Precise CD4 T-cell counting using red diode laser excitation: for richer, for poorer

Thirty-five years of CD4 T-cell counting in HIV infection: From flow cytometry in the lab to point-of-care testing in the field

CD4 T-cell counting was introduced in clinical laboratories shortly after the discovery of the human immune deficiency virus (HIV) in the early eighties. In western clinical laboratories, improvements in the CD4 T-cell counting methods were mainly driven by progress in the field of flow cytometry and immunology. In contrast, the development of dedicated CD4 T-cell counting technologies were needs driven. When antiretroviral treatment (ART) was made available on a large scale by international Acquired Immune Deficiency Syndrome (AIDS) relief programs to HIV+ patients living in low income countries in 2003, there was a distinct need for simplified and affordable CD4 T-cell counting technologies. The first decade of 2000, several compact flow cytometers appeared on the market, mainly to the benefit of low income countries with limited resources. More recently, however, portable point-of-care (POC) CD4 T-cell counting devices have been developed especially to improve access to affordable monitoring of HIV+ patients in low income countries. The accuracy of these POC instruments is not yet very well documented as many are still under development and clinical validation but preliminary evidence is encouraging. The new HIV treatment guidelines released by the World Health Organization in 2016 give CD4 T-cell counting a less central role in the management of HIV infection. It is, therefore, to be expected that CD4 T-cell counting will be phased out as a tool to assess eligibility of HIV+ patients for ART in the future. However, CD4 T-cell counting will remain a valuable tool for directing treatment against opportunistic infections. © 2016 International Clinical Cytometry Society.

Sensitivity improvement in fluorescence-based particle detection

Microfluidic flow cytometers are highly interesting candidates for biomedical point-of-care applications. However, the sensitivity, reliability, and throughput of these systems must be improved to provide the full functionality of established flow cytometric systems. One proposed method to improve fluorescence detection systems is to use spatial modulation techniques. We derive the noise-related statistics and calculate the coefficient of variation for a detection system with and without spatial modulation. We measure the noise properties of a nonmodulated microfluidic fluorescence particle detection system and analyze the possible performance gains using spatial modulation.

Flexible planar microfluidic chip employing a light emitting diode and a PIN-photodiode for portable flow cytometers

Detection of fluorescence particles is a key method of flow cytometry. We evaluate the performance of a design for a microfluidic fluorescence particle detection device. Due to the planar design with low layer thicknesses, we avoid optical components such as lenses or dichroic mirrors and substitute them with a shadow mask and colored film filters. A commercially available LED is used as the light source and a PIN-photodiode as detector. This design approach reduces component cost and power consumption and enables supplying the device with power from a standard USB port. From evaluation of this design, we obtain a maximum particle detection frequency of up to 600 particles per second at a sensitivity of better than 4.7 × 10(5) MESF (molecules of equivalent soluble fluorochrome) measured with particles for FITC sensitivity calibration. Lowering the flow rate increases the instrument sensitivity by an order of magnitude enabling the detection of particles with 4.5 × 10(4) MESF.

Oxazine dye-conjugated dna oligonucleotides: Förster resonance energy transfer in view of molecular dye-DNA interactions

In this work, the photophysical properties of two oxazine dyes (ATTO 610 and ATTO 680) covalently attached via a C6-amino linker to the 5'-end of short single-stranded as well as double-stranded DNA (ssDNA and dsDNA, respectively) of different lengths were investigated. The two oxazine dyes were chosen because of the excellent spectral overlap, the high extinction coefficients, and the high fluorescence quantum yield of ATTO 610, making them an attractive Förster resonance energy transfer (FRET) pair for bioanalytical applications in the far-red spectral range. To identify possible molecular dye-DNA interactions that cause photophysical alterations, we performed a detailed spectroscopic study, including time-resolved fluorescence anisotropy and fluorescence correlation spectroscopy measurements. As an effect of the DNA conjugation, the absorption and fluorescence maxima of both dyes were bathochromically shifted and the fluorescence decay times were increased. Moreover, the absorption of conjugated ATTO 610 was spectrally broadened, and a dual fluorescence emission was observed. Steric interactions with ssDNA as well as dsDNA were found for both dyes. The dye-DNA interactions were strengthened from ssDNA to dsDNA conjugates, pointing toward interactions with specific dsDNA domains (such as the top of the double helix). Although these interactions partially blocked the dye-linker rotation, a free (unhindered) rotational mobility of at least one dye facilitated the appropriate alignment of the transition dipole moments in doubly labeled ATTO 610/ATTO 680-dsDNA conjugates for the performance of successful FRET. Considering the high linker flexibility for the determination of the donor-acceptor distances, good accordance between theoretical and experimental FRET parameters was obtained. The considerably large Förster distance of ~7 nm recommends the application of this FRET pair not only for the detection of binding reactions between nucleic acids in living cells but also for monitoring interactions of larger biomolecules such as proteins.

