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Logan NZ, Kilmarx PH, Rolle I, Patel HK, Duong YT, Lee K, Shang JD, Bodika S, Koui IT, Balachandra S, Li M, Brown K, Nuwagaba-Biribonwoha H, Getaneh Y, Lulseged S, Haile A, West CA, Mengistu Y, McCracken SD, Kalua T, Jahn A, Kim E, Wadonda-Kabondo N, Jonnalagadda S, Hamunime N, Williams DB, McOllogi Juma J, Mgomella GS, Mdodo R, Kirungi WL, Mugisha V, Ndongmo CB, Nkwemu KC, Mugurungi O, Rogers JH, Saito S, Stupp P, Justman JE, Voetsch AC, Parekh BS. Brief Report: Self-Reported HIV-Positive Status but Subsequent HIV-Negative Test Results in Population-Based HIV Impact Assessment Survey Participants-11 Sub-Saharan African Countries, 2015-2018. J Acquir Immune Defic Syndr 2024; 95:313-317. [PMID: 38412045 DOI: 10.1097/qai.0000000000003363] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2023] [Accepted: 10/05/2023] [Indexed: 02/29/2024]
Abstract
BACKGROUND HIV testing is a critical step to accessing antiretroviral therapy (ART) because early diagnosis can facilitate earlier initiation of ART. This study presents aggregated data of individuals who self-reported being HIV-positive but subsequently tested HIV-negative during nationally representative Population-Based HIV Impact Assessment surveys conducted in 11 countries from 2015 to 2018. METHOD Survey participants aged 15 years or older were interviewed by trained personnel using a standard questionnaire to determine HIV testing history and self-reported HIV status. Home-based HIV testing and counseling using rapid diagnostic tests with return of results were performed by survey staff according to the respective national HIV testing services algorithms on venous blood samples. Laboratory-based confirmatory HIV testing for all participants identified as HIV-positives and self-reported positives, irrespective of HIV testing results, was conducted and included Geenius HIV-1/2 and DNA polymerase chain reaction if Geenius was negative or indeterminate. RESULTS Of the 16,630 participants who self-reported as HIV-positive, 16,432 (98.6%) were confirmed as HIV-positive and 198 (1.4%) were HIV-negative by subsequent laboratory-based testing. Participants who self-reported as HIV-positive but tested HIV-negative were significantly younger than 30 years, less likely to have received ART, and less likely to have received a CD4 test compared with participants who self-reported as HIV-positive with laboratory-confirmed infection. CONCLUSIONS A small proportion of self-reported HIV-positive individuals could not be confirmed as positive, which could be due to initial misdiagnosis, deliberate wrong self-report, or misunderstanding of the questionnaire. As universal ART access is expanding, it is increasingly important to ensure quality of HIV testing and confirmation of HIV diagnosis before ART initiation.
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Affiliation(s)
- Naeemah Z Logan
- Epidemic Intelligence Service, CDC, Atlanta, GA
- Division of Global HIV and TB, Center for Global Health, CDC, Atlanta, GA
| | - Peter H Kilmarx
- Fogarty International Center, National Institutes of Health, Bethesda, MD
| | - Italia Rolle
- Division of Global HIV and TB, Center for Global Health, CDC, Atlanta, GA
| | - Hetal K Patel
- Division of Global HIV and TB, Center for Global Health, CDC, Atlanta, GA
| | | | - Kiwon Lee
- ICAP-Columbia University, New York, NY
| | - Judith D Shang
- Division of Global HIV and TB, Center for Global Health, CDC, Atlanta, GA
| | - Stephane Bodika
- Division of Global HIV and TB, Center for Global Health, CDC, Atlanta, GA
| | | | - Shirish Balachandra
- Division of Global HIV and TB, Center for Global Health, CDC, Atlanta, GA
- Ethiopian Public Health Institute, Addis Ababa, Ethiopia
| | - Michelle Li
- Division of Global HIV and TB, Center for Global Health, CDC, Atlanta, GA
| | - Kristin Brown
- Division of Global HIV and TB, Center for Global Health, CDC, Atlanta, GA
| | | | - Yimam Getaneh
- Ethiopian Public Health Institute, Addis Ababa, Ethiopia
| | | | - Ashenafi Haile
- Division of Global HIV and TB, Center for Global Health, CDC, Atlanta, GA
| | - Christine A West
- Division of Global HIV and TB, Center for Global Health, CDC, Atlanta, GA
| | - Yohannes Mengistu
- Division of Global HIV and TB, Center for Global Health, CDC, Atlanta, GA
| | | | | | - Andreas Jahn
- Department for HIV and AIDS, Ministry of Health and Population, Lilongwe, Malawi
- I-TECH, Department of Global Health, University of Washington, Seattle, WA
| | - Evelyn Kim
- Division of Global HIV and TB, Center for Global Health, CDC, Atlanta, GA
| | | | - Sasi Jonnalagadda
- Division of Global HIV and TB, Center for Global Health, CDC, Atlanta, GA
| | - Ndapewa Hamunime
- Namibia Ministry of Health and Social Services, Windhoek, Namibia
| | - Daniel B Williams
- Division of Global HIV and TB, Center for Global Health, CDC, Atlanta, GA
| | - James McOllogi Juma
- Ministry of Health, Community Development, Gender, Elderly and Children, Dodoma, Tanzania
- Tanzania National AIDS Control Program, Dodoma, Tanzania
| | - George S Mgomella
- Division of Global HIV and TB, Center for Global Health, CDC, Atlanta, GA
| | - Rennatus Mdodo
- Division of Global HIV and TB, Center for Global Health, CDC, Atlanta, GA
| | | | | | - Clement B Ndongmo
- Division of Global HIV and TB, Center for Global Health, CDC, Atlanta, GA
| | | | | | - John H Rogers
- Division of Global HIV and TB, Center for Global Health, CDC, Atlanta, GA
| | | | - Paul Stupp
- Division of Global HIV and TB, Center for Global Health, CDC, Atlanta, GA
| | | | - Andrew C Voetsch
- Division of Global HIV and TB, Center for Global Health, CDC, Atlanta, GA
| | - Bharat S Parekh
- Division of Global HIV and TB, Center for Global Health, CDC, Atlanta, GA
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Hunt JH, Mwinnyaa G, Patel EU, Grabowski MK, Kagaayi J, Gray RH, Ssekasanvu J, Wawer MJ, Kigozi G, Chang LW, Kalibbala S, Nakalanzi M, Ndyanabo A, Quinn TC, Serwadda D, Reynolds SJ, Galiwango RM, Laeyendecker O. Longitudinal patterns in indeterminate HIV rapid antibody test results: a population-based, prospective cohort study. Microbiol Spectr 2024; 12:e0325323. [PMID: 38189332 PMCID: PMC10845946 DOI: 10.1128/spectrum.03253-23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2023] [Accepted: 11/03/2023] [Indexed: 01/09/2024] Open
Abstract
Rapid HIV tests are critical to HIV surveillance and universal testing and treatment programs. We assessed longitudinal patterns in indeterminate HIV rapid test results in an African population-based cohort. Prospective HIV rapid antibody test results, defined by two parallel rapid tests, among participants aged 15-49 years from three survey rounds of the Rakai Community Cohort Study, Uganda, from 2013 to 2018, were assessed. An indeterminate result was defined as any weak positive result or when one test was negative and the other was positive. A total of 31,405 participants contributed 54,459 person-visits, with 15,713 participants contributing multiple visits and 7,351 participants contributing 3 visits. The prevalence of indeterminate results was 2.7% (1,490/54,469). Of the participants with multiple visits who initially tested indeterminate (n = 591), 40.4% were negative, 18.6% were positive, and 41.0% were indeterminate at the subsequent visit. Of the participants with two consecutive indeterminate results who had a third visit (n = 67), 20.9% were negative, 9.0% were positive, and 70.2% remained indeterminate. Compared to a prior negative result, a prior indeterminate result was strongly associated with a subsequent indeterminate result [adjusted prevalence ratio, 23.0 (95% CI = 20.0-26.5)]. Compared to men, women were more likely to test indeterminate than negative [adjusted odds ratio, 2.3 (95% CI = 2.0-2.6)]. Indeterminate rapid HIV test results are highly correlated within an individual and 0.6% of the population persistently tested indeterminate over the study period. A substantial fraction of people with an indeterminate result subsequently tested HIV positive at the next visit, underscoring the importance of follow-up HIV testing protocols.IMPORTANCERapid HIV tests are a critical tool for expanding HIV testing and treatment to end the HIV epidemic. The interpretation and management of indeterminate rapid HIV test results pose a unique challenge for connecting all people living with HIV to the necessary care and treatment. Indeterminate rapid HIV test results are characterized by any weak positive result or discordant results (when one test is negative and the other is positive). We systematically tested all participants of a Ugandan population-based, longitudinal cohort study regardless of prior test results or HIV status to quantify longitudinal patterns in rapid HIV test results. We found that a substantial fraction (>15%) of participants with indeterminate rapid test results subsequently tested positive upon follow-up testing at the next visit. Our findings demonstrate the importance of follow-up HIV testing protocols for indeterminate rapid HIV test results.
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Affiliation(s)
- Joanne H. Hunt
- Laboratory of Immunoregulation, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Maryland, USA
| | - George Mwinnyaa
- Laboratory of Immunoregulation, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Maryland, USA
| | - Eshan U. Patel
- Department of Epidemiology, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland, USA
| | - M. Kate Grabowski
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
- Rakai Health Sciences Program, Kalisizo, Uganda
| | | | - Ronald H. Gray
- Department of Epidemiology, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland, USA
| | | | - Maria J. Wawer
- Department of Epidemiology, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland, USA
| | | | - Larry W. Chang
- Department of Epidemiology, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland, USA
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
- Rakai Health Sciences Program, Kalisizo, Uganda
| | | | | | | | - Thomas C. Quinn
- Laboratory of Immunoregulation, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Maryland, USA
- Department of Epidemiology, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland, USA
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - David Serwadda
- Rakai Health Sciences Program, Kalisizo, Uganda
- Makerere University, Kampala, Uganda
| | - Steven J. Reynolds
- Laboratory of Immunoregulation, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Maryland, USA
- Department of Epidemiology, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland, USA
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
- Rakai Health Sciences Program, Kalisizo, Uganda
| | | | - Oliver Laeyendecker
- Laboratory of Immunoregulation, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Maryland, USA
- Department of Epidemiology, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland, USA
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
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Boté-Casamitjana A, Faye-Joof T, Bah O, Jallow S, Camara A, Jallow O, Mohammed N, Forrest K, Nadjm B. Evaluating the sensitivity and specificity of Determine™ HIV-1/2 rapid test using a 0.01M phosphate-buffered saline produced at the Medical Research Council Unit The Gambia for the diagnosis of HIV. Trans R Soc Trop Med Hyg 2024; 118:127-135. [PMID: 37818849 PMCID: PMC10833640 DOI: 10.1093/trstmh/trad071] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2023] [Revised: 07/14/2023] [Accepted: 09/30/2023] [Indexed: 10/13/2023] Open
Abstract
BACKGROUND Human immunodeficiency virus (HIV) rapid diagnostic tests (RDTs) are widely used. However, buffer stockouts commonly lead to utilising non-approved liquids, resulting in errors. Our aim was to evaluate the diagnostic accuracy of an alternative buffer. METHODS Paired Determine HIV-1/2 rapid tests with commercial buffer and locally produced 0.01M phosphate-buffered saline (PBS) were performed on consecutive consenting individuals requiring HIV testing. Serum samples were sent for confirmation through the local gold-standard algorithm (Murex HIV Ag/Ab, Hexagon HIV with/without Geenius HIV 1/2). Test accuracy, κ and exact McNemar's test were also carried out. RESULTS Of 167 participants, 137 had confirmatory testing. The sensitivity of the Determine HIV-1/2 test using PBS compared with the gold standard was 100% (95% confidence interval [CI] 90.5 to 100) with a specificity of 98% (95% CI 92.9 to 99.8). The κ value was 0.94 compared with the gold standard and 0.92 compared with the Determine HIV-1/2 test using the commercial buffer. McNemar's test showed no evidence of differing sensitivities. Due to operational constraints, the study included 37 of the 49 positive cases as determined by the sample size calculation, resulting in an attained power of 80% instead of the intended 90%. CONCLUSIONS These results suggest that 0.01M PBS is an alternative solution for Determine HIV-1/2 when buffer stockouts occur.
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Affiliation(s)
- Anna Boté-Casamitjana
- Medical Research Council Unit The Gambia, London School of Hygiene and Tropical Medicine, Atlantic Boulevard, The Gambia
| | - Tisbeh Faye-Joof
- Medical Research Council Unit The Gambia, London School of Hygiene and Tropical Medicine, Atlantic Boulevard, The Gambia
| | - Ousman Bah
- Medical Research Council Unit The Gambia, London School of Hygiene and Tropical Medicine, Atlantic Boulevard, The Gambia
| | - Sira Jallow
- Medical Research Council Unit The Gambia, London School of Hygiene and Tropical Medicine, Atlantic Boulevard, The Gambia
| | - Alagie Camara
- Medical Research Council Unit The Gambia, London School of Hygiene and Tropical Medicine, Atlantic Boulevard, The Gambia
| | - Olimatou Jallow
- Medical Research Council Unit The Gambia, London School of Hygiene and Tropical Medicine, Atlantic Boulevard, The Gambia
| | - Nuredin Mohammed
- Medical Research Council Unit The Gambia, London School of Hygiene and Tropical Medicine, Atlantic Boulevard, The Gambia
| | - Karen Forrest
- Medical Research Council Unit The Gambia, London School of Hygiene and Tropical Medicine, Atlantic Boulevard, The Gambia
| | - Behzad Nadjm
- Medical Research Council Unit The Gambia, London School of Hygiene and Tropical Medicine, Atlantic Boulevard, The Gambia
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Estimating the lifetime risk of a false positive screening test result. PLoS One 2023; 18:e0281153. [PMID: 36791062 PMCID: PMC9931091 DOI: 10.1371/journal.pone.0281153] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2022] [Accepted: 01/14/2023] [Indexed: 02/16/2023] Open
Abstract
False positive results in screening tests have potentially severe psychological, medical, and financial consequences for the recipient. However, there have been few efforts to quantify how the risk of a false positive accumulates over time. We seek to fill this gap by estimating the probability that an individual who adheres to the U.S. Preventive Services Task Force (USPSTF) screening guidelines will receive at least one false positive in a lifetime. To do so, we assembled a data set of 116 studies cited by the USPSTF that report the number of true positives, false negatives, true negatives, and false positives for the primary screening procedure for one of five cancers or six sexually transmitted diseases. We use these data to estimate the probability that an individual in one of 14 demographic subpopulations will receive at least one false positive for one of these eleven diseases in a lifetime. We specify a suitable statistical model to account for the hierarchical structure of the data, and we use the parametric bootstrap to quantify the uncertainty surrounding our estimates. The estimated probability of receiving at least one false positive in a lifetime is 85.5% (±0.9%) and 38.9% (±3.6%) for baseline groups of women and men, respectively. It is higher for subpopulations recommended to screen more frequently than the baseline, including more vulnerable groups such as pregnant women and men who have sex with men. Since screening technology is imperfect, false positives remain inevitable. The high lifetime risk of a false positive reveals the importance of educating patients about this phenomenon.
