Early diagnosis of HIV-1 infection in infants in Dar es Salaam, Tanzania

Point-of-care tests detecting HIV nucleic acids for diagnosis of HIV-1 or HIV-2 infection in infants and children aged 18 months or less

BACKGROUND

The standard method of diagnosing HIV in infants and children less than 18 months is with a nucleic acid amplification test reverse transcriptase polymerase chain reaction test (NAT RT-PCR) detecting viral ribonucleic acid (RNA). Laboratory testing using the RT-PCR platform for HIV infection is limited by poor access, logistical support, and delays in relaying test results and initiating therapy in low-resource settings. The use of rapid diagnostic tests at or near the point-of-care (POC) can increase access to early diagnosis of HIV infection in infants and children less than 18 months of age and timely initiation of antiretroviral therapy (ART).

OBJECTIVES

To summarize the diagnostic accuracy of point-of-care nucleic acid-based testing (POC NAT) to detect HIV-1/HIV-2 infection in infants and children aged 18 months or less exposed to HIV infection.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (until 2 February 2021), MEDLINE and Embase (until 1 February 2021), and LILACS and Web of Science (until 2 February 2021) with no language or publication status restriction. We also searched conference websites and clinical trial registries, tracked reference lists of included studies and relevant systematic reviews, and consulted experts for potentially eligible studies.

SELECTION CRITERIA

We defined POC tests as rapid diagnostic tests conducted at or near the patient site. We included any primary study that compared the results of a POC NAT to a reference standard of laboratory NAT RT-PCR or total nucleic acid testing to detect the presence or absence of HIV infection denoted by HIV viral nucleic acids in infants and children aged 18 months or less who were exposed to HIV-1/HIV-2 infection. We included cross-sectional, prospective, and retrospective study designs and those that provided sufficient data to create the 2 × 2 table to calculate sensitivity and specificity. We excluded diagnostic case control studies with healthy controls.

DATA COLLECTION AND ANALYSIS

We extracted information on study characteristics using a pretested standardized data extraction form. We used the QUADAS-2 (Quality Assessment of Diagnostic Accuracy Studies) tool to assess the risk of bias and applicability concerns of the included studies. Two review authors independently selected and assessed the included studies, resolving any disagreements by consensus. The unit of analysis was the participant. We first conducted preliminary exploratory analyses by plotting estimates of sensitivity and specificity from each study on forest plots and in receiver operating characteristic (ROC) space. For the overall meta-analyses, we pooled estimates of sensitivity and specificity using the bivariate meta-analysis model at a common threshold (presence or absence of infection).

MAIN RESULTS

We identified a total of 12 studies (15 evaluations, 15,120 participants). All studies were conducted in sub-Saharan Africa. The ages of included infants and children in the evaluations were as follows: at birth (n = 6), ≤ 12 months (n = 3), ≤ 18 months (n = 5), and ≤ 24 months (n = 1). Ten evaluations were field evaluations of the POC NAT test at the point of care, and five were laboratory evaluations of the POC NAT tests.The POC NAT tests evaluated included Alere q HIV-1/2 Detect qualitative test (recently renamed m-PIMA q HIV-1/2 Detect qualitative test) (n = 6), Xpert HIV-1 qualitative test (n = 6), and SAMBA HIV-1 qualitative test (n = 3). POC NAT pooled sensitivity and specificity (95% confidence interval (CI)) against laboratory reference standard tests were 98.6% (96.1 to 99.5) (15 evaluations, 1728 participants) and 99.9% (99.7 to 99.9) (15 evaluations, 13,392 participants) in infants and children ≤ 18 months. Risk of bias in the included studies was mostly low or unclear due to poor reporting. Five evaluations had some concerns for applicability for the index test, as they were POC tests evaluated in a laboratory setting, but there was no difference detected between settings in sensitivity (-1.3% (95% CI -4.1 to 1.5)); and specificity results were similar.

AUTHORS' CONCLUSIONS

For the diagnosis of HIV-1/HIV-2 infection, we found the sensitivity and specificity of POC NAT tests to be high in infants and children aged 18 months or less who were exposed to HIV infection.

A randomized trial of vitamin A supplements in relation to mortality among human immunodeficiency virus-infected and uninfected children in Tanzania

OBJECTIVES

To determine whether vitamin A supplements result in reduced mortality among HIV-infected and uninfected children.

DESIGN

Randomized, double blind, placebo-controlled trial.