The cytometric future: it ain't necessarily flow!

Initial approaches to cytometry for classifying and characterizing cells were based on microscopy; it was necessary to collect relatively high-resolution images of cells because only a few specific reagents usable for cell identification were available. Although flow cytometry, now the dominant cytometric technology, typically utilizes lenses similar to microscope lenses for light collection, improved, more quantitative reagents allow the necessary information to be acquired in the form of whole-cell measurements of the intensities of light transmission, scattering, and/or fluorescence.Much of the cost and complexity of both automated microscopes and flow cytometers arises from the necessity for them to measure one cell at a time. Recent developments in digital camera technology now offer an alternative in which one or more low-magnification, low-resolution images are made of a wide field containing many cells, using inexpensive light-emitting diodes (LEDs) for illumination. Minimalist widefield imaging cytometers can provide a smaller, less complex, and substantially less expensive alternative to flow cytometry, critical in systems intended for in resource-poor areas. Minimalism is, likewise, a good philosophy in developing instrumentation and methodology for both clinical and large-scale research use; it simplifies quality assurance and compliance with regulatory requirements, as well as reduces capital outlays, material costs, and personnel training requirements. Also, importantly, it yields "greener" technology.

Flow cytometric profiles, biomolecular and morphological aspects of transfixed leukocytes and red cells

BACKGROUND

We evaluated the effects of the TransFix(TM) short-term stabilization technique on leukocyte subpopulations in both optimal and adverse storage temperatures and on different cellular concentrations. Particularly, we analyzed DNA cell content and membrane structure also for erythrocytes using a multiparametric approach.

METHODS

We studied biomolecular and morphological aspects of transfixed cells, by means of SEM, TEM, Western blotting, and by flow cytometry (FC). Furthermore, FC, Tunel, and electrophoresis were applied to evaluate DNA behavior.

RESULTS

We confirm preservation of scatter characteristics and immunophenotyping, extending such evaluations to cells stored in suboptimal conditions (25 degrees C and 37 degrees C) and in high density. Data demonstrate for lymphomonocytic cells an optimal conservation, slightly decreasing at higher temperatures for both 1/5 and 1/10 ratio (TransFix/sample), with enhanced autofluorescence. Eosinophils, basophils, and neutrophils are shown to preserve differently over time. The three different cellular concentrations evaluated (30,000-120,000 cell/microl) demonstrate substantial stability in FI values. Furthermore DNA content analysis attests the absence of any apoptotic pattern. Transfixed red cell protein profile as well as their morphological features appears almost unaltered.

CONCLUSIONS

Cytometric performance is suboptimal in aged unfixed specimens because of apoptosis that affects light scatter properties. Our findings highlight that lymphomonocytic cells are well stabilized even at suboptimal temperature and cell density. TransFix is able to abolish any apoptotic features and acts as an optimal blood preservative for appropriate preanalytical stabilization.

Particle focusing in staged inertial microfluidic devices for flow cytometry

Microfluidic inertial focusing has been demonstrated to be an effective method for passively positioning microparticles and cells without the assistance of sheath fluid. Because inertial focusing produces well-defined lateral equilibrium particle positions in addition to highly regulated interparticle spacing, its value in flow cytometry has been suggested. Particle focusing occurs in straight channels and can be manipulated through cross sectional channel geometry by the introduction of curvature. Here, we present a staged channel design consisting of both curved and straight sections that combine to order particles into a single streamline with longitudinal spacing. We have evaluated the performance of these staged inertial focusing channels using standard flow cytometry methods that make use of calibration microspheres. Our analysis has determined the measurement precision and resolution, as a function of flow velocity and particle concentration that is provided by these channels. These devices were found to operate with increasing effectiveness at higher flow rates and particle concentrations, within the examined ranges, which is ideal for high throughput analysis. Further, the prototype flow cytometer equipped with an inertial focusing microchannel matched the resolution provided by a commercial hydrodynamic focusing flow cytometer. Most notably, our analysis indicates that the inertial focusing channels virtually eliminated particle coincidence at the analysis point. These properties suggest a potentially significant role for inertial focusing in the development of inexpensive flow cytometry-based diagnostics and in applications requiring the analysis of high particle concentrations.