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5
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Skovdal M, Jensen FJB, Maswera R, Beckmann N, Nyamukapa C, Gregson S. Temporal discrepancies in "rapid" HIV testing: explaining misdiagnoses at the point-of-care in Zimbabwe. BMC Infect Dis 2023; 23:9. [PMID: 36609232 PMCID: PMC9817402 DOI: 10.1186/s12879-022-07972-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2022] [Accepted: 12/26/2022] [Indexed: 01/09/2023] Open
Abstract
BACKGROUND Rapid diagnostic tests have revolutionized the HIV response in low resource and high HIV prevalence settings. However, disconcerting levels of misdiagnosis at the point-of-care call for research into their root causes. As rapid HIV tests are technologies that cross borders and have inscribed within them assumptions about the context of implementation, we set out to explore the (mis)match between intended and actual HIV testing practices in Zimbabwe. METHODS We examined actual HIV testing practices through participant observations in four health facilities and interviews with 28 rapid HIV testers. As time was identified as a key sphere of influence in thematic analyses of the qualitative data, a further layer of analysis juxtaposed intended (as scripted in operating procedures) and actual HIV testing practices from a temporal perspective. RESULTS We uncover substantial discrepancies between the temporal flows assumed and inscribed into rapid HIV test kits (their intended use) and those presented by the high frequency testing and low resource and staffing realities of healthcare settings in Zimbabwe. Aside from pointing to temporal root causes of misdiagnosis, such as the premature reading of test results, our findings indicate that the rapidity of rapid diagnostic technologies is contingent on a slow, steady, and controlled environment. This not only adds a different dimension to the meaning of "rapid" HIV testing, but suggests that errors are embedded in the design of the diagnostic tests and testing strategies from the outset, by inscribing unrealistic assumptions about the context within which they used. CONCLUSION Temporal analyses can usefully uncover difficulties in attuning rapid diagnostic test technologies to local contexts. Such insight can help explain potential misdiagnosis 'crisis points' in point-of-care testing, and the need for public health initiatives to identify and challenge the underlying temporal root causes of misdiagnosis.
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Affiliation(s)
- Morten Skovdal
- grid.5254.60000 0001 0674 042XDepartment of Public Health, University of Copenhagen, Øster Farimagsgade 5, 1014 Copenhagen, Denmark
| | - Frederik Jacob Brainin Jensen
- grid.5254.60000 0001 0674 042XDepartment of Public Health, University of Copenhagen, Øster Farimagsgade 5, 1014 Copenhagen, Denmark
| | - Rufurwokuda Maswera
- grid.418347.d0000 0004 8265 7435Manicaland Centre for Public Health Research, Biomedical Research and Training Institute, Harare, Zimbabwe
| | - Nadine Beckmann
- grid.8991.90000 0004 0425 469XDepartment of Global Health and Development, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Constance Nyamukapa
- grid.418347.d0000 0004 8265 7435Manicaland Centre for Public Health Research, Biomedical Research and Training Institute, Harare, Zimbabwe ,grid.7445.20000 0001 2113 8111Department of Infectious Disease Epidemiology, Imperial College London, London, United Kingdom
| | - Simon Gregson
- grid.418347.d0000 0004 8265 7435Manicaland Centre for Public Health Research, Biomedical Research and Training Institute, Harare, Zimbabwe ,grid.7445.20000 0001 2113 8111Department of Infectious Disease Epidemiology, Imperial College London, London, United Kingdom
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Linkage to HIV Care Following HIV Self-testing Among Men: Systematic Review of Quantitative and Qualitative Studies from Six Countries in Sub-Saharan Africa. AIDS Behav 2023; 27:651-666. [PMID: 36094641 PMCID: PMC9466308 DOI: 10.1007/s10461-022-03800-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/17/2022] [Indexed: 11/16/2022]
Abstract
Gender disparities are pervasive throughout the HIV care continuum in sub-Saharan Africa, with men testing, receiving treatment, and achieving viral suppression at lower rates, and experiencing mortality at higher rates, compared with women. HIV self-testing (HIVST) has been shown to be highly acceptable among men in sub-Saharan Africa. However, evidence on linkage to HIV care following a reactive HIVST result is limited. In this systematic review, we aimed to synthesize the quantitative and qualitative literature from sub-Saharan Africa on men's rates of linkage to HIV care after receiving a reactive HIVST result. We systematically searched 14 bibliometric databases. The Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) flow diagram was used to document the screening results. The Mixed Methods Appraisal Tool (MMAT) was used to assess the methodological quality of the included studies. Of 22,446 references screened, 15 articles were eligible for inclusion in this review. Linkage to HIV care following a reactive HIVST result was subject to several barriers: financial constraints due to travelling costs, potential long waiting hours at the clinics, stigma, discrimination, and privacy concerns. Men's rates of seeking confirmatory testing and linking to HIV care following a reactive HIVST result were inconsistent across studies. Combining financial incentives with HIVST was found to increase the likelihood of linking to HIV care following a reactive HIVST result. The variable rates of linkage to HIV care following a reactive HIVST result suggest a need for further research and development into strategies to increase linkage to HIV care.
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Barranca E. When serology contradicts the experience of the disease: Ethics, research, and announcements about Ebola in Guinea. SANTE PUBLIQUE (VANDOEUVRE-LES-NANCY, FRANCE) 2023; 35:65-73. [PMID: 37328418 DOI: 10.3917/spub.231.0065] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/18/2023]
Abstract
INTRODUCTION In Guinea, serological tests have shown the absence of antibodies in people declared cured of Ebola Virus Disease (EVD), thus refuting their previous diagnosis; and the presence of antibodies in contact cases who had not been diagnosed. These findings have led to reflections on the implications of telling those affected. PURPOSE OF RESEARCH The objectives of this study are to identify the stakes of announcing these results in the Guinean health context. 24 people, cured of Ebola or with expertise in ethics or health, were interviewed between November 2019 and February 2020 in Conakry. They presented their experiences in terms of medical announcements in Guinea, and their opinions on the relevance of announcing these discordant serological results. RESULTS Although it is an important step in the care relationship, the medical announcement sometimes seems neglected in Guinea. In addition, the opinions of the interviewees are rather homogeneous and favorable to the announcement to people seropositive to the Ebola virus who had not been diagnosed. However, their views are varied regarding the announcement of a negative serology to people declared cured of the EVD. They follow two trends, between Ebola survivors who say the announcement is undesirable, and ethicists and healthcare professionals for whom it is preferable. CONCLUSIONS This survey shows that certain biological results deserve critical reflection before being announced, especially when they indicate a new diagnosis. In order to decide on a course of action for the situations exposed, a second expertise would be useful, taking into account our results and new knowledge about the virus.
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Affiliation(s)
- Eva Barranca
- UMI TransVIHMI (Université de Montpellier, IRD, INSERM) – Montpellier – France
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8
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Implementation of Novel Quality Assurance Program for Hepatitis C Viral Load Point of Care Testing. Viruses 2022; 14:v14091929. [PMID: 36146736 PMCID: PMC9504144 DOI: 10.3390/v14091929] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2022] [Revised: 08/27/2022] [Accepted: 08/29/2022] [Indexed: 11/17/2022] Open
Abstract
All patients should have access to accurate and timely test results. The introduction of point of care testing (PoCT) for infectious diseases has facilitated access to those unable to access traditional laboratory-based medical testing, including those living in remote and regional locations, or individuals who are marginalized or incarcerated individuals. In many countries, laboratory testing for infectious diseases, such as hepatitis C virus (HCV), is performed in a highly regulated environment. However, this is not the case for PoCT, where testing is performed by non-laboratory staff and quality controls are often lacking. An assessment of the provision of laboratory-based quality assurance to PoCT for infectious disease was conducted and the barriers to participation identified. A novel approach to providing quality assurance to PoCT sites, in particular those testing for HCV, was designed and piloted. This novel approach incudes identifying and validating sample types that are inactivated and stable at ambient temperature, creating cost-effective supply chains to facilitate logistics of samples, and the development of a smart phone-enabled portal for data entry and analyses. The creation and validation of this approach to quality assurance of PoCT removes the barriers to participation and acts to improve the quality and accuracy of testing, reduce errors and waste, and improve patient outcomes.
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9
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Nsibande DF, Woldesenbet SA, Puren A, Barron P, Maduna VI, Lombard C, Cheyip M, Mogashoa M, Pillay Y, Magasana V, Ramraj T, Kufa T, Kindra G, Goga A, Chirinda W. Investigating the quality of HIV rapid testing practices in public antenatal health care facilities, South Africa. PLoS One 2022; 17:e0268687. [PMID: 36037237 PMCID: PMC9423613 DOI: 10.1371/journal.pone.0268687] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2022] [Accepted: 05/05/2022] [Indexed: 11/19/2022] Open
Abstract
Monitoring HIV prevalence using antenatal HIV sentinel surveillance is important for efficient epidemic tracking, programme planning and resource allocation. HIV sentinel surveillance usually employs unlinked anonymous HIV testing which raises ethical, epidemiological and public health challenges in the current era of universal test and treat. The World Health Organization (WHO) recommends that countries should consider using routine prevention of mother-to-child transmission of HIV (PMTCT) data for surveillance. We audited antenatal care clinics to assess the quality of HIV rapid testing practices as the first step to assess whether South Africa is ready to utilize PMTCT programme data for antenatal HIV surveillance. In 2017, we conducted a cross-sectional survey in 360 randomly sampled antenatal care clinics using the adapted WHO Stepwise-Process-for-Improving-the-Quality-of-HIV-Rapid-Testing (SPI-RT) checklist. We calculated median percentage scores within a domain (domain-specific median score), and across all domains (overall median percentage scores). The latter was used to classify sites according to five implementation levels; (from 0:<40% to 4: 90% or higher). Of 346 (96.1%) facilities assessed, an overall median percentage score of 62.1% (inter-quartile range (IQR): 50.8–71.9%) was obtained. The lowest domain-specific median percentage scores were obtained under training/certification (35% IQR: 10.0–50.0%) and external quality assurance (12.5% IQR: 0.0–50.0%), respectively. The majority (89%) of sites had an overall median score at level 2 or below; of these, 37% required improvement in specific areas and 6.4% in all areas. Facilities in districts implementing the HIV Rapid Test Quality Improvement Initiative and supported by the President’s Emergency Plan for AIDS Relief (PEPFAR) had significantly higher median overall scores (65.6% IQR: 53.9–74.2%) (P-value from rank sum test: <0.001) compared with non–PEPFAR–supported facilities (56.6% IQR:47.7–66.0%). We found sub-optimal implementation of HIV rapid testing practices. We recommend the expansion of the PEPFAR-funded Rapid Test Continuous Quality Improvement (RTCQI) support to all antenatal care testing sites.
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Affiliation(s)
- Duduzile F. Nsibande
- Health Systems Research Unit, South African Medical Research Council, Cape Town, South Africa
- HIV and other Infectious Diseases Research Unit, South African Medical Research Council, Cape Town, South Africa
- * E-mail:
| | - Selamawit A. Woldesenbet
- Center for HIV and STI, National Institute for Communicable Diseases, Johannesburg, South Africa
- School of Public Health, University of the Witwatersrand, Johannesburg, South Africa
| | - Adrian Puren
- Center for HIV and STI, National Institute for Communicable Diseases, Johannesburg, South Africa
| | - Peter Barron
- School of Public Health, University of the Witwatersrand, Johannesburg, South Africa
| | - Vincent I. Maduna
- Directorate of Research & Innovation, Tshwane University of Technology, Pretoria, South Africa
| | - Carl Lombard
- Biostatistics Unit, South African Medical Research Council, Cape Town, South Africa
- Division of Epidemiology and Biostatistics, Department of Global Health, University of Stellenbosch, Cape Town, South Africa
| | - Mireille Cheyip
- United States Centers for Disease Control and Prevention, Pretoria, South Africa
| | - Mary Mogashoa
- United States Centers for Disease Control and Prevention, Pretoria, South Africa
| | - Yogan Pillay
- National Department of Health, Pretoria, South Africa
| | - Vuyolwethu Magasana
- Health Systems Research Unit, South African Medical Research Council, Cape Town, South Africa
- HIV and other Infectious Diseases Research Unit, South African Medical Research Council, Cape Town, South Africa
| | - Trisha Ramraj
- Health Systems Research Unit, South African Medical Research Council, Cape Town, South Africa
- HIV and other Infectious Diseases Research Unit, South African Medical Research Council, Cape Town, South Africa
| | - Tendesayi Kufa
- Center for HIV and STI, National Institute for Communicable Diseases, Johannesburg, South Africa
- School of Public Health, University of the Witwatersrand, Johannesburg, South Africa
| | - Gurpreet Kindra
- United States Centers for Disease Control and Prevention, Pretoria, South Africa
| | - Ameena Goga
- Health Systems Research Unit, South African Medical Research Council, Cape Town, South Africa
- HIV and other Infectious Diseases Research Unit, South African Medical Research Council, Cape Town, South Africa
- Department of Paediatrics and Child Health, University of Pretoria, Pretoria, South Africa
| | - Witness Chirinda
- Health Systems Research Unit, South African Medical Research Council, Cape Town, South Africa
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10
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Skovdal M, Beckmann N, Maswera R, Nyamukapa C, Gregson S. The (in)visibility of misdiagnosis in point-of-care HIV testing in Zimbabwe. Med Anthropol 2022; 41:404-417. [PMID: 35412919 DOI: 10.1080/01459740.2022.2054715] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
There is a global trend to introduce point-of-care diagnostic tests, enabling healthcare workers at any level to test, provide results, and initiate immediate treatment if necessary. This article explores how healthcare workers conducting rapid HIV tests - in contexts of limited external quality assurance mechanisms - ascertain the accuracy of their test results. Drawing on interview data and participant observations from health facilities in Zimbabwe, we open the black box of misdiagnosis (in)visibility and reveal a range of proxies and markers that HIV testers draw on to develop certainty, or question, the reliability of their diagnostic classifications.
