected mothers in four diverse provinces of China where multiple subtypes coexist were enrolled. The status of the infants' infection was determined by HIV antibody enzyme immunoassay and Western blot analysis at ≥18 months of age or by convincing clinical and epidemiologic data for deceased infants. A total of 1028 DBSs were collected during follow-up, which were tested to obtain anti-HIV signal to cut-off ratio (S/CO) data.

For uninfected infants, anti-HIV S/CO decreased with age. Seropositivity percentage declined most rapidly at 6 months to 9 months of age and 98.7% children seroreverted by 12 months of age. For most infected infants, minimum S/CO values were obtained at ≤6 months of age. Antibody negative predictive value was 100% at ≥6 months of age. An S/CO increase ≥1.86 after three months follow-up can determine HIV infection. S/CO threshold of 3.17 can differentiate infected from uninfected infants for exposed kids at 9 months or older with sensitivity as 100% and specificity ≥94.2%.

Suggestions obtained through studying seroreversion data of Chinese HIV-exposed infants help improve antibody strategies for HIV EID in China. The infection can be determined as early as 3 months of age and excluded as early as 6 months of age.

• Dried blood spots
• Early infant diagnosis
• HIV

• Dried blood spots
• Early infant diagnosis
• HIV

Early diagnosis of infants infected with HIV (EID) and early initiation of treatment significantly reduces the rate of disease progression and mortality. One of the challenges to identification of HIV-1-infected infants is availability and/or access to quality molecular laboratory facilities which perform molecular virologic assays suitable for accurate identification of the HIV status of infants.

We conducted a joint site assessment and designed laboratories for the expansion of DNA polymerase chain reaction (PCR) testing based on dried blood spot (DBS) for EID in six regions of Ethiopia. Training of appropriate laboratory technologists and development of required documentation including standard operating procedures (SOPs) was carried out. The impact of the expansion of EID laboratories was assessed by the number of tests performed as well as the turn-around time.

DNA PCR for EID was introduced in 2008 in six regions. From April 2006 to April 2008, a total of 2848 infants had been tested centrally at the Ethiopian Health and Nutrition Research Institute (EHNRI) in Addis Ababa, and which was then the only laboratory with the capability to perform EID; 546 (19.2%) of the samples were positive. By November 2010, EHNRI and the six laboratories had tested an additional 16 985 HIV-exposed infants, of which 1915 (11.3%) were positive. The median turn-around time for test results was 14 days (range 14–21 days).

Expansion of HIV DNA PCR testing facilities that can provide quality and reliable results is feasible in resource-limited settings. Regular supervision and monitoring for quality assurance of these laboratories is essential to maintain accuracy of testing.

The Ministry of Health in Malawi is implementing a pragmatic and innovative approach for the management of all HIV-infected pregnant women, termed Option B+, which consists of providing life-long antiretroviral treatment, regardless of their CD4 count or clinical stage. Our objective was to determine if Option B+ represents a cost-effective option.

A decision model simulates the disease progression of a cohort of HIV-infected pregnant women receiving prophylaxis and antiretroviral therapy, and estimates the number of paediatric infections averted and maternal life years gained over a ten-year time horizon. We assess the cost-effectiveness from the Ministry of Health perspective while taking into account the practical realities of implementing ART services in Malawi.

If implemented as recommended by the World Health Organization, options A, B and B+ are equivalent in preventing new infant infections, yielding cost effectiveness ratios between US$ 37 and US$ 69 per disability adjusted life year averted in children. However, when the three options are compared to the current practice, the provision of antiretroviral therapy to all mothers (Option B+) not only prevents infant infections, but also improves the ten-year survival in mothers more than four-fold. This translates into saving more than 250,000 maternal life years, as compared to mothers receiving only Option A or B, with savings of 153,000 and 172,000 life years respectively. Option B+ also yields favourable incremental cost effectiveness ratios (ICER) of US$ 455 per life year gained over the current practice.

In Malawi, Option B+ represents a favorable policy option from a cost-effectiveness perspective to prevent future infant infections, save mothers' lives and reduce orphanhood. Although Option B+ would require more financial resources initially, it would save societal resources in the long-term and represents a strategic option to simplify and integrate HIV services into maternal, newborn and child health programmes.

• Adult
• Antiviral Agents/administration & dosage
• Antiviral Agents/economics
• Child
• Child, Preschool
• Costs and Cost Analysis
• Female
• HIV Infections/economics
• HIV Infections/epidemiology
• HIV Infections/prevention & control
• Humans
• Infant
• Infant, Newborn
• Malawi/epidemiology
• Male
• Pregnancy
• Pregnancy Complications, Infectious/economics
• Pregnancy Complications, Infectious/epidemiology
• Pregnancy Complications, Infectious/prevention & control
• World Health Organization

• Dried Blood spot
• early infant diagnosis
• hiv testing in children
• whole blood sample

Background In 2009, there were 8273 local screening laboratories, 254 confirmatory laboratories, 35 provincial confirmatory central laboratories and 1 National AIDS Reference Laboratory (NARL) in China. These laboratories were located in Center for Disease Control and Prevention (CDC) facilities, hospitals, blood donation clinics, maternal and child health (MCH) hospitals and border health quarantine health-care facilities.

Methods The NARL and provincial laboratories provide quality assurance through technical, bio-safety and managerial training; periodic proficiency testing; on-site supervisory inspections; and commercial serologic kit evaluations.

Results From 2002 to 2009, more than 220 million HIV antibody tests were performed at screening laboratories, and all reactive and indeterminate samples were confirmed at confirmatory laboratories. The use of highly technically complex tests, including CD4 cell enumeration, viral load, dried blood spot (DBS)-based early infant diagnosis (EID), drug resistance (DR) genotyping, HIV-1 subtyping and incidence assays, have increased in recent years and their performance quality is closely monitored.