Reagents and instruments for multiplexed analysis using microparticles

Multiplexed molecular analysis by means of flow cytometry using optically encoded microspheres is a rapidly expanding application that has its roots in the earliest days of flow cytometry. The approach is driven by increasing demand for analytical methods to measure large numbers of biomolecules quantitatively and sensitively in small volumes of sample. Encoded microspheres and flow cytometry have been employed for a wide range of multiplexed molecular analysis, and detailed protocols for many of these have been developed. The goal of this unit is to provide an overview of the concepts, instruments, and reagents that enable these assays.

Flow cytometry as the spearhead for delivering sustainable and versatile laboratory services to HIV-burdened health care systems of the developing world: a Caribbean model

HIV is targeting the developing nations of the world, threatening their economic development, overwhelming public health systems, and depleting human capital. The Caribbean is no exception, with the second highest incidence of HIV/AIDS outside Sub-Saharan Africa, sharing similar mixed fortunes from a postcolonial heritage, limited resources, and an HIV population dispersed in small population centers. Here we share the experience of Barbados, an island state of 280,000 people, in mounting a holistic and sustainable program against HIV/AIDS. At the forefront of this response has been the growth in clinical flow cytometry used for CD4 monitoring, which has prompted a welcome expansion in diagnostic capacity even beyond HIV/AIDS. A pan-Caribbean extension to Barbados' program has been the founding of the Caribbean Cytometry & Analytical Society (CCAS), which acts as a regional forum to accelerate technology transfer and develop the human resources needed to mount an effective response against HIV/AIDS. The 4th CCAS workshop in 2007 produced a consensus statement on the desirable characteristics for a "diagnostic dream machine": a simple-to-use, rugged flow cytometer capable of carrying out multiple diagnostic functions at the point of patient care in rural or island settings of the developing world, including CD4 count, blood count, and opportunistic infections, without the need for a supply cold-chain or dependable power source. It is our ambitious vision that the spread of flow cytometry, primarily to monitor CD4 in HIV/AIDS, can act as a Trojan horse to deliver better general and specialized diagnostic services to the developing world.

Simplified cytometry for routine monitoring of infectious diseases

The interacting epidemics of HIV/AIDS, tuberculosis (TB) and malaria in resource-poor areas of the world have created a critical need for rapid, simple, affordable apparatus and tests that will permit patients with these diseases to be promptly diagnosed and properly managed. As documented in the current issue of Clinical Cytometry, complex flow cytometric analyses used in affluent countries for CD4+ T cell counting in HIV/AIDS have been simplified, introduced, and quality assessed in resource-restricted countries of Africa and the Caribbean, where simple gating protocols such as panleucogating now provide accurate and precise CD4+ T cell counts on a large scale. CD4/CD8 ratios in infants may replace more expensive molecular tests for HIV infection; simplified flow cytometry is also compatible with HIV viral load-associated lymphocyte activation tests and with antigen-specific cellular immune response assays that rapidly diagnose active TB in both HIV-negative and HIV-TB co-infected individuals. In addition, it is becoming evident that smaller, much less expensive fluorescence imaging cytometers can be used for CD4 counting, immunophenotyping, and hematology and for other applications such as diagnosis and drug-susceptibility testing of TB and diagnosis of malaria. With the gradual, organized expansion of the much-needed diagnostic networks in the underprivileged countries, the most cost-effective apparatus may be one capable of performing tests for all the three diseases mentioned. The most sustainable systems will be those that can be assembled and maintained, to the greatest extent possible, in the countries where they will be used.

The changing pattern of "smart" flow cytometry (S-FC) to assist the cost-effective diagnosis of HIV, tuberculosis, and leukemias in resource-restricted conditions

There is a need to introduce cytometry into areas of the globe that have remained virtually untouched by modern laboratory medicine. With the demand to carry out tests on 100,000 s of individuals requiring antiretroviral therapy (ART), flow cytometry must remain simple and cost-effective - while being sustainable and industry supported as well as proven by quality assessment (QA). This outlook is referred to as "smart flow cytometry" (S-FC). There are five main areas where the power of S-FC is demonstrated. These are: (i) the use of CD45 to assist precise cell counting in blood and tissue samples; (ii) the primary CD4 gating to count CD4+ T cells in patients waiting for ART, including the combination (i) and (ii) in the panleucogating (PLG) protocol; (iii) monitoring of human immunodeficiency virus (HIV+) patients during ART by the decreasing levels of lymphocyte activation in a CD8/CD38 test - leading to economies of viral-load assays; (iv) in tuberculosis and HIV-TB coinfections the use of TB-antigen-stimulated cytokine-synthetic CD4+ T cells to identify active disease; and (v) the utilization of "minimal residual disease (MRD)-Lite" technology in patients 19 days after the start of antileukemic therapy to detect MRD. These methods of S-FC have been successfully introduced in "resource-restricted" countries with international and local QA.