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Affiliation(s)
- Morten Skovdal
- Department of Public Health, University of Copenhagen, Copenhagen, Denmark
| | - Nadine Beckmann
- Anthropology, University of Roehampton, Centre for Research in Evolutionary, Social & Inter Disciplinary, London, UK
| | - Rufurwokuda Maswera
- Manicaland Centre for Public Health Research, Biomedical Research and Training Institute, Harare, Zimbabwe
| | - Constance Nyamukapa
- Manicaland Centre for Public Health Research, Biomedical Research and Training Institute, Harare, Zimbabwe.,Department of Infectious Disease Epidemiology, Imperial College London, London, UK
| | - Simon Gregson
- Manicaland Centre for Public Health Research, Biomedical Research and Training Institute, Harare, Zimbabwe.,Department of Infectious Disease Epidemiology, Imperial College London, London, UK
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11
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Srichatrapimuk S, Setthaudom C, Apiwattanakul N, Sungkanuparph S, Phuphuakrat A. Anti-HIV serological test algorithms to reduce false-positive and inconclusive results for low HIV prevalence and resource-limited areas. Int J STD AIDS 2021; 33:63-72. [PMID: 34565235 DOI: 10.1177/09564624211044354] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
A false-positive anti-human immunodeficiency virus (HIV) test result can have devastating consequences. Sequential HIV serological testing is a strategy that could be applied in resource-limited settings to reduce false-positive results when a nucleic acid test is not affordable. We aimed to compare the results of sequential anti-HIV testing algorithms recommended by the national guidelines and our hospital algorithm in the setting of low HIV prevalence. We retrospectively reviewed individuals whose anti-HIV tested positive by Architect HIV Ag/Ab Combo with a signal/cut-off ratio of 1.00-20.00 between January 2015 and June 2016 at a university hospital in Bangkok, Thailand. A total of 111,224 samples were requested for anti-HIV tests during the study period. Sixty-six adults and nine children/adolescents met the inclusion criteria of this study. Compared to the national guidelines, our hospital HIV diagnosis algorithm could identify two individuals with false-positive anti-HIV tests and a reduction of inconclusive diagnoses from 45 to one adult cases (p <.001). It also eliminated inconclusive diagnoses in four non-infected children with HIV-negative mothers. Our hospital HIV diagnosis algorithm can reduce the number of HIV misdiagnoses of serological tests in an area with low HIV prevalence. The sequential HIV serological test algorithms should be reviewed and evaluated in each institute.
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Affiliation(s)
- Sirawat Srichatrapimuk
- Chakri Naruebodindra Medical Institute, Faculty of Medicine Ramathibodi Hospital, 26687Mahidol University, Samut Prakan, Thailand
| | - Chavachol Setthaudom
- Department of Pathology, Faculty of Medicine Ramathibodi Hospital, 26687Mahidol University, Bangkok, Thailand
| | - Nopporn Apiwattanakul
- Department of Pediatrics, Faculty of Medicine Ramathibodi Hospital, 26687Mahidol University, Bangkok, Thailand
| | - Somnuek Sungkanuparph
- Chakri Naruebodindra Medical Institute, Faculty of Medicine Ramathibodi Hospital, 26687Mahidol University, Samut Prakan, Thailand
| | - Angsana Phuphuakrat
- Department of Medicine, Faculty of Medicine Ramathibodi Hospital, 432716Mahidol University, Bangkok, Thailand
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12
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Barquín D, Ndarabu A, Carlos S, Fernández-Alonso M, Rubio-Garrido M, Makonda B, Holguín Á, Reina G. HIV-1 diagnosis using dried blood spots from patients in Kinshasa, DRC: a tool to detect misdiagnosis and achieve World Health Organization 2030 targets. Int J Infect Dis 2021; 111:253-260. [PMID: 34419584 DOI: 10.1016/j.ijid.2021.08.035] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2021] [Revised: 08/16/2021] [Accepted: 08/17/2021] [Indexed: 10/20/2022] Open
Abstract
INTRODUCTION Currently, only 54% of the population of the Democratic Republic of the Congo (DRC) know their HIV status. The aim of this study was to detect HIV misdiagnosis from rapid diagnostic tests (RDT) and to evaluate serological immunoassays using dried blood spots (DBS) from patients in Kinshasa, DRC. METHODS Between 2016 and 2018, 365 DBS samples were collected from 363 individuals and shipped to Spain. The samples were from people with a new HIV positive (n = 123) or indeterminate (n = 23) result, known HIV-positive patients (n = 157), and a negative control group (n = 62). HIV serology was performed using Elecsys HIV combi PT (Roche), VIDAS HIV Duo Quick (BioMérieux), and Geenius (Bio-Rad). In addition, HIV RNA detection was performed in all samples using the COBAS AmpliPrep/COBAS Taqman HIV-1 Test 2.0 (Roche). RESULTS Overall, 272 samples were found to be positive and 93 to be negative for HIV serology. The sensitivity was 100% for both Elecsys and VIDAS techniques, but specificity was slightly higher for the VIDAS test: 100% (96.1-100%) vs 98.9% (94.1-99.9%). Of the 23 indeterminate cases using RDT, only three cases were true-positives with a detectable viral load. Eleven samples out of the 280 classified as positive by RDT corresponded to nine patients who had received a false diagnosis of HIV through RDT (3.9%); six of them had been on antiretroviral therapy for at least 2 years. CONCLUSIONS Elecsys HIV combi PT and VIDAS HIV Duo Quick immunoassays showed high sensitivity and specificity when using DBS. RDT-based serological diagnosis can lead to HIV misdiagnosis with personal and social consequences in sub-Saharan Africa.
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Affiliation(s)
- David Barquín
- Microbiology Department, Clínica Universidad de Navarra, Pamplona, Spain
| | - Adolphe Ndarabu
- Centre Hospitalier Monkole, Kinshasa, Democratic Republic of the Congo
| | - Silvia Carlos
- ISTUN, Institute of Tropical Health, Universidad de Navarra, Pamplona, Spain; IdiSNA, Navarra Institute for Health Research, Pamplona, Spain; Department of Preventive Medicine and Public Health, Universidad de Navarra, Pamplona, Spain
| | - Mirian Fernández-Alonso
- Microbiology Department, Clínica Universidad de Navarra, Pamplona, Spain; ISTUN, Institute of Tropical Health, Universidad de Navarra, Pamplona, Spain; IdiSNA, Navarra Institute for Health Research, Pamplona, Spain
| | - Marina Rubio-Garrido
- HIV-1 Molecular Epidemiology Laboratory, Microbiology and Parasitology Department, University Hospital Ramón y Cajal-IRYCIS and CIBEREsp-RITIP, Madrid, Spain
| | - Benit Makonda
- Centre Hospitalier Monkole, Kinshasa, Democratic Republic of the Congo
| | - África Holguín
- HIV-1 Molecular Epidemiology Laboratory, Microbiology and Parasitology Department, University Hospital Ramón y Cajal-IRYCIS and CIBEREsp-RITIP, Madrid, Spain
| | - Gabriel Reina
- Microbiology Department, Clínica Universidad de Navarra, Pamplona, Spain; ISTUN, Institute of Tropical Health, Universidad de Navarra, Pamplona, Spain; IdiSNA, Navarra Institute for Health Research, Pamplona, Spain.
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13
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Domaoal RA, Sleeman K, Sawadogo S, Dzinamarira T, Frans N, Shatumbu SP, Kakoma LN, Shuumbwa TK, Cox MH, Stephens S, Nisbet L, Metz M, Saito S, Williams DB, Voetsch AC, Patel H, Parekh B, Duong YT. Successful Use of Near Point-of-Care Early Infant Diagnosis in NAMPHIA to Improve Turnaround Times in a National Household Survey. J Acquir Immune Defic Syndr 2021; 87:S67-S72. [PMID: 34166314 PMCID: PMC8754064 DOI: 10.1097/qai.0000000000002706] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2021] [Accepted: 04/07/2021] [Indexed: 11/26/2022]
Abstract
BACKGROUND In the population-based HIV impact assessment surveys, early infant diagnosis (EID) was provided to infants <18 months without a prior diagnosis. For the Namibia population-based HIV impact assessment (NAMPHIA), the GeneXpert platform was assessed for the feasibility of near POC EID testing compared with the standard Roche COBAS AmpliPrep/COBAS TaqMan (CAP/CTM) platform. Quality assurance measures and turnaround time were compared to improve EID results reporting. METHODS NAMPHIA participants were screened for HIV exposure using Determine HIV-1/2 rapid test; samples reactive on Determine received EID testing on the GeneXpert instrument and Xpert HIV-1 Qual assay using whole blood. Results were confirmed at the Namibia Institute of Pathology using dried blood spots on the Roche CAP/CTM platform per national guidelines. RESULTS Of the 762 screened infants, 61 (8.0%) were Determine-reactive and considered HIV-exposed. Of the 61 exposed infants, 2 were found to be HIV-infected whereas 59 were negative on both GeneXpert and Roche platforms, achieving 100% concordance. Average turnaround time was 3.4 days for the Xpert HIV-1 Qual assay, and average time from collection to testing was 1.0 days for GeneXpert compared with 10.7 days for Roche. No samples failed using GeneXpert whereas 1 sample failed using Roche and was repeated. CONCLUSION Quality POC EID testing is feasible in a national survey through extensive training and external quality assurance measures. The use of decentralized POC EID for national testing would provide rapid diagnosis and improve TATs which may prevent loss to follow-up, ensure linkage to care, and improve clinical outcomes for infants.
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Affiliation(s)
- Robert A. Domaoal
- International Laboratory Branch, Division of Global HIV & TB, CGH, CDC, Atlanta, GA, USA
| | - Katrina Sleeman
- International Laboratory Branch, Division of Global HIV & TB, CGH, CDC, Atlanta, GA, USA
| | | | | | | | | | | | | | - Mackenzie Hurlston Cox
- International Laboratory Branch, Division of Global HIV & TB, CGH, CDC, Atlanta, GA, USA
| | - Sally Stephens
- University of California San Francisco, Windhoek, Namibia
| | - Lydia Nisbet
- University of California San Francisco, Windhoek, Namibia
| | | | | | | | - Andrew C. Voetsch
- Epidemiology and Surveillance Branch, Division of Global HIV & TB, CGH, CDC, Atlanta, GA, USA
| | - Hetal Patel
- International Laboratory Branch, Division of Global HIV & TB, CGH, CDC, Atlanta, GA, USA
| | - Bharat Parekh
- International Laboratory Branch, Division of Global HIV & TB, CGH, CDC, Atlanta, GA, USA
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14
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Fonner VA, Sands A, Figueroa C, Baggaley R, Quinn C, Jamil MS, Johnson C. Country adherence to WHO recommendations to improve the quality of HIV diagnosis: a global policy review. BMJ Glob Health 2021; 5:bmjgh-2019-001939. [PMID: 32371571 PMCID: PMC7228476 DOI: 10.1136/bmjgh-2019-001939] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2019] [Revised: 02/17/2020] [Accepted: 02/28/2020] [Indexed: 12/21/2022] Open
Abstract
Introduction Ensuring a correct and timely HIV diagnosis is critical. WHO publishes guidelines on HIV testing strategies that maximise the likelihood of correctly determining one’s HIV status. A review of national HIV testing policies in 2014 found low adherence to WHO guidelines. We updated this review to determine adherence to current recommendations. Methods We conducted a comprehensive policy review through April 2018. We extracted data on HIV testing strategies, recommendations on HIV retesting prior to antiretroviral therapy (ART) initiation and pre-exposure prophylaxis (PrEP)-related HIV testing information. Descriptive analyses disaggregated by region were conducted to ascertain adherence to recommendations and to describe testing strategy characteristics. Results Of 91 policies included, 26% (n=24/91) adhered to WHO recommendations. Having a two-assay testing strategy to rule-in HIV infection as opposed to the recommended three-assay testing strategy was a major reason for non-adherence. Of 72 country policies providing sufficient information, 31% (n=22) recommended retesting for HIV prior to initiating ART. Of 25 countries and two regions reporting PrEP-related HIV testing guidelines, almost all recommended testing prior to initiating PrEP and every 3 months during PrEP use. Conclusions Global adherence to WHO recommendations for HIV testing strategies have improved since 2014 but remain low. We found adherence existed on a continuum. Such a system provides insights into how countries can move towards adherence by making relatively minor changes to testing strategies. Guidance from WHO on the role of new HIV testing technologies within testing algorithms and identifying ways to simplify testing guidance is warranted.
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Affiliation(s)
- Virginia A Fonner
- Department of Psychiatry and Behavioral Sciences, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Anita Sands
- Department of Regulation and Prequalification, World Health Organization, Geneve, GE, Switzerland
| | - Carmen Figueroa
- Global HIV, Hepatitis and STI Programme, World Health Organization, Geneva, GE, Switzerland
| | - Rachel Baggaley
- Global HIV, Hepatitis and STI Programme, World Health Organization, Geneva, GE, Switzerland
| | - Caitlin Quinn
- Global HIV, Hepatitis and STI Programme, World Health Organization, Geneva, GE, Switzerland
| | - Muhammad S Jamil
- Global HIV, Hepatitis and STI Programme, World Health Organization, Geneva, GE, Switzerland
| | - Cheryl Johnson
- Global HIV, Hepatitis and STI Programme, World Health Organization, Geneva, GE, Switzerland
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15
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Neilan AM, Cohn J, Sacks E, Gandhi AR, Fassinou P, Walensky RP, Kouadio MN, Freedberg KA, Ciaranello AL. Evaluating Point-of-Care Nucleic Acid Tests in Adult Human Immunodeficiency Virus Diagnostic Strategies: A Côte d'Ivoire Modeling Analysis. Open Forum Infect Dis 2021; 8:ofab225. [PMID: 34189169 PMCID: PMC8231387 DOI: 10.1093/ofid/ofab225] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2021] [Accepted: 04/29/2021] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND The World Health Organization (WHO) human immunodeficiency virus (HIV) diagnostic strategy requires 6 rapid diagnostic tests (RDTs). Point-of-care nucleic acid tests (POC NATs) are costlier, less sensitive, but more specific than RDTs. METHODS We simulated a 1-time screening process in Côte d'Ivoire (CI; undiagnosed prevalence: 1.8%), comparing WHO- and CI-recommended RDT-based strategies (RDT-WHO, RDT-CI) and an alternative: POC NAT to resolve RDT discordancy (NAT-Resolve). Costs included assays (RDT: $1.47; POC NAT: $27.92), antiretroviral therapy ($6-$22/month), and HIV care ($27-$38/month). We modeled 2 sensitivity/specificity scenarios: high-performing (RDT: 99.9%/99.1%; POC NAT: 95.0%/100.0%) and low-performing (RDT: 91.1%/82.9%; POC NAT: 93.3%/99.5%). Outcomes included true-positive (TP), false-positive (FP), true-negative (TN), or false-negative (FN) results; life expectancy; costs; and incremental cost-effectiveness ratios (ICERs: $/year of life saved [YLS]; threshold ≤$1720/YLS [per-capita gross domestic product]). RESULTS Model-projected impacts of misdiagnoses were 4.4 years lost (FN vs TP; range, 3.0-13.0 years) and a $5800 lifetime cost increase (FP vs TN; range, $590-$14 680). In the high-performing scenario, misdiagnoses/10 000 000 tested were lowest for NAT-Resolve vs RDT-based strategies (FN: 409 vs 413-429; FP: 14 vs 21-28). Strategies had similar life expectancy (228 months) and lifetime costs ($220/person) among all tested; ICERs were $3450/YLS (RDT-CI vs RDT-WHO) and $120 910/YLS (NAT-Resolve vs RDT-CI). In the low-performing scenario, misdiagnoses were higher (FN: 22 845-30 357; FP: 83 724-112 702) and NAT-Resolve was cost-saving. CONCLUSIONS We projected substantial clinical and economic impacts of misdiagnoses. Using POC NAT to resolve RDT discordancy generated the fewest misdiagnoses and was not cost-effective in high-performing scenarios, but may be an important adjunct to existing RDT-based strategies in low-performing scenarios.