METHODS

Starting in April, 1993, we randomized 687 children age 6 months to 5 years who were admitted to the hospital with pneumonia. Children who were severely malnourished or had clinical signs of vitamin A deficiency were excluded. At baseline children received placebo or 400 000 IU (or half that for infants) of vitamin A, in addition to standard treatment for pneumonia. They received further doses of the same regimen 4 and 8 months after hospital discharge. Sera from children were tested for HIV antibodies by enzyme-linked immunosorbent assay and Western blot tests. For positive children <15 months of age, HIV infection was confirmed by amplified heat-denatured HIV-p24 antigen assays with confirmatory neutralization assays. HIV status was ascertained for 648 of 687 enrolled children. The mean duration of follow-up was 24.4 months (SD = 12.1).

RESULTS

Of 648 children 58 (9%) were HIV-infected. Compared with uninfected children, all-cause mortality was higher among HIV-infected children, as was mortality caused by pneumonia or diarrhea (P < 0.001 for each). Overall vitamin A supplements resulted in a 49% reduction in mortality [relative risk (RR), 0.51; 95% confidence interval (CI), 0.29 to 0.90, P = 0.02]. Vitamin A supplements reduced all-cause mortality by 63% among HIV-infected children (RR 0.37; CI 0.14 to 0.95, P = 0.04) and by 42% among uninfected children (RR 0.58, CI 0.28 to 1.19, P = 0.14). Vitamin A supplements were also associated with a 68% reduction in AIDS-related deaths (P = 0.05) and a 92% reduction in diarrhea-related deaths (P = 0.01).

CONCLUSION

Vitamin A deficiency, which is common among children in many developing countries, is particularly severe among HIV-infected children. Our findings indicate that vitamin A supplements, a low cost intervention, reduce mortality of HIV-infected children.

Late postnatal transmission of human immunodeficiency virus type 1 infection from mothers to infants in Dar es Salaam, Tanzania

OBJECTIVE

To study late postnatal transmission of human immunodeficiency virus type 1 in a cohort of children born to HIV-1-seropositive mothers who delivered at Muhimbili Medical Centre in Dar es Salaam, Tanzania.

MATERIALS AND METHODS

Since 1991 a prospective cohort study of mother-to-child transmission of HIV-1 has been conducted at Muhimbili Medical Centre in Dar es Salaam. HIV-1-seropositive mothers and age-matched seronegative controls were recruited into the cohort at delivery together with their newborns. Diagnosis of HIV-1 infection in children was based on polymerase chain reaction, HIV-1 p24 antigen tests and HIV antibody tests. Late postnatal transmission was defined as HIV-1 infection occurring after 6 months of age in a child who was uninfected at 6 months of age and who had an HIV-1-seropositive mother. Children born to HIV-seronegative mothers were used as controls. Breast-feeding was universal in this cohort. CD4 and CD8 T lymphocytes were assayed by flow cytometry in the mothers.

RESULTS

Among 139 children born to HIV-1-seropositive mothers and known to be HIV-uninfected at 6 months of age, 8 children became HIV-1-infected at the end of their first year of life or later. No conversions were observed in children younger than 11 months. The 8 conversions were observed during a follow-up covering 1555 child months between 6 and 27 months of age corresponding to a conversion rate of 6.2 per 100 child years. Among 260 children with HIV-seronegative mothers no child became HIV-infected during the follow-up. The percentage of CD4 T lymphocytes was similar in mothers with early and late transmission but was significantly lower in transmitting than in nontransmitting mothers.

CONCLUSION

Because no HIV-1 infection occurred in children with HIV-seronegative mothers, we conclude that the observed infections at the end of the first year of life or later among children born to HIV-seropositive women were caused by late transmission from mother to child, most likely through breast-feeding.

Comparison of in-house and commercial sample preparation and PCR amplification systems for detection of human immunodeficiency virus type 1 DNA in blood samples from Tanzanian adults

This study compared the performance of several in-house nested PCR systems and the Amplicor human immunodeficiency virus type 1 (HIV-1) PCR kit in the detection of HIV-1 DNA in Tanzanian samples prepared by two different methods. All six of the in-house primer sets evaluated had a higher sensitivity for HIV DNA detection in samples prepared by the Amplicor PCR sample preparation method than in those prepared by the Ficoll-Isopaque (FIP) density gradient centrifugation method. A sensitivity of 100% was achieved by combining two in-house primer sets. The sensitivity of the standard Amplicor HIV-1 PCR kit was only 59%, whereas a modified Amplicor HIV-1 PCR test had a sensitivity of 98%. Our data show that Tanzanian samples prepared by the Amplicor preparation method are more suitable for HIV-1 PCR testing than samples prepared by the FIP method. The modified, but not the standard, Amplicor HIV-1 PCR kit provides an alternative to the nested in-house PCR technique for the diagnosis of HIV infection.