Evaluation of a green laser pointer for flow cytometry

Flow cytometers typically incorporate expensive lasers with high-quality (TEM00) output beam structure and very stable output power, significantly increasing system cost and power requirements. Red diode lasers minimize power consumption and cost, but limit fluorophore selection. Low-cost DPSS laser pointer modules could possibly offer increased wavelength selection but presumed emission instability has limited their use. A $160 DPSS 532 nm laser pointer module was first evaluated for noise characteristics and then used as the excitation light source in a custom-built flow cytometer for the analysis of fluorescent calibration and alignment microspheres. Eight of ten modules tested were very quiet (RMS noise < or = 0.6% between 0 and 5 MHz). With a quiet laser pointer module as the light source in a slow-flow system, fluorescence measurements from alignment microspheres produced CVs of about 3.3%. Furthermore, the use of extended transit times and < or =1 mW of laser power produced both baseline resolution of all 8 peaks in a set of Rainbow microspheres, and a detection limit of <20 phycoerythrin molecules per particle. Data collected with the transit time reduced to 25 micros (in the same instrument but at 2.4 mW laser output) demonstrated a detection limit of approximately 75 phycoerythrin molecules and CVs of about 2.7%. The performance, cost, size, and power consumption of the tested laser pointer module suggests that it may be suitable for use in conventional flow cytometry, particularly if it were coupled with cytometers that support extended transit times.

A single platform image cytometer for resource-poor settings to monitor disease progression in HIV infection

BACKGROUND

For resource-poor countries, affordable methods are required for enumeration of CD4(+) T lymphocytes of HIV-positive patients. For infants, additional determination of CD4/CD8 ratio is needed.

METHODS

We determine the CD4(+) and CD8(+) T lymphocytes as the CD3(+)CD4(+) and CD3(+)CD8(+) population of blood cells. Target cells are CD3-immunomagnetically separated from the whole blood, and CD4-Phycoerythrin and CD8-PerCP immunofluorescently labeled. A point-of-care single platform image cytometer was developed to enumerate the target CD3(+)CD4(+) and CD3(+)CD8(+) populations. It has light-emitting diodes illumination, is fully computer-controlled, operates from a 12 V battery, and was designed to be cheap and easy-to-handle. Target cells are imaged on a CCD camera and enumerated by an image analysis algorithm. The cytometer outputs the absolute number of CD4(+) and CD8(+) T lymphocytes/microl and CD4/CD8 ratio.

RESULTS

The quality of the cell images obtained with the cytometer is sufficient for a reliable enumeration of target cells. The image cytometer achieves an accuracy of better than 10% in the range of 50-1700 cells/microl. Analysis of blood samples from HIV patients yields a good agreement with the TruCount method for CD4 and CD8 count and CD4/CD8 ratio.

CONCLUSIONS

The image cytometer is affordable (component costs $3,000), compact (25 x 25 x 20 cm(3)), and uses disposable test materials, making it a good candidate to monitor progression of immunodeficiency disease in resource-poor settings.

First application of a microsphere-based immunoassay to the detection of genetically modified organisms (GMOs): quantification of Cry1Ab protein in genetically modified maize

An innovative covalent microsphere immunoassay, based on the usage of fluorescent beads coupled to a specific antibody, was developed for the quantification of the endotoxin Cry1Ab present in MON810 and Bt11 genetically modified (GM) maize lines. In particular, a specific protocol was developed to assess the presence of Cry1Ab in a very broad range of GM maize concentrations, from 0.1 to 100% [weight of genetically modified organism (GMO)/weight]. Test linearity was achieved in the range of values from 0.1 to 3%, whereas fluorescence signal increased following a nonlinear model, reaching a plateau at 25%. The limits of detection and quantification were equal to 0.018 and 0.054%, respectively. The present study describes the first application of quantitative high-throughput immunoassays in GMO analysis.