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Affiliation(s)
- Anne M Neilan
- Division of General Academic Pediatrics, Department of Pediatrics, Massachusetts General Hospital for Children, Boston, Massachusetts, USA
- Medical Practice Evaluation Center, Massachusetts General Hospital, Boston, Massachusetts, USA
- Division of Infectious Diseases, Massachusetts General Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
| | - Jennifer Cohn
- Elizabeth Glaser Pediatric AIDS Foundation, Geneva, Switzerland
| | - Emma Sacks
- Elizabeth Glaser Pediatric AIDS Foundation, Geneva, Switzerland
- Johns Hopkins School of Public Health, Baltimore, Maryland, USA
| | - Aditya R Gandhi
- Medical Practice Evaluation Center, Massachusetts General Hospital, Boston, Massachusetts, USA
| | | | - Rochelle P Walensky
- Medical Practice Evaluation Center, Massachusetts General Hospital, Boston, Massachusetts, USA
- Division of Infectious Diseases, Massachusetts General Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
| | - Marc N Kouadio
- Elizabeth Glaser Pediatric AIDS Foundation, Abidjan, Côte d’Ivoire
| | - Kenneth A Freedberg
- Medical Practice Evaluation Center, Massachusetts General Hospital, Boston, Massachusetts, USA
- Division of Infectious Diseases, Massachusetts General Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
- Division of General Internal Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Andrea L Ciaranello
- Medical Practice Evaluation Center, Massachusetts General Hospital, Boston, Massachusetts, USA
- Division of Infectious Diseases, Massachusetts General Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
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16
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Mageras A, Brazier E, Niyongabo T, Murenzi G, D'Amour Sinayobye J, Adedimeji AA, Twizere C, Kelvin EA, Anastos K, Nash D, Jones HE. Comparison of cohort characteristics in Central Africa International Epidemiology Databases to Evaluate AIDS and Demographic Health Surveys: Rwanda and Burundi. Int J STD AIDS 2021; 32:551-561. [PMID: 33530894 DOI: 10.1177/0956462420983783] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
Clinical health record data are used for HIV surveillance, but the extent to which these data are population representative is not clear. We compared age, marital status, body mass index, and pregnancy distributions in the Central Africa International Databases to Evaluate AIDS (CA-IeDEA) cohorts in Burundi and Rwanda to all people living with HIV and the subpopulation reporting receiving a previous HIV test result in the Demographic and Health Survey (DHS) data, restricted to urban areas, where CA-IeDEA sites are located. DHS uses a probabilistic sample for population-level HIV prevalence estimates. In Rwanda, the CA-IeDEA cohort and DHS populations were similar with respect to age and marital status for men and women, which was also true in Burundi among women. In Burundi, the CA-IeDEA cohort had a greater proportion of younger and single men than the DHS data, which may be a result of outreach to sexual minority populations at CA-IeDEA sites and economic migration patterns. In both countries, the CA-IeDEA cohorts had a higher proportion of underweight individuals, suggesting that symptomatic individuals are more likely to access care in these settings. Multiple sources of data are needed for HIV surveillance to interpret potential biases in epidemiological data.
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Affiliation(s)
- Anna Mageras
- Department of Epidemiology & Biostatistics, 436523City University of New York (CUNY) School of Public Health, New York, NY, USA
| | - Ellen Brazier
- Department of Epidemiology & Biostatistics, 436523City University of New York (CUNY) School of Public Health, New York, NY, USA.,Institute for Implementation Science in Population Health, 2009City University of New York, New York, NY, USA
| | - Théodore Niyongabo
- Centre Hospitalo-Universitaire de Kamenge, Bujumbura, Burundi.,Centre National de Référence en Matière de VIH/SIDA au Burundi, Bujumbura, Burundi
| | - Gad Murenzi
- Clinical Education and Research Division, 390454Rwanda Military Hospital, Kigali, Rwanda
| | - Jean D'Amour Sinayobye
- Clinical Education and Research Division, 390454Rwanda Military Hospital, Kigali, Rwanda
| | - Adebola A Adedimeji
- Department of Epidemiology & Population Health, 2013Albert Einstein College of Medicine and Montefiore Medical Center, Bronx, NY, USA
| | - Christella Twizere
- Centre National de Référence en Matière de VIH/SIDA au Burundi, Bujumbura, Burundi
| | - Elizabeth A Kelvin
- Department of Epidemiology & Biostatistics, 436523City University of New York (CUNY) School of Public Health, New York, NY, USA.,Institute for Implementation Science in Population Health, 2009City University of New York, New York, NY, USA
| | - Kathryn Anastos
- Departments of Medicine and Epidemiology & Population Health, 2013Montefiore Medical Center/Albert Einstein College of Medicine, Bronx, NY, USA
| | - Denis Nash
- Department of Epidemiology & Biostatistics, 436523City University of New York (CUNY) School of Public Health, New York, NY, USA.,Institute for Implementation Science in Population Health, 2009City University of New York, New York, NY, USA
| | - Heidi E Jones
- Department of Epidemiology & Biostatistics, 436523City University of New York (CUNY) School of Public Health, New York, NY, USA.,Institute for Implementation Science in Population Health, 2009City University of New York, New York, NY, USA
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Ochola J, Imbach M, Eller LA, de Souza M, Nwoga C, Otieno JD, Otieno L, Rono E, Kamau E, Crowell TA, Owuoth JK, Polyak CS, Sing'oei V. False reactive HIV-1 diagnostic test results in an individual from Kenya on multiple testing platforms-A case report. IDCases 2021; 23:e01035. [PMID: 33489756 PMCID: PMC7808907 DOI: 10.1016/j.idcr.2020.e01035] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2020] [Revised: 12/21/2020] [Accepted: 12/21/2020] [Indexed: 11/29/2022] Open
Abstract
Background Rapid diagnostic tests (RDT) are routinely used in screening for HIV infection. More complex diagnostic algorithms incorporating fourth-generation screening and confirmatory HIV-1/HIV-2 differentiation immunoassays (IA) may be used to confirm HIV infection. Co-infections and autoimmune diseases may lead to falsely reactive HIV diagnostic test results. Case presentation A Kenyan man with asymptomatic schistosomiasis and low risk factors for HIV infection demonstrated an inconsistent and discordant pattern of reactivity on HIV RDT, repeated reactivity on fourth-generation IA and positive at a single time-point for HIV-1 on the Geenius HIV1/HIV2 confirmatory assay during the course of a prospective cohort study with HIV repeat testing. The individual initiated antiretroviral therapy following HIV diagnosis. However, his bi-annual behavioral questionnaire suggested low-risk factors for infection. Supplementary confirmatory serologic and nucleic acid tests were performed and gave discordant results. The participant was determined to be HIV uninfected using cell-associated HIV-1 DNA/RNA testing and antiretroviral therapy was discontinued. Discussion and conclusions Sole reliance on diagnostic test results may result in misdiagnosis of HIV infection, social harm and potential antiretroviral induced drug toxicity. Interpretation of HIV test results should incorporate multiple parameters.
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Affiliation(s)
- Jew Ochola
- HJF Medical Research International, Kisumu, Kenya.,U.S. Army Medical Research Directorate - Africa, Kisumu, Kenya
| | - Michelle Imbach
- U.S. Military HIV Research Program, Walter Reed Army Institute of Research, Silver Spring, MD, USA.,Henry M. Jackson Foundation for the Advancement of Military Medicine, Bethesda, MD, USA
| | - Leigh Anne Eller
- U.S. Military HIV Research Program, Walter Reed Army Institute of Research, Silver Spring, MD, USA.,Henry M. Jackson Foundation for the Advancement of Military Medicine, Bethesda, MD, USA
| | - Mark de Souza
- U.S. Military HIV Research Program, Walter Reed Army Institute of Research, Silver Spring, MD, USA.,Henry M. Jackson Foundation for the Advancement of Military Medicine, Bethesda, MD, USA
| | - Chiaka Nwoga
- U.S. Military HIV Research Program, Walter Reed Army Institute of Research, Silver Spring, MD, USA.,Henry M. Jackson Foundation for the Advancement of Military Medicine, Bethesda, MD, USA
| | - June Doryne Otieno
- U.S. Army Medical Research Directorate - Africa, Kisumu, Kenya.,Kenya Medical Research Institute, Kisumu, Kenya
| | - Lucas Otieno
- U.S. Army Medical Research Directorate - Africa, Kisumu, Kenya.,Kenya Medical Research Institute, Kisumu, Kenya
| | - Eric Rono
- U.S. Army Medical Research Directorate - Africa, Kisumu, Kenya.,Kenya Medical Research Institute, Kisumu, Kenya
| | - Edwin Kamau
- U.S. Military HIV Research Program, Walter Reed Army Institute of Research, Silver Spring, MD, USA
| | - Trevor A Crowell
- U.S. Military HIV Research Program, Walter Reed Army Institute of Research, Silver Spring, MD, USA.,Henry M. Jackson Foundation for the Advancement of Military Medicine, Bethesda, MD, USA
| | - John Kevin Owuoth
- HJF Medical Research International, Kisumu, Kenya.,U.S. Army Medical Research Directorate - Africa, Kisumu, Kenya
| | - Christina S Polyak
- U.S. Military HIV Research Program, Walter Reed Army Institute of Research, Silver Spring, MD, USA.,Henry M. Jackson Foundation for the Advancement of Military Medicine, Bethesda, MD, USA
| | - Valentine Sing'oei
- HJF Medical Research International, Kisumu, Kenya.,U.S. Army Medical Research Directorate - Africa, Kisumu, Kenya
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The use of dried tube specimens of Plasmodium falciparum in an external quality assessment programme to evaluate health worker performance for malaria rapid diagnostic testing in healthcare centres in Togo. Malar J 2021; 20:50. [PMID: 33472640 PMCID: PMC7819240 DOI: 10.1186/s12936-020-03569-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2020] [Accepted: 12/24/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The use of rapid diagnostic tests (RDTs) to diagnose malaria is common in sub-Saharan African laboratories, remote primary health facilities and in the community. Currently, there is a lack of reliable methods to ascertain health worker competency to accurately use RDTs in the testing and diagnosis of malaria. Dried tube specimens (DTS) have been shown to be a consistent and useful method for quality control of malaria RDTs; however, its application in National Quality Management programmes has been limited. METHODS A Plasmodium falciparum strain was grown in culture and harvested to create DTS of varying parasite density (0, 100, 200, 500 and 1000 parasites/µL). Using the dried tube specimens as quality control material, a proficiency testing (PT) programme was carried out in 80 representative health centres in Togo. Health worker competency for performing malaria RDTs was assessed using five blinded DTS samples, and the DTS were tested in the same manner as a patient sample would be tested by multiple testers per health centre. RESULTS All the DTS with 100 parasites/µl and 50% of DTS with 200 parasites/µl were classified as non-reactive during the pre-PT quality control step. Therefore, data from these parasite densities were not analysed as part of the PT dataset. PT scores across all 80 facilities and 235 testers was 100% for 0 parasites/µl, 63% for 500 parasites/µl and 93% for 1000 parasites/µl. Overall, 59% of the 80 healthcare centres that participated in the PT programme received a score of 80% or higher on a set of 0, 500 and 1000 parasites/ µl DTS samples. Sixty percent of health workers at these centres recorded correct test results for all three samples. CONCLUSIONS The use of DTS for a malaria PT programme was the first of its kind ever conducted in Togo. The ease of use and stability of the DTS illustrates that this type of samples can be considered for the assessment of staff competency. The implementation of quality management systems, refresher training and expanded PT at remote testing facilities are essential elements to improve the quality of malaria diagnosis.
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Armstrong-Mensah E, Tetteh AK, Choi S. Utilization of Rapid Diagnostic Testing in sub-Saharan Africa: Challenges and Effects on HIV Prevention. Int J MCH AIDS 2021; 10:1-6. [PMID: 33442487 PMCID: PMC7792746 DOI: 10.21106/ijma.423] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
Abstract
The human immunodeficiency virus (HIV) remains a global threat to health. To prevent and control the disease caused by the virus, developed and developing countries continue to invest heavily in research and equipment so as to accurately detect the virus. The utilization of highly sensitive and effective rapid diagnostic tests (RDTs) have the potential to detect HIV in high-burden countries, especially those in sub-Saharan Africa (SSA). Yet, in SSA, challenges associated with HIV-RDT result inaccuracy, HIV misdiagnosis, poor tester capacity, and the improper storage of HIV-RDT kits have negatively impacted the benefits, and threaten to undermine HIV prevention. This paper focuses on the utilization of RDTs in HIV diagnosis in SSA, HIV-RDT challenges, and the effects of HIV-RDT challenges on HIV prevention. Subsequent to reviewing available literature, the authors found that although HIV-RDTs can negatively impact HIV-prevention efforts in SSA due to the likelihood of false positive HIV diagnoses, they generally provide quick results for people in resource poor settings, and do not require them to return to the testing sites to obtain their results. Obtaining accurate rapid HIV results means people who test positive can immediately seek care and take steps to prevent future transmission of the virus.