Conclusion China has made significant progress in establishing a well-coordinated HIV laboratory network and QA systems. However, the coverage and intensity of HIV testing and quality assurance programmes need to be strengthened so as to ensure that more infected persons are diagnosed and that they receive timely prevention and treatment services.

The aim of this study was to develop an economical 'in-house' single round polymerase chain reaction (PCR) assay using filter paper-dried blood spots (FP-DBS) for early infant HIV-1 diagnosis and to evaluate its performance in an African setting.

An 'in-house' single round PCR assay that targets conserved regions in the HIV-1 polymerase (pol) gene was validated for use with FP-DBS; first we validated this assay using FP-DBS spiked with cell standards of known HIV-1 copy numbers. Next, we validated the assay by testing the archived FP-DBS (N = 115) from infants of known HIV-1 infection status. Subsequently this 'in-house' HIV-1 pol PCR FP-DBS assay was then established in Nairobi, Kenya for further evaluation on freshly collected FP-DBS (N = 186) from infants, and compared with findings from a reference laboratory using the Roche Amplicor^® HIV-1 DNA Test, version 1.5 assay.

The HIV-1 pol PCR FP-DBS assay could detect one HIV-1 proviral copy in 38.7% of tests, 2 copies in 46.9% of tests, 5 copies in 72.5% of tests and 10 copies in 98.1% of tests performed with spiked samples. Using the archived FP-DBS samples from infants of known infection status, this assay was 92.8% sensitive and 98.3% specific for HIV-1 infant diagnosis. Using 186 FP-DBS collected from infants recently defined as HIV-1 positive using the commercially available Roche Amplicor v1.5 assay, 178 FP-DBS tested positive by this 'in-house' single-round HIV-1 pol PCR FP-DBS PCR assay. Upon subsequent retesting, the 8 infant FP-DBS samples that were discordant were confirmed as HIV-1 negative by both assays using a second blood sample.

HIV-1 was detected with high sensitivity and specificity using both archived and more recently collected samples. This suggests that this 'in-house' HIV-1 pol FP-DBS PCR assay can provide an alternative cost-effective, reliable and rapid method for early detection of HIV-1 infection in infants.

In Tanzania, less than a third of HIV infected children estimated to be in need of antiretroviral therapy (ART) are receiving it. In this setting where other infections and malnutrition mimic signs and symptoms of AIDS, early diagnosis of HIV among HIV-exposed infants without specialized virologic testing can be a complex process. We aimed to introduce an Early Infant Diagnosis (EID) pilot program using HIV DNA Polymerase Chain Reaction (PCR) testing with the intent of making EID nationally available based on lessons learned in the first 6 months of implementation.

In September 2006, a molecular biology laboratory at Bugando Medical Center was established in order to perform HIV DNA PCR testing using Dried Blood Spots (DBS). Ninety- six health workers from 4 health facilities were trained in the identification and care of HIV-exposed infants, HIV testing algorithms and collection of DBS samples. Paper-based tracking systems for monitoring the program that fed into a simple electronic database were introduced at the sites and in the laboratory. Time from birth to first HIV DNA PCR testing and to receipt of test results were assessed using Kaplan-Meier curves.

From October 2006 to March 2007, 510 HIV-exposed infants were identified from the 4 health facilities. Of these, 441(87%) infants had an HIV DNA PCR test at a median age of 4 months (IQR 1 to 8 months) and 75(17%) were PCR positive. Parents/guardians for a total of 242(55%) HIV-exposed infants returned to receive PCR test results, including 51/75 (68%) of those PCR positive, 187/361 (52%) of the PCR negative, and 4/5 (80%) of those with indeterminate PCR results. The median time between blood draw for PCR testing and receipt of test results by the parent or guardian was 5 weeks (range <1 week to 14 weeks) among children who tested PCR positive and 10 weeks (range <1 week to 21 weeks) for those that tested PCR negative.

The EID pilot program successfully introduced systems for identification of HIV-exposed infants. There was a high response as hundreds of HIV-exposed infants were registered and tested in a 6 month period. Challenges included the large proportion of parents not returning for PCR test results. Experience from the pilot phase has informed the national roll-out of the EID program currently underway in Tanzania.

To evaluate the performance of dried blood spots (DBSs) with subsequent analyses of glutamic acid decarboxylase (GADA) and islet antigen-2 (IA-2A) with the RSR-ELISAs, we selected 80 children newly diagnosed with type 1 diabetes and 120 healthy women. DBSs from patients and controls were used for RSR-ELISAs while patients samples were analysed also with in-house RIAs. The RSR-ELISA-GADA performed well with a specificity of 100%, albeit sensitivity (46%) was lower compared to in RIA (56%; P = .008). No prozone effect was observed after dilution of discrepant samples. RSR-ELISA-IA-2A achieved specificity of 69% and sensitivity was lower (59%) compared with RIA (66%; P < .001). Negative or low positive patients and control samples in the RSR-ELISA-IA-2A increased after dilution. Eluates from DBS can readily be used to analyse GADA with the RSR-ELISA, even if low levels of autoantibodies were not detected. Some factor could disturb RSR-ELISA-IA-2A analyses.

• HIV
• point-of-care
• resource-limited settings

• Caregivers
• Child, Preschool
• Counseling
• DNA, Viral/blood
• Female
• HIV Antibodies/blood
• HIV Infections/diagnosis
• HIV Infections/epidemiology
• Humans
• Infant
• Infant, Newborn
• Informed Consent
• Male
• Parents
• Polymerase Chain Reaction
• Zambia/epidemiology

• U2G PS001423 NCHHSTP CDC HHS