Microchip-based enumeration of human white blood cells

The advent of flow cytometry has considerably changed the ways in which medical testing is conducted. However, the cost of flow cytometers, their large size, and their maintenance needs make them scarce in resource-poor settings and available almost only in clinical pathology laboratories in developed countries. Because cell enumeration is a basic and crucial support of diagnosis, prognosis, and treatment, an alternative cell-counting method that would potentially be cost-effective, portable, and suitable for use in resource-poor settings is warranted. We describe here a protocol for conducting cell-counting experiments in a simple microfluidic structure. This protocol describes how to build a simple microfluidic cell and perform a total white blood cell (WBC) count through capture and immunolabeling of the WBCs with an anti-CD45 antibody.

Personal cytometers: slow flow or no flow?

BACKGROUND

Although some manufacturers have optimistically described instruments with prices in the 40,000 US dollars range as "personal cytometers", analogy with the personal computer suggests that the target price for a true "personal" cytometer should be under 5,000 US dollars. Since such an apparatus could find a wide range of applications in cytomics in both developing and developed countries, it seemed desirable to consider its technical and economic feasibility.

METHODS

Using resolution targets and a variety of fluorescent bead standards immobilized on filters and/or slides, we evaluated high-intensity LEDs as fluorescence excitation sources, relatively inexpensive CCD cameras as detectors, and 35 mm camera lenses and plastic low-power microscope optics for light collection in a simple, inexpensive low-resolution imaging cytometer.

RESULTS

The components tested could be combined toproduce an instrument capable of detecting fewer than 10,000 molecules of cell-associated fluorescent label, and thus applicable to a broad range of cytometric tasks.

CONCLUSIONS

Given the requirements for light sources, detectors, optics, mechanics, electronics and data analysis hardware and software, and the components presently available, it should be easier to reach the desired 5,000 US dollars price point with an image cytometer than with a flow cytometer.

Flow rate calibration. III. The use of stabilized biostandards to calibrate the flow rate and calculate absolute CD4+ T-cell counts

BACKGROUND

We have previously reported a flow rate calibration method for the determination of absolute CD4(+) T-lymphocyte counts that removes the need for the addition of latex beads to each sample. However, a limitation with this approach is that a calibration factor (CF) needs to be applied to adjust for differences in viscosity between latex bead suspensions and biological specimens. We have also demonstrated the value of using stabilized whole blood samples in external quality assessment (EQA) studies; such samples have a stable absolute lymphocyte count for over 1 year, at 4 degrees C. It was successfully demonstrated that this material can be used as a flow rate biocalibration (FRB) material for use as a flow cytometric control to provide a sample with a known CD4(+) T-lymphocyte count. Such material has advantages over latex bead technology as it can act as a full process control as well as having the same matrix and viscosity characteristics as the test material, thus removing the need for a CF.

METHODS

In this study, we have analyzed 268 consecutive normal, abnormal, and HIV(+) samples using FRB, incorporating the PanLeucoGating approach and compared this to the MultiSet method, defined as the predicate.

RESULTS

Percentage similarity statistics revealed the following: 0-3,000 CD4(+) cells/mul mean percentage difference (MPD; bias) 1.2%, 95% CI of 5.6-8%; 0-200 CD4(+) cells/microl MPD of 1.25%, 95% CI of 11.63-14.13%; 201-500 CD4(+) cells/microl MPD of 1%, 95% CI of 4.6-6.6%.

DISCUSSION

This study demonstrates that stabilized whole blood can be used for FRB. It has the advantage of being a full process control, in addition to costing less than latex beads with highly comparable results. As bench top flow cytometers are extremely stable, this is a low cost and robust alternative to bead based methods for generating absolute CD4 counts.

Ultrasonic particle-concentration for sheathless focusing of particles for analysis in a flow cytometer

BACKGROUND

The development of inexpensive small flow cytometers is recognized as an important goal for many applications ranging from medical uses in developing countries for disease diagnosis to use as an analytical platform in support of homeland defense. Although hydrodynamic focusing is highly effective at particle positioning, the use of sheath fluid increases assay cost and reduces instrument utility for field and autonomous remote operations.

METHODS

This work presents the creation of a novel flow cell that uses ultrasonic acoustic energy to focus small particles to the center of a flowing stream for analysis by flow cytometry. Experiments using this flow cell are described wherein its efficacy is evaluated under flow cytometric conditions with fluorescent microspheres.