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Affiliation(s)
| | - Ato Kwamena Tetteh
- School of Public Health, Georgia State University, Atlanta, Georgia 30303, USA
| | - Seung Choi
- School of Public Health, Georgia State University, Atlanta, Georgia 30303, USA
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Dupwa B, Kumar AMV, Tripathy JP, Mugurungi O, Takarinda KC, Dzangare J, Bara H, Mukeredzi I. Retesting for verification of HIV diagnosis before antiretroviral therapy initiation in Harare, Zimbabwe: Is there a gap between policy and practice? Trans R Soc Trop Med Hyg 2020; 113:610-616. [PMID: 31225614 DOI: 10.1093/trstmh/trz047] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2019] [Revised: 02/28/2019] [Accepted: 06/10/2019] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND WHO recommends retesting of HIV-positive patients before starting antiretroviral therapy (ART). There is no evidence on implementation of retesting guidelines from programmatic settings. We aimed to assess implementation of HIV retesting among clients diagnosed HIV-positive in the public health facilities of Harare, Zimbabwe, in June 2017. METHODS This cohort study involved analysis of secondary data collected routinely by the programme. RESULTS Of 1729 study participants, 639 (37%) were retested. Misdiagnosis of HIV was found in six (1%) of the patients retested-all were infants retested with DNA-PCR. There was no HIV misdiagnosis among adults. Among those retested, 95% were retested on the same day and two-thirds were tested by a different provider as per national guidelines. Among those retested and found positive, 95% were started on ART, while none of those with negative retest results were started on ART. Of those not retested, about half (51%) were started on ART. The median (IQR) time to ART initiation from diagnosis was 0 (0-1) d. CONCLUSION The implementation of HIV-retesting policy in Harare was poor. While most HIV retest positives were started on ART, only half non-retested received ART. Future research is needed to understand the reasons for non-retesting and non-initiation of ART among those not retested.
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Affiliation(s)
- Beatrice Dupwa
- Ministry of Health and Child Care (AIDS and TB programme), Zimbabwe
| | - Ajay M V Kumar
- International Union against Tuberculosis and Lung Disease, Paris, France.,The Union South-East Asia Office, International Union against Tuberculosis and Lung Disease, New Delhi, India
| | - Jaya Prasad Tripathy
- International Union against Tuberculosis and Lung Disease, Paris, France.,The Union South-East Asia Office, International Union against Tuberculosis and Lung Disease, New Delhi, India
| | - Owen Mugurungi
- Ministry of Health and Child Care (AIDS and TB programme), Zimbabwe
| | | | - Janet Dzangare
- Ministry of Health and Child Care (AIDS and TB programme), Zimbabwe
| | - Hilda Bara
- Harare City Health Department, Harare, Zimbabwe
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Skovdal M, Beckmann N, Maswera R, Nyamukapa C, Gregson S. Uncertainties, work conditions and testing biases: Potential pathways to misdiagnosis in point-of-care rapid HIV testing in Zimbabwe. PLoS One 2020; 15:e0237239. [PMID: 32790692 PMCID: PMC7425930 DOI: 10.1371/journal.pone.0237239] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2020] [Accepted: 07/22/2020] [Indexed: 01/26/2023] Open
Abstract
Disconcerting levels of misdiagnosis are common in point-of-care rapid HIV testing programmes in sub-Saharan Africa. To investigate potential pathways to misdiagnosis, we interviewed 28 HIV testers in Zimbabwe and conducted weeklong observations at four testing facilities. Approaching adherence to national HIV testing algorithms as a social and scripted practice, dependent on the integration of certain competences, materials and meanings, our thematic analysis revealed three underlying causes of misdiagnosis: One, a lack of confidence in using certain test-kits, coupled with changes in testing algorithms and inadequate training, fed uncertainties with some testing practices. Two, difficult work conditions, including high workloads and resource-depleted facilities, compounded these uncertainties, and meant testers got distracted or resorted to testing short-cuts. Three, power struggles between HIV testers, and specific client-tester encounters created social interactions that challenged the testing process. We conclude that these contexts contribute to deviances from official and recommended testing procedures, as well as testing and interpretation biases, which may explain cases of misdiagnoses. We caution against user-error explanations to misdiagnosis in the absence of a broader recognition of how broader structural determinants affect HIV testing practices.
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Affiliation(s)
- Morten Skovdal
- Department of Public Health, University of Copenhagen, Copenhagen, Denmark
| | - Nadine Beckmann
- Centre for Research in Evolutionary, Social and Inter-Disciplinary Anthropology, University of Roehampton, London, United Kingdom
| | - Rufurwokuda Maswera
- Manicaland Centre for Public Health Research, Biomedical Research and Training Institute, Harare, Zimbabwe
| | - Constance Nyamukapa
- Manicaland Centre for Public Health Research, Biomedical Research and Training Institute, Harare, Zimbabwe
- Department of Infectious Disease Epidemiology, Imperial College London, London, United Kingdom
| | - Simon Gregson
- Manicaland Centre for Public Health Research, Biomedical Research and Training Institute, Harare, Zimbabwe
- Department of Infectious Disease Epidemiology, Imperial College London, London, United Kingdom
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Use of an Indeterminate Range in HIV Early Infant Diagnosis: A Systematic Review and Meta-Analysis. J Acquir Immune Defic Syndr 2020; 82:281-286. [PMID: 31609927 DOI: 10.1097/qai.0000000000002104] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
BACKGROUND Expanded access to HIV antiretrovirals has dramatically reduced mother-to-child transmission of HIV. However, there is increasing concern around false-positive HIV test results in perinatally HIV-exposed infants but few insights into the use of indeterminate range to improve infant HIV diagnosis. METHODS A systematic review and meta-analysis was conducted to evaluate the use of an indeterminate range for HIV early infant diagnosis. Published and unpublished studies from 2000 to 2018 were included. Study quality was evaluated using GRADE and QUADAS-2 criteria. A random-effects model compared various indeterminate ranges for identifying true and false positives. RESULTS The review identified 32 studies with data from over 1.3 million infants across 14 countries published from 2000 to 2018. Indeterminate results accounted for 16.5% of initial non-negative test results, and 76% of indeterminate results were negative on repeat testing. Most results were from Roche tests. In the random-effects model, an indeterminate range using a polymerase chain reaction cycle threshold value of ≥33 captured over 93% of false positives while classifying fewer than 9% of true positives as indeterminate. CONCLUSIONS Without the use of an indeterminate range, over 10% of infants could be incorrectly diagnosed as HIV positive if their initial test results are not confirmed. Use of an indeterminate range appears to lead to substantial improvements in the accuracy of early infant diagnosis testing and supports current recommendations to confirm all initial positive tests.
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Clinical Consequences of Using an Indeterminate Range for Early Infant Diagnosis of HIV: A Decision Model. J Acquir Immune Defic Syndr 2020; 82:287-296. [PMID: 31609928 DOI: 10.1097/qai.0000000000002155] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND To minimize false-positive diagnoses of HIV in exposed infants, the World Health Organization recommends confirmatory testing for all infants initiating antiretroviral therapy (ART). In settings where confirmatory testing is not feasible or intermittently performed, clinical decisions may be aided by semi-quantitative cycle thresholds (Cts) that identify positive results most likely to be false-positive. METHODS We developed a decision analysis model of HIV-exposed infants in sub-Saharan Africa to estimate the clinical consequences of deferring ART for infants with weakly positive ("indeterminate") results. We assessed the degree to which "indeterminate" results may reduce the number of infants starting ART unnecessarily while missing a small number of HIV-infected infants. Our primary outcome was the ratio of averted unnecessary ART regimens to additional HIV-related deaths (due to false-negative diagnosis) at different Ct cutoffs. RESULTS The clinical consequences of adopting an indeterminate range varied with the prevalence of HIV and Ct cutoff. Considering a Ct cutoff ≥33, adopting an indeterminate range could prevent a median of 1.4 infants from receiving ART unnecessarily (95% UR: 1.0-2.0) for each additional HIV-related death. This ratio could be improved by prioritizing infants with indeterminate results for confirmatory testing [median 8.8 (95% UR: 6.0-13.3)] and by adopting a higher cutoff [median 82.3 (95% UR: 49.0-155.8) with Ct ≥36]. CONCLUSIONS When implemented in settings where confirmatory testing is not universal, the benefits of classifying weakly positive results as "indeterminate" may outweigh the risks. Accordingly, the World Health Organization has recommended Ct values ≥33 be considered indeterminate for infant HIV diagnosis.
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Repeated false reactive ADVIA centaur® and bio-rad Geenius™ HIV tests in a patient self-administering anabolic steroids. BMC Infect Dis 2020; 20:9. [PMID: 31906866 PMCID: PMC6945705 DOI: 10.1186/s12879-019-4722-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2019] [Accepted: 12/22/2019] [Indexed: 11/25/2022] Open
Abstract
Background An individual is considered HIV positive when a confirmatory HIV-1/HIV-2 differentiation test returns positive following an initial reactive antigen/antibody combination screen. Falsely reactive HIV screens have been reported in patients with various concomitant infectious and autoimmune conditions. Falsely positive confirmatory HIV differentiation assays are seen less frequently, but have been observed in cases of pregnancy, pulmonary embolism, and malaria. Case presentation A healthy 27 year-old man was referred after a reactive ADVIA Centaur® HIV Ag/Ab screen and positive Bio-Rad Geenius™ HIV 1/2 Confirmatory assay, suggesting HIV-1 infection. The patient’s HIV viral load was undetectable prior to initiation of antiretroviral therapy, and remained undetectable on subsequent testing after initiation of antiretroviral therapy. Both Centaur® and Geenius™ tests were repeated and returned reactive. As this patient was believed to be at low risk of acquiring HIV infection, samples were additionally run on Genscreen™ HIV-1 Ag assay and Fujirebio Inno-LIA™ HIV-1/2 score, with both returning non-reactive. For confirmation, the patient’s proviral HIV DNA testing was negative, confirming the initial results as being falsely positive. The patient disclosed that he had been using a variety of anabolic steroids before and during the time of HIV testing. Discussion and conclusions The erroneous diagnosis of HIV can result in decreased quality of life and adverse effects of antiretroviral therapy if initiated, hence the importance of interpreting the results of HIV testing in the context of an individual patient. This reports suggests a potential association between the use of anabolic steroids and falsely-reactive HIV testing.
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Woldesenbet SA, Kalou M, Mhlongo D, Kufa T, Makhanya M, Adelekan A, Diallo K, Maleka M, Singh B, Parekh B, Mohlala A, Manyike PT, Tucker TJ, Puren AJ. An overview of the quality assurance programme for HIV rapid testing in South Africa: Outcome of a 2-year phased implementation of quality assurance program. PLoS One 2019; 14:e0221906. [PMID: 31557176 PMCID: PMC6762059 DOI: 10.1371/journal.pone.0221906] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2019] [Accepted: 08/16/2019] [Indexed: 11/22/2022] Open
Abstract
Objective This is the first large-scale assessment of the implementation of HIV Rapid Test Quality Improvement Initiative in South Africa. Methods We used a quasi-experimental one group post-test only design. The intervention implemented starting April 2014 comprised health-care worker training on quality assurance (QA) of HIV rapid testing and enrolment of the facilities in proficiency testing (PT), targeting 2,077 healthcare facilities in 32 high HIV burden districts. Following the intervention, two consecutive rounds of site assessments were undertaken. The first, conducted after a median of 7.5 months following the training, included 1,915 facilities that participated in the QA training, while the second, conducted after a median of one-year following the first-round assessment included 517 (27.0%) of the 1,915 facilities. In both assessments, the Stepwise-Process-for-Improving-the-quality-of-HIV-Rapid-Testing (SPI-RT) checklist was used to score facilities’ performance in 7 domains: training, physical facility, safety, pre-testing, testing, post-testing and external quality assessment. Facilities’ level of readiness for national certification was assessed. Result Between 2016 and 2017, there were four PT cycles. PT participation increased from 32.4% (620/1,915) in 2016 to 91.5% (1,753/1,915) in 2017. In each PT cycle, PT results were returned by 76%–87% of facilities and a satisfactory result (>80%) was achieved by ≥95% of facilities. In the SPI-RT assessment, in round-one, 22.3% of facilities were close to or eligible for national certification—this significantly increased to 38.8% in round-two (P-value<0.001). The median SPI-RT score for the domains HIV pre-testing (83.3%) and post-testing (72.2%) remained the same between the two rounds. The median score for the testing domain increased by 5.6% (to 77.8%). Conclusion Facilities performance on the domains that are critical for accuracy of diagnosis (i.e. pre-testing, testing and post-testing) remained largely unchanged. This study provided several recommendations to improve QA implementation in South Africa, including the need to improve routine use of internal quality control for corrective actions.