Nested PCR assays with novel primers yield greater sensitivity to Tanzanian HIV-1 samples than a commercial PCR detection kit

To investigate the efficacy of the SK431/SK145 primer pair and two nested primer assays in amplifying African HIV-1 samples, a total of 35 Tanzanian PBMC samples were examined. These were assayed by two HIV-1 specific nested in-house PCR assays and a commercial HIV-1 PCR kit (GeneAmp) using SK431/SK145 as the primer pair. One of the nested PCR assays has been evaluated previously (old assay), whereas the modified assay was constructed from the HIV-1 sequence alignment released in August 1993. The modified nested primer assay showed increased sensitivity in the gag and env regions compared to the old nested primer assay. However, both the old and the modified nested primer assays displayed higher sensitivity for the detection of Tanzanian HIV-1 proviruses than the GeneAmp assay. When two regions were used (gag and env) as targets for the amplification, the modified nested primer assay detected 97.1% (34/35) of the proteinase K lysed samples, compared to 68.6% (24/35) using the SK431/SK145 primer pair (P < 0.01**). The results indicate that the SK431/SK145 primer pair may be less suitable when HIV-1 samples from Africa are analysed. The results also show that continuous modification of primer sequences can improve and maintain high sensitivity for the detection of highly divergent HIV-1 strains.

Performance of a modified HIV-1 p24 antigen assay for early diagnosis of HIV-1 infection in infants and prediction of mother-to-infant transmission of HIV-1 in Dar es Salaam, Tanzania

The aim of this study was to determine the utility of an amplified human immunodeficiency virus type 1 (HIV-1) p24 antigen (ag) assay using heated plasma or serum samples for the early diagnosis of HIV-1 infection in infants and for the prediction of the risk of mother-to-infant (MTI) transmission of HIV-1 in Dar es Salaam, Tanzania. The study included 125 samples from 76 infants positive for HIV-1 DNA by the polymerase chain reaction (PCR), 106 samples from 101 PCR-negative infants and 116 and 160 samples from seropositive and seronegative mothers, respectively. Samples were boiled to dissociate immune complexes and tested for HIV-1 p24 ag using a p24 ag amplification assay. Reactive samples were confirmed by a neutralization assay. Altogether, 123 of 125 samples from 76 PCR-positive infants were positive for p24 ag (sensitivity = 98.7%). HIV-1 p24 ag was found in all 18 samples collected at 1-8 weeks, in 35 of 36 samples collected at 9-26 weeks, in all 40 samples collected at 27-52 weeks, and in 30 of 31 samples collected > 52 weeks after birth. Detection of HIV-1 p24 ag was significantly more common in transmitting mothers (12 of 29, 41.4%) than in nontransmitting mothers (nine of 87, 10.3%) (p < 0.001). Among mothers with p24 antigenemia, the vertical transmission rate was significantly higher (12 of 21, 57%) than in mothers without p24 antigenemia (17 of 95, 18%) (p < 0.001). All samples from 101 PCR-negative children and 160 seronegative mothers were negative for p24 ag (specificity = 100%). We conclude that using heated plasma or serum increases the sensitivity of the p24 ag assay significantly. This modified simple test may be sufficient for the early diagnosis of HIV-1 infection in infants in settings with limited laboratory facilities. It is also useful for prediction of the risk of MTI transmission of HIV-1.

Protection against mucosal SIVsm challenge in macaques infected with a chimeric SIV that expresses HIV type 1 envelope

In a monkey model we used a chimeric SIV expressing the HIV-1 envelope gene (SHIV-4) as a live attenuated vaccine and a virulent SIVsm as a mucosal challenge. Four cynomolgus monkeys were inoculated intravenously with SHIV-4. Virus was repeatedly isolated from blood mononuclear cells of all four animals for 2 to 7 months after the inoculation of SHIV. All monkeys developed neutralizing antibodies to HIV-1 and high antibody titers to HIV-1 envelope glycoproteins. In contrast, no neutralizing antibodies to SIVsm were detected and cross-reacting antibodies to SIV envelope glycoproteins were demonstrable in low titers. Nine to 12 months after the SHIV inoculation the four monkeys and six naive control monkeys were challenged intrarectally with 10 monkey infectious doses of macaque cell-grown SIVsm. After a follow-up period of 1 year, two of four SHIV-infected monkeys were completely protected against SIVsm infection as shown by repeated negative virus isolations and negative polymerase chain reaction for SIV envelope DNA. One naive monkey that received blood from the two protected monkeys showed no signs of infection. The remaining two SHIV-infected monkeys showed an initial infection on challenge with SIVsm, but viral replication was thereafter suppressed. Cytotoxic T lymphocytes to SIV Nef and RT were demonstrable in one of four SHIV-infected monkeys before SIVsm challenge, but this monkey was not protected against SIV infection. All six control animals yielded virus repeatedly after SIVsm challenge and three of them showed declining CD4 cell counts. Thus, infection with SHIV expressing HIV-1 envelope could induce cross-protection against mucosal SIVsm challenge.