RESULTS

Preliminary laboratory experiments demonstrate acoustic focusing of flowing 10-microm latex particles into a tight sample stream that is approximately 40 microm in diameter. Prototype flow cytometer measurements using an acoustic-focusing flow chamber demonstrated focusing of a microsphere sample to a central stream approximately 40 microm in diameter, yielding a definite fluorescence peak for the microspheres as compared with a broad distribution for unfocused microspheres.

CONCLUSIONS

The flow cell developed here uses acoustic focusing, which inherently concentrates the sample particles to the center of the sample stream. This method could eliminate the need for sheath fluid, and will enable increased interrogation times for enhanced sensitivity, while maintaining high particle-analysis rates. The concentration effect will also enable the analysis of extremely dilute samples on the order of several particles per liter, at analysis rates of a few particles per second. Such features offer the possibility of a truly versatile low-cost portable flow cytometer for field applications.

A microchip CD4 counting method for HIV monitoring in resource-poor settings

BACKGROUND

More than 35 million people in developing countries are living with HIV infection. An enormous global effort is now underway to bring antiretroviral treatment to at least 3 million of those infected. While drug prices have dropped considerably, the cost and technical complexity of laboratory tests essential for the management of HIV disease, such as CD4 cell counts, remain prohibitive. New, simple, and affordable methods for measuring CD4 cells that can be implemented in resource-scarce settings are urgently needed.

METHODS AND FINDINGS

Here we describe the development of a prototype for a simple, rapid, and affordable method for counting CD4 lymphocytes. Microliter volumes of blood without further sample preparation are stained with fluorescent antibodies, captured on a membrane within a miniaturized flow cell and imaged through microscope optics with the type of charge-coupled device developed for digital camera technology. An associated computer algorithm converts the raw digital image into absolute CD4 counts and CD4 percentages in real time. The accuracy of this prototype system was validated through testing in the United States and Botswana, and showed close agreement with standard flow cytometry (r = 0.95) over a range of absolute CD4 counts, and the ability to discriminate clinically relevant CD4 count thresholds with high sensitivity and specificity.

CONCLUSION

Advances in the adaptation of new technologies to biomedical detection systems, such as the one described here, promise to make complex diagnostics for HIV and other infectious diseases a practical global reality.

Advances in laboratory testing for HIV

In 2004, the diagnosis of established human immunodeficiency virus (HIV) infection can be made with close to 100% assurity. The extraordinarily engineered performances of HIV-screening assays are unprecedented. The well-established confirmatory tests performed by well-versed laboratories using criteria that are well understood in order to interpret the results of these tests give highly accurate outcomes of diagnostic testing strategies. Furthermore, the ability to monitor the progress of the infection and the viral pathogenesis is possible through the use of tests that quantify viral load or the peripheral CD4+ T-cells and other lymphocyte sub-type levels. Newer laboratory testing mechanisms, such as assessment of reverse transcriptase activity and sophisticated cell staining and flow cytometric analyses, have been used to map disease processes and progress on a research level and may be used in future to fine-tune therapy and to follow disease progression in even greater detail. Regulation of all HIV tests is of the highest level in Australia. In-house tests will be expected to conform to the levels specified for commercially produced tests.

Absolute CD4 T-Cell Counting in Resource-Poor Settings

Flow cytometry is an accurate but expensive method to determine absolute CD4 cell counts. We compared different methods to measure absolute CD4 counts in blood samples from HIV-infected and uninfected subjects using a research/clinical flow cytometer (FACScan); a dedicated clinical instrument (FACSCount); and a volumetric, mobile, open-system flow cytometer equipped with 3 fluorescence and 2 light scatter detectors (Cyflow SL blue). The FACScan and Cyflow were used as single-platform instruments, but they differ in running cost, which is a central factor for resource-poor settings. Direct volumetric and bead-based CD4 measurements on the Cyflow were compared with 2 bead-based single-platform CD4 measurements on the FACSCount and on FACScan (TruCount) in "Le Dantec" Hospital, Dakar, Senegal, using whole blood samples from 102 HIV+ and 28 HIV- subjects. The agreement between the various measurement methods was evaluated by Bland-Altman analysis. Volumetric CD4 measurements on the Cyflow using a no-lyse-no-wash (NLNW) procedure and a lyse-no-wash (LNW) procedure correlated well with each other (R2 = 0.98) and with CD4 measurements on the FACSCount (R2 = 0.97) and FACScan (R2 = 0.97), respectively. Red blood cell lysis had no negative effect on the accuracy of absolute CD4 counting on the Cyflow. An excellent correlation was observed between bead-based CD4 measurements on the Cyflow and CD4 measurements on the FACSCount (R2 = 0.99) and FACScan (R2 = 0.99). Rigid internal and external quality control monitoring and adequate training of technicians were considered essential to generate accurate volumetric CD4 measurements on the Cyflow.