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Affiliation(s)
- Selamawit Alemu Woldesenbet
- Center for HIV and STI, National Institute for Communicable Diseases, Johannesburg, South Africa
- School of Public Health, University of the Witwatersrand, Johannesburg, South Africa
- * E-mail:
| | - Mireille Kalou
- International Laboratory Branch, Division of Global HIV and Tuberculosis, Center for Global Health, Centers for Disease Control and Prevention, Atlanta, Georgia, United States of America
| | - Dumisani Mhlongo
- National Clinic Laboratory Interface programme, National Health Laboratory Service, Johannesburg, South Africa
| | - Tendesayi Kufa
- Center for HIV and STI, National Institute for Communicable Diseases, Johannesburg, South Africa
- School of Public Health, University of the Witwatersrand, Johannesburg, South Africa
| | - Makhosazana Makhanya
- Laboratory Branch, Centers for Disease Control and Prevention South Africa, Pretoria, South Africa
| | - Adeboye Adelekan
- Laboratory Branch, Centers for Disease Control and Prevention South Africa, Pretoria, South Africa
| | - Karidia Diallo
- Laboratory Branch, Centers for Disease Control and Prevention South Africa, Pretoria, South Africa
| | - Mahlatse Maleka
- Academic Affairs, Research and Quality Assurance National Health Laboratory Service, Johannesburg, South Africa
| | - Beverley Singh
- Center for HIV and STI, National Institute for Communicable Diseases, Johannesburg, South Africa
| | - Bharat Parekh
- International Laboratory Branch, Division of Global HIV and Tuberculosis, Center for Global Health, Centers for Disease Control and Prevention, Atlanta, Georgia, United States of America
| | - Amanda Mohlala
- Strategic Evaluation, Advisory and Development (SEAD) Consulting, Cape Town, South Africa
| | - Peter T. Manyike
- Strategic Evaluation, Advisory and Development (SEAD) Consulting, Cape Town, South Africa
| | - Tim J. Tucker
- Strategic Evaluation, Advisory and Development (SEAD) Consulting, Cape Town, South Africa
- School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Adrian J. Puren
- Center for HIV and STI, National Institute for Communicable Diseases, Johannesburg, South Africa
- Virology Department, University of the Witwatersrand, Johannesburg, South Africa
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Cost implications of HIV retesting for verification in Africa. PLoS One 2019; 14:e0218936. [PMID: 31260467 PMCID: PMC6602186 DOI: 10.1371/journal.pone.0218936] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2017] [Accepted: 06/12/2019] [Indexed: 01/06/2023] Open
Abstract
INTRODUCTION HIV misdiagnosis leads to severe individual and public health consequences. Retesting for verification of all HIV-positive cases prior to antiretroviral therapy initiation can reduce HIV misdiagnosis, yet this practice has not been not widely implemented. METHODS We evaluated and compared the cost of retesting for verification of HIV seropositivity (retesting) to the cost of antiretroviral treatment (ART) for misdiagnosed cases in the absence of retesting (no retesting), from the perspective of the health care system. We estimated the number of misdiagnosed cases based on a review of misdiagnosis rates, and the number of positives persons needing ART initiation by 2020. We presented the total and per person costs of retesting as compared to no retesting, over a ten-year horizon, across 50 countries in Africa grouped by income level. We conducted univariate sensitivity analysis on all model input parameters, and threshold analysis to evaluate the parameter values where the total costs of retesting and the costs no retesting are equivalent. Cost data were adjusted to 2017 United States Dollars. RESULTS AND DISCUSSION The estimated number of misdiagnoses, in the absence of retesting was 156,117, 52,720 and 29,884 for lower-income countries (LICs), lower-middle income countries (LMICs), and upper middle-income countries (UMICs), respectively, totaling 240,463 for Africa. Under the retesting scenario, costs per person initially diagnosed were: $40, $21, and $42, for LICs, LMICs, and UMICs, respectively. When retesting for verification is implemented, the savings in unnecessary ART were $125, $43, and $75 per person initially diagnosed, for LICs, LMICs, and UMICs, respectively. Over the ten-year horizon, the total costs under the retesting scenario, over all country income levels, was $475 million, and was $1.192 billion under the no retesting scenario, representing total estimated savings of $717 million in HIV treatment costs averted. CONCLUSIONS Results show that to reduce HIV misdiagnosis, countries in Africa should implement the WHO's recommendation of retesting for verification prior to ART initiation, as part of a comprehensive quality assurance program for HIV testing services.
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Simwinga M, Kumwenda MK, Dacombe RJ, Kayira L, Muzumara A, Johnson CC, Indravudh P, Sibanda EL, Nyirenda L, Hatzold K, Corbett EL, Ayles H, Taegtmeyer M. Ability to understand and correctly follow HIV self-test kit instructions for use: applying the cognitive interview technique in Malawi and Zambia. J Int AIDS Soc 2019; 22 Suppl 1:e25253. [PMID: 30907496 PMCID: PMC6432102 DOI: 10.1002/jia2.25253] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2018] [Accepted: 01/18/2019] [Indexed: 12/02/2022] Open
Abstract
INTRODUCTION The ability to achieve an accurate test result and interpret it correctly is critical to the impact and effectiveness of HIV self-testing (HIVST). Simple and easy-to-use devices, instructions for use (IFU) and other support tools have been shown to be key to good performance in sub-Saharan Africa and may be highly contextual. The objective of this study was to explore the utility of cognitive interviewing in optimizing the local understanding of manufacturers' IFUs to achieve an accurate HIVST result. METHODS Functionally literate and antiretroviral therapy-naive participants were purposefully selected between May 2016 and June 2017 to represent intended users of HIV self-tests from urban and rural areas in Malawi and Zambia. Participants were asked to follow IFUs for HIVST. We then conducted cognitive interviews and observed participants while they attempted to complete the HIVST steps using a structured guide, which mirrored the steps in the IFU. Qualitative data were analysed using a thematic approach. RESULTS Of a total of 61 participants, many successfully performed most steps in the IFU. Some had difficulties in understanding these and made errors, which could have led to incorrect test results, such as incorrect use of buffer and reading the results prematurely. Participants with lower levels of literacy and inexperience with standard pictorial images were more likely to struggle with IFUs. Difficulties tended to be more pronounced among those in rural settings. Ambiguous terms and translations in the IFU, unfamiliar images and symbols, and unclear order of the steps to be followed were most commonly linked to errors and lower comprehension among participants. Feedback was provided to the manufacturer on the findings, which resulted in further optimization of IFUs. CONCLUSIONS Cognitive interviewing identifies local difficulties in conducting HIVST from manufacturer-translated IFUs. It is a useful and practical methodology to optimize IFUs and make them more understandable.
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Affiliation(s)
| | - Moses K Kumwenda
- Malawi Liverpool Wellcome Trust Clinical Research ProgrammeBlantyreMalawi
| | - Russell J Dacombe
- Department of International Public HealthLiverpool School of Tropical MedicineLiverpoolUK
| | - Lusungu Kayira
- Malawi Liverpool Wellcome Trust Clinical Research ProgrammeBlantyreMalawi
| | | | - Cheryl C Johnson
- HIV and Global Hepatitis DepartmentWorld Health OrganizationGenevaSwitzerland
- Clinical Research DepartmentFaculty of Infectious and Tropical DiseasesLondon School of Hygiene and Tropical MedicineLondonUK
| | - Pitchaya Indravudh
- Malawi Liverpool Wellcome Trust Clinical Research ProgrammeBlantyreMalawi
| | | | - Lot Nyirenda
- Department of International Public HealthLiverpool School of Tropical MedicineLiverpoolUK
| | - Karin Hatzold
- Population Services InternationalJohannesburgSouth Africa
| | - Elizabeth L Corbett
- Malawi Liverpool Wellcome Trust Clinical Research ProgrammeBlantyreMalawi
- Clinical Research DepartmentFaculty of Infectious and Tropical DiseasesLondon School of Hygiene and Tropical MedicineLondonUK
| | - Helen Ayles
- ZambartLusakaZambia
- Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical MedicineLondonUK
| | - Miriam Taegtmeyer
- Department of International Public HealthLiverpool School of Tropical MedicineLiverpoolUK
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Jean Louis F, Excellent ML, Anselme R, Buteau J, Stanislas M, Boncy J, Domercant JW. External quality assessment for HIV rapid tests: challenges and opportunities in Haiti. BMJ Glob Health 2018; 3:e001074. [PMID: 30498590 PMCID: PMC6254742 DOI: 10.1136/bmjgh-2018-001074] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2018] [Revised: 09/28/2018] [Accepted: 10/01/2018] [Indexed: 12/02/2022] Open
Abstract
HIV rapid diagnostic tests (RDTs) are instrumental in scaling-up HIV testing services (HTS) in low-income and middle-income countries (LMICs). HIV misdiagnosis is a growing concern in the era of expanded and decentralised access to HTS. External quality assurance (EQA) programme including proficiency testing (PT) for HIV RDTs is a priority to guarantee the accuracy and reliability of the patients’ result. Here we are sharing Haiti’s 11 years’ experience in implementing HIV RDTs EQA programme to help address some of the challenges faced by other LMICs. HTS is expanding beyond laboratory walls and HIV RDTs are increasingly performed by non-laboratory personnel and closer to the community. EQA programmes for HIV RDTs in Haiti have faced significant challenges. In expanded HTS settings, non-laboratory personnel (nurses, aid-nurses) involved in HIV RDT are usually undertrained and participate poorly in PT programs. In more than half of the lab enrolled in the PT programme in Haiti, the panels are always tested by the most experienced technician, defying the purpose of the program which is to evaluate the performance of the technician performing the test daily. EQA programme in Haiti and other LMICs are usually not tailored to address community HIV testing challenges. With decreased funding and absence of government financial commitment to HIV RDTs EQA programmes, more innovative and cost-efficient strategies are sought to ensure the quality of HIV diagnosis in LMICs. Qualified human resources, continuous training, supervision and community-tailored PT programmes remain key components for the success of HIV RDT quality management.
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Affiliation(s)
| | | | - Renette Anselme
- National Public Health Laboratory, Ministry of Public Health and population of Haiti, Port-au-Prince, Haiti
| | - Josiane Buteau
- National Public Health Laboratory, Ministry of Public Health and population of Haiti, Port-au-Prince, Haiti
| | - Magalie Stanislas
- National Public Health Laboratory, Ministry of Public Health and population of Haiti, Port-au-Prince, Haiti
| | - Jacques Boncy
- National Public Health Laboratory, Ministry of Public Health and population of Haiti, Port-au-Prince, Haiti
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Abstract
HIV diagnostics have played a central role in the remarkable progress in identifying, staging, initiating, and monitoring infected individuals on life-saving antiretroviral therapy. They are also useful in surveillance and outbreak responses, allowing for assessment of disease burden and identification of vulnerable populations and transmission "hot spots," thus enabling planning, appropriate interventions, and allocation of appropriate funding. HIV diagnostics are critical in achieving epidemic control and require a hybrid of conventional laboratory-based diagnostic tests and new technologies, including point-of-care (POC) testing, to expand coverage, increase access, and positively impact patient management. In this review, we provide (i) a historical perspective on the evolution of HIV diagnostics (serologic and molecular) and their interplay with WHO normative guidelines, (ii) a description of the role of conventional and POC testing within the tiered laboratory diagnostic network, (iii) information on the evaluations and selection of appropriate diagnostics, (iv) a description of the quality management systems needed to ensure reliability of testing, and (v) strategies to increase access while reducing the time to return results to patients. Maintaining the central role of HIV diagnostics in programs requires periodic monitoring and optimization with quality assurance in order to inform adjustments or alignment to achieve epidemic control.
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Rufu A, Chitimbire VTS, Nzou C, Timire C, Owiti P, Harries AD, Apollo T. Implementation of the 'Test and Treat' policy for newly diagnosed people living with HIV in Zimbabwe in 2017. Public Health Action 2018; 8:145-150. [PMID: 30271732 DOI: 10.5588/pha.18.0030] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2018] [Accepted: 07/24/2018] [Indexed: 11/10/2022] Open
Abstract
Setting: Sixteen mission hospitals in Zimbabwe that are implementing the 'Test and Treat' programme for people living with the human immunodeficiency virus (HIV). Objectives: To assess linkages of HIV diagnosis to care and treatment, time taken from being diagnosed with HIV infection to initiation of antiretroviral therapy (ART) and 3-month programmatic outcomes for those starting ART. Design: Cross-sectional study using secondary data. Results: Among 972 people newly diagnosed with HIV, 915 (94%) enrolled for HIV care and 771 (79%) were initiated on ART. Enrolment in care and initiation on ART on the same day as testing occurred in respectively 864 (89%) and 628 (65%) newly diagnosed patients. Over 80% of those who underwent HIV testing in maternal and child health departments initiated ART on the same day. Of the 144 (16%) people in care who were not initiated on ART, the principal reason in 102 (71%) was being transferred out. Most patients (90%) on ART were retained in care at 3 months, with transfer out accounting for most of the remainder. Conclusion: The 'Test and Treat' approach was feasible and successful in getting newly HIV-infected people initiated early on ART. More research is needed to better understand the processes, benefits and potential risks.
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Affiliation(s)
- A Rufu
- Zimbabwe Association of Church-Related Hospitals, Harare, Zimbabwe
| | - V T S Chitimbire
- Zimbabwe Association of Church-Related Hospitals, Harare, Zimbabwe
| | - C Nzou
- Zimbabwe Association of Church-Related Hospitals, Harare, Zimbabwe
| | - C Timire
- International Union Against Tuberculosis and Lung Disease (The Union), Harare, Zimbabwe.,National TB Control Programme, Ministry of Health and Child Care Zimbabwe, Harare, Zimbabwe
| | - P Owiti
- Academic Model Providing Access to Healthcare, Eldoret, Kenya.,The Union, Paris, France
| | - A D Harries
- The Union, Paris, France.,London School of Hygiene & Tropical Medicine, London, UK
| | - T Apollo
- National AIDS Programme, Ministry of Health and Child Care Zimbabwe, Harare, Zimbabwe
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Bwana P, Ochieng’ L, Mwau M. Performance and usability evaluation of the INSTI HIV self-test in Kenya for qualitative detection of antibodies to HIV. PLoS One 2018; 13:e0202491. [PMID: 30212525 PMCID: PMC6136890 DOI: 10.1371/journal.pone.0202491] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2017] [Accepted: 08/03/2018] [Indexed: 12/05/2022] Open
Abstract
BACKGROUND HIV testing is often undermined by lack of confidentiality, stigma, shortage of counselors and long distances to testing centers. Self-testing has the potential to circumvent these constraints. OBJECTIVE To determine the performance and usability characteristics of the INSTI® HIV-1/HIV-2 Self-Test. METHODS The performance evaluation was a cross sectional study and the usability a mixed methods study. For method comparison, Bioelisa HIV-1+2 Ag/Ab test was used as the reference test. When the test results were discrepant, results from Alere Determine™ HIV-1/2 and First Response HIV-1-2 Antibody tests were used for confirmation of status. RESULTS Sensitivity of the INSTI HIV Self-Test was 98.99% (95% CI 96.05-99.75%), and specificity 98.15% (95% CI 95.63-99.23%). The concordance was therefore 97.27%. A total of 354 participants took part in the usability study. Of those, 343 (98.00%) found instructions for use easy to follow, 330 (94.29%) found the finger prick device easy to use, 303 (86.57%) were confident while performing the test, 342 (97.71%) felt result interpretation was easy, while 304 (86.86%) declared results within the recommended five minutes. Three hundred and forty two (342, 97.71%) were willing to use the test again while 344 (98.29%) would recommend the kit to a sexual partner. None of the 350 participants quit the process at any stage. Three hundred and eighteen (318, 91.12%) participants felt the test needed no further improvement. All 91 lay users correctly identified cartridges that showed positive, negative and invalid results. Only 31 (34.07%) participants correctly identified weak positive dummy test results. CONCLUSION The excellent performance and usability characteristics of INSTI HIV-1/HIV-2 self-test make the kit a viable option for HIV self-testing. To improve the identification of weak positive results, the manufacturer should indicate on the IFU that even a faint test spot should be interpreted as positive.
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Affiliation(s)
| | | | - Matilu Mwau
- Kenya Medical Research Institute, Busia, Kenya
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Neilan AM, Cohn JE, Lemaire JF, Sacks E, Alban R, Freedberg KA, Walensky RP, Ciaranello AL. HIV Testing After a First Positive Rapid Diagnostic Test: A Role for Nucleic Acid Testing? Open Forum Infect Dis 2018; 5:ofy170. [PMID: 30182030 PMCID: PMC6114195 DOI: 10.1093/ofid/ofy170] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2018] [Accepted: 07/12/2018] [Indexed: 11/12/2022] Open
Abstract
We developed an open-access, Excel-based model simulating currently recommended and alternative algorithms for adult HIV testing as a preliminary investigation of trade-offs between accuracy and costs. Despite higher costs, simpler HIV testing algorithms incorporating point of care nucleic acid testing may improve outcomes and thus merit additional research and field testing.
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Affiliation(s)
- Anne M Neilan
- Division of Infectious Diseases and Medical Practice Evaluation Center, Massachusetts General Hospital, and Harvard Medical School, Boston, Massachusetts.,Department of Pediatrics, Massachusetts General Hospital Boston, Massachusetts
| | - Jennifer E Cohn
- Elizabeth Glaser Pediatric AIDS Foundation, Geneva, Switzerland.,Division of Infectious Diseases, University of Pennsylvania, Philadelphia, Pennsylvania
| | | | - Emma Sacks
- Elizabeth Glaser Pediatric AIDS Foundation, Geneva, Switzerland.,Johns Hopkins School of Public Health, Baltimore, Maryland
| | - Rebecca Alban
- Elizabeth Glaser Pediatric AIDS Foundation, Geneva, Switzerland
| | - Kenneth A Freedberg
- Division of Infectious Diseases and Medical Practice Evaluation Center, Massachusetts General Hospital, and Harvard Medical School, Boston, Massachusetts.,Division of General Internal Medicine, Massachusetts General Hospital, Boston, Massachusetts
| | - Rochelle P Walensky
- Division of Infectious Diseases and Medical Practice Evaluation Center, Massachusetts General Hospital, and Harvard Medical School, Boston, Massachusetts.,Division of General Internal Medicine, Massachusetts General Hospital, Boston, Massachusetts
| | - Andrea L Ciaranello
- Division of Infectious Diseases and Medical Practice Evaluation Center, Massachusetts General Hospital, and Harvard Medical School, Boston, Massachusetts
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Response to comment on "Alert, but not alarmed" - a comment on "Towards more accurate HIV testing in sub-Saharan Africa: a multi-site evaluation of HIV RDTs and risk factors for false positives (Kosack et al. 2017)". J Int AIDS Soc 2018; 20:22098. [PMID: 28664682 PMCID: PMC5515039 DOI: 10.7448/ias.20.1.22098] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
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HIV testing and human rights: the right to the right test. Lancet HIV 2018; 3:e457-8. [PMID: 27687035 DOI: 10.1016/s2352-3018(16)30160-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2016] [Accepted: 08/22/2016] [Indexed: 11/23/2022]
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Tianyi FL, Tochie JN, Agbor VN, Kadia BM. Audit of HIV counselling and testing services among primary healthcare facilities in Cameroon: a protocol for a multicentre national cross-sectional study. BMJ Open 2018; 8:e020611. [PMID: 29496897 PMCID: PMC5855192 DOI: 10.1136/bmjopen-2017-020611] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
INTRODUCTION HIV testing is an invaluable entry point to prevention, care and treatment services for people living with HIV and AIDS. Poor adherence to recommended protocols and guidelines reduces the performance of rapid diagnostic tests, leading to misdiagnosis and poor estimation of HIV seroprevalence. This study seeks to evaluate the adherence of primary healthcare facilities in Cameroon to recommended HIV counselling and testing (HCT) procedures and the impact this may have on the reliability of HIV test results. METHODS AND ANALYSIS This will be an analytical cross-sectional study involving primary healthcare facilities from all the 10 regions of Cameroon, selected by a multistaged random sampling of primary care facilities in each region. The study will last for 9 months. A structured questionnaire will be used to collect general information concerning the health facility, laboratory and other departments involved in the HCT process. The investigators will directly observe at least 10 HIV testing processes in each facility and fill out the checklist accordingly. ETHICS AND DISSEMINATION Clearance has been obtained from the National Ethical Committee to carry out the study. Informed consent will be sought from the patients to observe the HIV testing process. The final study will be published in a peer-reviewed journal and the findings presented to health policy-makers and the general public.
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Affiliation(s)
| | - Joel Noutakdie Tochie
- Faculty of Medicine and Biomedical Sciences, University of Yaoundé I, Yaoundé, Cameroon
| | | | - Benjamin Momo Kadia
- HIV Treatment Center, Foumbot District Hospital, Foumbot, Cameroon
- Grace Community Health and Development Association, Kumba, Cameroon
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Coleman SM, Gnatienko N, Lloyd-Travaglini CA, Winter MR, Bridden C, Blokhina E, Lioznov D, Adong J, Samet JH, Liegler T, Hahn JA. False-positive HIV diagnoses: lessons from Ugandan and Russian research cohorts. HIV CLINICAL TRIALS 2018; 19:15-22. [PMID: 29384717 PMCID: PMC5949866 DOI: 10.1080/15284336.2018.1429846] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
BACKGROUND Research studies rely on accurate assessment of entry criteria in order to maintain study integrity and participant safety, however, challenges can exist with HIV studies in international settings. OBJECTIVE Examine the unexpectedly high proportion of study participants with an undetectable HIV viral load found in Ugandan and Russian research cohorts meeting antiretroviral therapy (ART)-naïve entry criteria. METHODS Russian participants with documented HIV and ART-naïve status were recruited between 2012 and 2015 from clinical and non-clinical sites in St. Petersburg. Participants in Uganda were recruited from Mbarara Regional Referral Hospital from 2011 to 2014 with documented HIV infection via rapid diagnostic testing and recorded ART-naïve in the clinic database. HIV viral load testing of baseline samples was performed; the lower limit of detection was 500 copies/mL in Russia and 40 in Uganda. Due to an unexpectedly high proportion of participants with undetectable viremia, additional tests were performed: enzyme-linked immunosorbent assay HIV testing and testing for ART. RESULTS In Russia, 16% (58/360) had undetectable viremia; 3% (9/360) re-tested HIV-seronegative and 4% (13/360) tested positive for ART. In Uganda 11% (55/482) had undetectable viremia; 5% (26/482) re-tested HIV-seronegative, while <1% (4/482) tested positive for ART. CONCLUSIONS In both Russia & Uganda, undetectable viremia was much higher than would be expected for an HIV-infected ART-naïve cohort. Misclassification of study participants was due to misdiagnosis of HIV with rapid diagnostic testing and inaccurate accounting of ART use. Confirmatory HIV testing could improve accuracy of participants meeting entry criteria for HIV infection as might increased scrutiny of medication use in an ART-naïve cohort.
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Affiliation(s)
| | - Natalia Gnatienko
- Department of Medicine, Section of General Internal Medicine, Clinical Addiction Research and Education Unit, Boston Medical Center, Boston, MA, USA
| | | | | | - Carly Bridden
- Department of Medicine, Section of General Internal Medicine, Clinical Addiction Research and Education Unit, Boston Medical Center, Boston, MA, USA
| | - Elena Blokhina
- Laboratory of Clinical Pharmacology of Addictions, First Pavlov State Medical University, St. Petersburg, Russia
| | - Dmitry Lioznov
- Laboratory of Clinical Pharmacology of Addictions, First Pavlov State Medical University, St. Petersburg, Russia
| | - Julian Adong
- Mbarara University of Science and Technology, Mbarara, Uganda
| | - Jeffrey H. Samet
- Department of Medicine, Section of General Internal Medicine, Clinical Addiction Research and Education Unit, Boston Medical Center, Boston, MA, USA
- Department of Community Health Sciences, Boston University School of Public Health, Boston, MA, United States
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Tonen-Wolyec S, Batina-Agasa S, Muwonga J, Fwamba N’kulu F, Mboumba Bouassa RS, Bélec L. Evaluation of the practicability and virological performance of finger-stick whole-blood HIV self-testing in French-speaking sub-Saharan Africa. PLoS One 2018; 13:e0189475. [PMID: 29320504 PMCID: PMC5761859 DOI: 10.1371/journal.pone.0189475] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2017] [Accepted: 11/28/2017] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND Opportunities for HIV testing could be enhanced by offering HIV self-testing (HIVST) in populations that fear stigma and discrimination when accessing conventional HIV counselling and testing in health care facilities. Field experience with HIVST has not yet been reported in French-speaking African countries. METHODS The practicability of HIVST was assessed using the prototype the Exacto® Test HIV (Biosynex, Strasbourg, France) self-test in 322 adults living in Kisangani and Bunia, Democratic Republic of the Congo, according to World Health Organization's recommendations. Simplified and easy-to-read leaflet was translated in French, Lingala and Swahili. RESULTS Forty-nine percent of participants read the instructions for use in French, while 17.1% and 33.9% read the instructions in Lingala and Swahili, respectively. The instructions for use were correctly understood in 79.5% of cases. The majority (98.4%) correctly performed the HIV self-test; however, 20.8% asked for oral assistance. Most of the participants (95.3%) found that performing the self-test was easy, while 4.7% found it difficult. Overall, the results were correctly interpreted in 90.2% of cases. Among the positive, negative, and invalid self-tests, misinterpretation occurred in 6.5%, 11.2%, and 16.0% of cases, respectively (P<0.0001). The Cohen's κ coefficient was 0.84. The main obstacle for HIVST was educational level, with execution and interpretation difficulties occurring among poorly educated people. The Exacto® Test HIV self-test showed 100.0% (95% CI; 98.8-100.0) sensitivity and 99.2% (95% CI; 97.5-99.8) specificity. CONCLUSIONS Our field observations demonstrate: (i) the need to adapt the instructions for use to the Congolese general public, including adding educational pictograms as well as instructions for use in the local vernacular language(s); (ii) frequent difficulties understanding the instructions for use in addition to frequent misinterpretation of test results; and (iii) the generally good practicability of the HIV self-test despite some limitations. Supervised use of HIVST is recommended among poorly-educated people.
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Affiliation(s)
- Serge Tonen-Wolyec
- Ecole Doctorale Régionale D’Afrique Centrale en Infectiologie Tropicale, Franceville, Gabon
- Faculté de Médecine, Université de Bunia, Bunia, Democratic Republic of the Congo
- Faculté de Médecine et de Pharmacie, Université de Kisangani, Kisangani, Democratic Republic of the Congo
| | - Salomon Batina-Agasa
- Faculté de Médecine et de Pharmacie, Université de Kisangani, Kisangani, Democratic Republic of the Congo
| | - Jérémie Muwonga
- Laboratoire National de Référence du Sida, Kinshasa, Democratic Republic of the Congo
| | - Franck Fwamba N’kulu
- Programme National de lutte Contre le VIH/SIDA et les IST, Kinshasa, Democratic Republic of the Congo
| | - Ralph-Sydney Mboumba Bouassa
- Laboratoire de virologie, hôpital Européen Georges Pompidou, and Université Paris Descartes, Paris Sorbonne Cité, Paris, France
| | - Laurent Bélec
- Laboratoire de virologie, hôpital Européen Georges Pompidou, and Université Paris Descartes, Paris Sorbonne Cité, Paris, France
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Identification of misdiagnosed HIV clients in an Early Access to ART for All implementation study in Swaziland. J Int AIDS Soc 2018; 20:21756. [PMID: 28872273 PMCID: PMC5625592 DOI: 10.7448/ias.20.7.21756] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
Introduction: Rapid diagnostic testing has made HIV diagnosis and subsequent treatment more accessible. However, multiple factors, including improper implementation of testing strategies and clerical errors, have been reported to lead to HIV misdiagnosis. The World Health Organization has recommended HIV retesting prior to antiretroviral therapy (ART) initiation which has become pertinent with scaling up of Early Access to ART for All (EAAA). In this analysis, misdiagnosed clients are identified from a subgroup of clients enrolled in EAAA implementation study in Swaziland. Methods: The subgroup to assess misdiagnosis was identified from enrolled EAAA study clients, who had an undetectable viral load prior to ART initiation between September 1, 2014 and May 31, 2016. One hundred and five of 2533 (4%) clients had an undetectable viral load prior to initiation to ART (pre-ART). The HIV status of clients was confirmed using the Determine HIV 1/2 and Uni-Gold HIV 1/2 rapid tests performed serially as recommended by the national testing algorithm. The status of clients on ART was additionally confirmed by fourth-generation HIV Ag/Ab combo tests, Architect and Genscreen Ultra. Results: Fourteen of the 105 (13%) clients were false positive (HIV negative) on confirmation testing, of whom five (36%) were still in pre-ART care, while nine (64%) were in ART care. Overall, proportion of false positive was 0.6% (14/2533). The false-positive clients had a median CD4 of 791 cells/ml (interquartile range (IQR): 628, 967) compared to 549 cells/ml (IQR: 387, 791) for true positives (HIV positive) (p = 0.0081) and were nearly 20 years older (p = 0.0008). Conclusions: Overall 0.6% of all enrolled EAAA clients were misdiagnosed, and 64% of misdiagnosed clients were initiated on ART. With adoption of EAAA guidelines by national governments, ART initiation regardless of immunological criteria, strengthening of proficiency testing and adoption of retesting prior to ART initiation would allow identification of misdiagnosed clients and further reduce potential of initiating misdiagnosed clients on ART.
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Understanding low sensitivity of community-based HIV rapid testing: experiences from the HPTN 071 (PopART) trial in Zambia and South Africa. J Int AIDS Soc 2018; 20:21780. [PMID: 28872272 PMCID: PMC5625636 DOI: 10.7448/ias.20.7.21780] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Introduction: Population-wide HIV testing services (HTS) must be delivered in order to achieve universal antiretroviral treatment (ART) coverage. To accurately deliver HTS at such scale, non-facility-based HIV point-of-care testing (HIV-POCT) is necessary but requires rigorous quality assurance (QA). This study assessed the performance of community-wide HTS in Zambia and South Africa (SA) as part of the HPTN 071 (PopART) study and explores the impact of quality improvement interventions on HTS performance. Methods: Between 2014 and 2016, HIV-POCT was undertaken within households both as part of the randomly selected HPTN 071 research cohort (Population Cohort [PC]) and as part of the intervention provided by community HIV-care providers. HIV-POCT followed national algorithms in both countries. Consenting PC participants provided a venous blood sample in addition to being offered HIV-POCT. We compared results obtained in the PC using a laboratory-based gold standard (GS) testing algorithm and HIV-POCT. Comprehensive QA mechanisms were put in place to support the community-wide testing. Participants who were identified as having a false negative or false positive HIV rapid test were revisited and offered retesting. Results: We initially observed poor sensitivity (45–54%, 95% confidence interval [CI] 31–69) of HIV-POCT in the PC in SA compared to sensitivity in Zambia for the same time period of 95.8% (95% CI 93–98). In both countries, specificity of HIV-POCT was >98%. With enhanced QA interventions and adoption of the same HIV-POCT algorithm, sensitivity in SA improved to a similar level as in Zambia. Conclusions: This is one of the first reports of HIV-POCT performance during wide-scale delivery of HTS compared to a GS laboratory algorithm. HIV-POCT in a real-world setting had a lower sensitivity than anticipated. Appropriate choice of HIV-POCT algorithms, intensive training and supervision, and robust QA mechanisms are necessary to optimize HIV-POCT test performance when testing is delivered at a community level. HIV-POCT in clients who did not disclose that they were on ART may have contributed to false negative HIV-POCT results and should be the topic of future research.