T lymphocytes among HIV-infected and -uninfected infants: CD4/CD8 ratio as a potential tool in diagnosis of infection in infants under the age of 2 years

BACKGROUND: Serologic tests for HIV infection in infants less than 18 months do not differentiate exposure and infection since maternally acquired IgG antibodies may be detected in infants. Thus, the gold standard for diagnosis of HIV-1 infection in infants under the age of 2 years is DNA or reverse transcriptase polymerase chain reaction. There is an urgent need to evaluate alternative and cost effective laboratory methods for early diagnosis of infant HIV-1 infection as well as identifying infected infants who may benefit from cotrimoxazole prophylaxis and/or initiation of highly active antiretroviral therapy. METHODS: Whole blood was collected in EDTA from 137 infants aged 0 to 18 months. DNA polymerase chain reaction was used as the reference standard for diagnosis of HIV-1 infection. T-cell subset profiles were determined by flow cytometry. RESULTS: Seventy-six infants were DNA PCR positive while 61 were negative. The median CD4 counts of PCR negative infants were significantly higher than those of the PCR positive infants, p < 0.001. The median CD4/CD8 ratio and the %CD4 of the PCR positive infants were both significantly lower than those of the negative infants, p < 0.001. The CD4/CD8 ratio had a >98% sensitivity for diagnosis of HIV-1 infection and a specificity of >98%. CONCLUSION: The CD4/CD8 ratio appears useful in identifying HIV-infected infants. The development of lower cost and more robust flow cytometric methods that provide both CD4/CD8 ratio and %CD4 may be cost-effective for HIV-1 diagnosis and identification of infants for cotrimoxazole prophylaxis and/or highly active antiretroviral therapy.

HIV/AIDS in Central Africa: pathogenesis, immunological and medical issues

The estimated worldwide prevalence of human immunodeficiency virus (HIV) infections topped 52.5 million in June 2003, a mere 20 years after the aetiological agent was shown to be a sexually transmissible virus with a predilection for CD4+ T lymphocytes. More than 22 million people have died of the acquired immunodeficiency syndrome (AIDS) and the condition has in one generation become the most devastating and persistent epidemics in recorded history. More than two thirds of the world total of HIV-infected people live in Sub-Saharan Africa. In Central and Southern Africa at least 20% of the adult population is infected. As these adults die, they leave increasing numbers of orphans. Life expectancy at birth declined by 10 years per decade since the late 1980s to 50 years in the late 1990s, and in Botswana it is estimated to be as low as 33 years by 2010. The epidemic is increasing unabated and prospects for a curative or protective vaccine remain remote. The impact on HIV in Africa has been so profound that it influences political, economic, agriculture/food security, social, education, defence, science and health considerations. The medical and in particular immunology communities in Central Africa have the invidious challenge of on the one hand diagnosing the condition, monitoring its impact and contributing to treatment and management efforts. The science and clinical practice of immunology is challenged to find answers to the epidemic, perhaps including a vaccine. In this review we address the peculiarities of the HIV epidemic in Africa, its epidemiology and immunopathogenesis. We address the effect of the epidemic on individual patients, in their homes, workplaces and the knock-on effects on families and friends of the infected. Respective specialists discuss special groups (women, children) that are predominantly seen in Africa. We also discuss the impact of the epidemic on the clinical practice of medicine in general and challenges faced in the introduction of antiretroviral medicines. We also discuss options available for the diagnosis, treatment and monitoring of HIV-infected patients in this region.

Flow rate calibration II: a clinical evaluation study using PanLeucoGating as a single-platform protocol

BACKGROUND

CD4(+) T-lymphocyte enumeration is vital for monitoring disease progression in individuals positive for the human immunodeficiency virus (HIV), and as a result, there is a need to develop cost-effective protocols that provide accuracy, precision, and affordability. Recently, PanLeucoGating has been shown to fulfill these requirements; however, although comparable to state-of-the-art single-platform protocols (SP), there is still a requirement for an accurate total white cell count. To overcome this limitation, we recently developed a flow-rate based calibration method that enables the PanLeucoGating protocol to be used as a SP approach, and in this study show that this approach can be used for CD4(+) T-lymphocyte enumeration.

METHODS

A total of 113 HIV samples were analyzed using three protocols: (a) state-of-the art SP bead-based method (MultiSet; predicate protocol), (b) PanLeucoGating protocol used as a dual-platform (DP) approach, and (c) the newly developed flow rate-based SP approach. We demonstrate that flow rate calibration can be achieved easily and that the method is highly comparable to the state-of-the-art SP method.

RESULTS

A high correlation was observed between the predicate protocol and the SP PanLeucoGating approach over the whole range of CD4 counts tested (r(2) = 0.9928; bias 8 cells/microl), including the clinically relevant range (e.g., 0-200 CD4 cells/microl; bias 0 cells/microl). For batched samples, the cost of providing a CD4(+) T-lymphocyte count was reduced to approximately US $1.

CONCLUSIONS

The SP PanLeucoGating is a cost-effective approach to CD4(+) T-lymphocyte enumeration that maintains accuracy and precision.

Affordable CD4(+)-T-cell counting by flow cytometry: CD45 gating for volumetric analysis

The flow cytometers that are currently supported by industry provide accurate CD4(+)-T-cell counts for monitoring human immunodeficiency virus disease but remain unaffordable for routine service work under resource-poor conditions. We therefore combined volumetric flow cytometry (measuring absolute lymphocyte counts in unit volumes of blood) and simpler protocols with generic monoclonal antibodies (MAbs) to increase cost efficiency. Volumetric absolute counts were generated using CD45/CD4 and CD45/CD8 MAb combinations in two parallel tubes. The percentage values for the various subsets were also determined within the leukocyte and lymphocyte populations utilizing a fully automated protocol. The levels of agreement between the newly developed method and the present industry standards, including both volumetric and bead-based systems using a full MAb panel for subset analysis, were tested by Bland-Altman analyses. The limits of agreement for CD4 counts generated by the volumetric methods using either CD45/CD4 (in a single tube) or the full Trio MAb panel (in three tubes) on the CytoronAbsolute flow cytometer were between -29 and +46 cells/mm(3) with very little bias for CD4 counts (in favor of the Trio method: +8 CD4(+) lymphocytes/mm(3); 0.38% of lymphocytes). The limits of agreement for absolute CD4 counts yielded by the volumetric CD45/CD4 method and the bead-based method were between -118 and +98 cells/mm(3), again with a negligible bias (-10 CD4(+) lymphocytes/mm(3)). In the volumetric method using CD45/CD8, the strongly CD8(+) cells were gated and the levels of agreement with the full Trio showed a minor bias (in favor of the Trio; +40 CD8(+) cells/mm(3); 5.2% of lymphocytes) without a significant influence on CD4/CD8 ratios. One trained flow cytometrist was able to process 300 to 400 stained tubes per day. This workload extrapolates to a throughput of >30,000 samples per year if both CD45/CD4 and CD45/CD8 stainings are performed for each patient or a throughput of >60,000 samples if only CD45/CD4 counts are tested in a single tube. Thus, on the basis of the high efficiency and excellent agreement with the present industry standards, volumetric flow cytometers with automated gating protocols and autobiosamplers, complemented by generic CD45, CD4, and CD8 MAbs used in two-color immunofluorescence, represent the most suitable arrangements for large regional laboratories in resource-poor settings.

T-cell subset counting and the fight against AIDS: reflections over a 20-year struggle

The story of T-lymphocyte subset immunophenotyping technology is reviewed on the occasion of the 20th anniversary of CD4 T-cell enumeration. Over time, immunophenotyping has evolved into precise, reliable, but complicated and expensive technology requiring fresh blood samples. The gating technologies that were universally adapted for clinical flow cytometry for the past decade relied on rapidly deteriorating morphological scatter characteristics of leukocytes. This special issue dedicated to CD4 T-cell enumeration features most of the available new options that will have a significant impact on how this technology will be implemented within the first decade of the 21st century. In a series of original publications, including the new NIH guideline for T-cell subset enumeration, contemporary gating protocols that use immunologically logical parameters are presented as part of the more reliable and affordable immunophenotyping alternative. Some of the improvements addressed here include the costs of the assays and the capacity to monitor interlaboratory and intralaboratory performances. It is clear that an effective attack on the human immunodeficiency virus (HIV) epidemic has to embrace resource-poor regions. Reducing the cost of the assay while improving reliability and durability is a move in the right direction.