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Beaudry IS, Gile KJ, Mehta SH. Inference for respondent-driven sampling with misclassification. Ann Appl Stat 2017. [DOI: 10.1214/17-aoas1063] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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Abstract
Introduction: We evaluated the diagnostic accuracy of HIV testing algorithms at six programmes in five sub-Saharan African countries. Methods: In this prospective multisite diagnostic evaluation study (Conakry, Guinea; Kitgum, Uganda; Arua, Uganda; Homa Bay, Kenya; Doula, Cameroun and Baraka, Democratic Republic of Congo), samples from clients (greater than equal to five years of age) testing for HIV were collected and compared to a state-of-the-art algorithm from the AIDS reference laboratory at the Institute of Tropical Medicine, Belgium. The reference algorithm consisted of an enzyme-linked immuno-sorbent assay, a line-immunoassay, a single antigen-enzyme immunoassay and a DNA polymerase chain reaction test. Results: Between August 2011 and January 2015, over 14,000 clients were tested for HIV at 6 HIV counselling and testing sites. Of those, 2786 (median age: 30; 38.1% males) were included in the study. Sensitivity of the testing algorithms ranged from 89.5% in Arua to 100% in Douala and Conakry, while specificity ranged from 98.3% in Doula to 100% in Conakry. Overall, 24 (0.9%) clients, and as many as 8 per site (1.7%), were misdiagnosed, with 16 false-positive and 8 false-negative results. Six false-negative specimens were retested with the on-site algorithm on the same sample and were found to be positive. Conversely, 13 false-positive specimens were retested: 8 remained false-positive with the on-site algorithm. Conclusions: The performance of algorithms at several sites failed to meet expectations and thresholds set by the World Health Organization, with unacceptably high rates of false results. Alongside the careful selection of rapid diagnostic tests and the validation of algorithms, strictly observing correct procedures can reduce the risk of false results. In the meantime, to identify false-positive diagnoses at initial testing, patients should be retested upon initiating antiretroviral therapy.
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Parry JV, Easterbrook P, Sands AR. One or two serological assay testing strategy for diagnosis of HBV and HCV infection? The use of predictive modelling. BMC Infect Dis 2017; 17:705. [PMID: 29143611 PMCID: PMC5688456 DOI: 10.1186/s12879-017-2774-1] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Initial serological testing for chronic hepatitis B virus (HBV) and hepatitis C virus (HCV) infection is conducted using either rapid diagnostic tests (RDT) or laboratory-based enzyme immunoassays (EIA)s for detection of hepatitis B surface antigen (HBsAg) or antibodies to HCV (anti-HCV), typically on serum or plasma specimens and, for certain RDTs, capillary whole blood. WHO recommends the use of standardized testing strategies - defined as a sequence of one or more assays to maximize testing accuracy while simplifying the testing process and ideally minimizing cost. Our objective was to examine the diagnostic outcomes of a one- versus two-assay serological testing strategy. These data were used to inform recommendations in the 2017 WHO Guidelines on hepatitis B and C testing. METHODS Few published studies have compared diagnostic outcomes for one-assay versus two-assay serological testing strategies for HBsAg and anti-HCV. Therefore, the principles of Bayesian statistics were used to conduct a modelling exercise to examine the outcomes of a one-assay versus two-assay testing strategy when applied to a hypothetical population of 10,000 individuals. The resulting model examined the diagnostic outcomes (true and false positive diagnoses; true and false negative diagnoses; positive and negative predictive values as a function of prevalence; and total tests required) for both one-assay and two-assay testing strategies. The performance characteristics assumed for assays used within the testing strategies were informed by WHO prequalification assessment findings and systematic reviews for diagnostic accuracy studies. Each of the presumptive testing strategies (one-assay or two-assay) was modelled at varying prevalences of HBsAg (10%, 2% and 0.4%) and of anti-HCV (40%, 10%, 2% and 0.4%), aimed at representing the range of testing populations typically encountered in WHO Member States. When the two-assay testing strategy was considered, the model assumed the independence of the two assays. RESULTS Modeling demonstrated that applying a single assay (HBsAg or anti-HCV), even with high specificity (99%), may result in considerable numbers of false positive diagnoses and low positive predictive values (PPV), particularly in lower prevalence settings. Even at very low prevalences shifting to a two-assay testing strategy would result in a PPV approaching 1.0. When test sensitivity is high (>99%) false negative reactions are rare at all but the highest prevalences; but a two-test strategy might yield more false negative diagnoses. The order in which the tests are used has no impact on the overall accuracy of a two-assay strategy though it may impact the total number of tests needed to complete the diagnostic strategy, incurring added cost and complexity. HBsAg assays may have a low sensitivity (<90%), and result in large numbers of false negative diagnoses, particularly in high prevalence settings, which would be exacerbated in the two-assay testing strategy. In contrast, most anti-HCV assays have high sensitivity and lead to fewer false negative results, both in the one-assay and two-assay testing strategies. At prevalences ≤2% the number of tests needed using a second assay was nearly always small, at <300 per 10,000 individuals tested, making sustainability of a second assay uncertain in such a setting. CONCLUSIONS A key public health objective of an effective testing strategy is to identify all individuals who would benefit from treatment. Therefore, a strategy that prioritizes a high NPV (minimal false negatives) may be acceptable even if the PPV is suboptimal (some false positives) as the implementation of such a public health programme must also take account of other factors such as costs, feasibility, impact on testing uptake and linkage to care, and consequences of a false-positive test. This rationale informed the development of the WHO Viral Hepatitis Testing Guidelines, with a conditional recommendation for a one-assay serological testing strategy in most testing settings and populations (≥0.4% prevalence in population tested). A one-test strategy results in few failures to diagnose infection and, although it is associated under most assumptions with a sub-optimal PPV, benefits include greater simplicity, easier implementation, lower costs and better feasibility, uptake and linkage to care. Furthermore, prior to antiviral therapy all those diagnosed either HBsAg or anti-HCV positive will require confirmation of viræmia, preventing unnecessary treatment of those who may be false positive on serology. For HBsAg, in low-prevalence settings (≤0.4%), a second recommendation was made to consider a two-assay testing strategy, using a confirmatory neutralization step or a second different HBsAg assay.
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Affiliation(s)
- John V Parry
- Virus Reference Department, Public Health England, 61 Colindale Avenue, London, NW9 5HT, UK. .,Centre for Research on Drugs & Health Behaviour, London School of Hygiene & Tropical Medicine, London, UK.
| | - Philippa Easterbrook
- Global Hepatitis Programme, HIV Department, World Health Organization, Geneva, Switzerland
| | - Anita R Sands
- Department of Essential Medicines and Health Products, World Health Organization, Geneva, Switzerland
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Dunning L, Francke JA, Mallampati D, MacLean RL, Penazzato M, Hou T, Myer L, Abrams EJ, Walensky RP, Leroy V, Freedberg KA, Ciaranello A. The value of confirmatory testing in early infant HIV diagnosis programmes in South Africa: A cost-effectiveness analysis. PLoS Med 2017; 14:e1002446. [PMID: 29161262 PMCID: PMC5697827 DOI: 10.1371/journal.pmed.1002446] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2016] [Accepted: 10/18/2017] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND The specificity of nucleic acid amplification tests (NAATs) used for early infant diagnosis (EID) of HIV infection is <100%, leading some HIV-uninfected infants to be incorrectly identified as HIV-infected. The World Health Organization recommends that infants undergo a second NAAT to confirm any positive test result, but implementation is limited. Our objective was to determine the impact and cost-effectiveness of confirmatory HIV testing for EID programmes in South Africa. METHOD AND FINDINGS Using the Cost-effectiveness of Preventing AIDS Complications (CEPAC)-Pediatric model, we simulated EID testing at age 6 weeks for HIV-exposed infants without and with confirmatory testing. We assumed a NAAT cost of US$25, NAAT specificity of 99.6%, NAAT sensitivity of 100% for infants infected in pregnancy or at least 4 weeks prior to testing, and a mother-to-child transmission (MTCT) rate at 12 months of 4.9%; we simulated guideline-concordant rates of testing uptake, result return, and antiretroviral therapy (ART) initiation (100%). After diagnosis, infants were linked to and retained in care for 10 years (false-positive) or lifelong (true-positive). All parameters were varied widely in sensitivity analyses. Outcomes included number of infants with false-positive diagnoses linked to ART per 1,000 ART initiations, life expectancy (LE, in years) and per-person lifetime HIV-related healthcare costs. Both without and with confirmatory testing, LE was 26.2 years for HIV-infected infants and 61.4 years for all HIV-exposed infants; clinical outcomes for truly infected infants did not differ by strategy. Without confirmatory testing, 128/1,000 ART initiations were false-positive diagnoses; with confirmatory testing, 1/1,000 ART initiations were false-positive diagnoses. Because confirmatory testing averted costly HIV care and ART in truly HIV-uninfected infants, it was cost-saving: total cost US$1,790/infant tested, compared to US$1,830/infant tested without confirmatory testing. Confirmatory testing remained cost-saving unless NAAT cost exceeded US$400 or the HIV-uninfected status of infants incorrectly identified as infected was ascertained and ART stopped within 3 months of starting. Limitations include uncertainty in the data used in the model, which we examined with sensitivity and uncertainty analyses. We also excluded clinical harms to HIV-uninfected infants incorrectly treated with ART after false-positive diagnosis (e.g., medication toxicities); including these outcomes would further increase the value of confirmatory testing. CONCLUSIONS Without confirmatory testing, in settings with MTCT rates similar to that of South Africa, more than 10% of infants who initiate ART may reflect false-positive diagnoses. Confirmatory testing prevents inappropriate HIV diagnosis, is cost-saving, and should be adopted in all EID programmes.
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Affiliation(s)
- Lorna Dunning
- Division of Epidemiology and Biostatistics, School of Public Health & Family Medicine, University of Cape Town, Cape Town, South Africa
- Medical Practice Evaluation Centre, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, United States of America
| | - Jordan A. Francke
- Medical Practice Evaluation Centre, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, United States of America
| | - Divya Mallampati
- Department of Obstetrics and Gynecology, Northwestern University, Chicago, Illinois, United States of America
| | - Rachel L. MacLean
- Medical Practice Evaluation Centre, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, United States of America
| | - Martina Penazzato
- Department of HIV/AIDS, World Health Organization, Geneva, Switzerland
| | - Taige Hou
- Medical Practice Evaluation Centre, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, United States of America
| | - Landon Myer
- Division of Epidemiology and Biostatistics, School of Public Health & Family Medicine, University of Cape Town, Cape Town, South Africa
- Centre for Infectious Diseases Epidemiology & Research, School of Public Health & Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Elaine J. Abrams
- ICAP at Columbia University, Mailman School of Public Health, Columbia University, New York, New York, United States of America
- College of Physicians & Surgeons, Columbia University, New York, New York, United States of America
| | - Rochelle P. Walensky
- Medical Practice Evaluation Centre, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, United States of America
- Division of Infectious Diseases, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, United States of America
- Division of Infectious Diseases, Brigham and Women’s Hospital, Boston, Massachusetts, United States of America
- Center for AIDS Research, Harvard University, Boston, Massachusetts, United States of America
| | | | - Kenneth A. Freedberg
- Medical Practice Evaluation Centre, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, United States of America
- Division of Infectious Diseases, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, United States of America
- Center for AIDS Research, Harvard University, Boston, Massachusetts, United States of America
- Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, United States of America
| | - Andrea Ciaranello
- Medical Practice Evaluation Centre, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, United States of America
- Division of Infectious Diseases, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, United States of America
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Madaline TF, Hochman SE, Seydel KB, Liomba A, Saidi A, Matebule G, Mowrey WB, O'Hare B, Milner DA, Kim K. Rapid Diagnostic Testing of Hospitalized Malawian Children Reveals Opportunities for Improved HIV Diagnosis and Treatment. Am J Trop Med Hyg 2017; 97:1929-1935. [PMID: 29141709 DOI: 10.4269/ajtmh.17-0067] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
Recent World Health Organization (WHO) guidelines recommend antiretroviral therapy (ART) for all HIV-infected people; previously CD4+ T lymphocyte quantification (CD4 count) or clinical staging determined eligibility for children ≥ 5 years old in low- and middle-income countries. We examined positive predictive value (PPV) of a rapid diagnostic test (RDT) algorithm and ART eligibility for hospitalized children with newly diagnosed HIV infection. We enrolled 363 hospitalized Malawian children age 2 months to 16 years with two serial positive HIV RDT from 2013 to 2015. Children aged ≤ 18 months whose nucleic acid testing was negative or unavailable were later excluded from the analysis (N = 16). If RNA PCR was undetectable, human immunodeficiency virus (HIV) enzyme immunoassay (EIA) and western blot (WB) were performed. Those with negative or discordant EIA and WB were considered HIV negative and excluded from further analysis (N = 6). ART eligibility was assessed using age, CD4 count, and clinical HIV stage. Among 150 patients with HIV RNA PCR results, 15 had undetectable HIV RNA. Of those, EIA and WB were positive in nine patients and negative or discordant in six patients. PPV of serial RDT was 90% versus RNA PCR alone and 96% versus combined RNA PCR, EIA, and WB. Of all patients aged ≥ 5 years, 8.9% were ineligible for ART under previous WHO guidelines. Improved HIV testing algorithms are needed for accurate diagnosis of HIV infection in children as prevalence of pediatric HIV declines. Universal treatment will significantly increase the numbers of older children who qualify for ART.
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Affiliation(s)
- Theresa F Madaline
- Department of Medicine, Montefiore Medical Center and Albert Einstein College of Medicine, Bronx, New York
| | - Sarah E Hochman
- Department of Medicine, New York University Langone Medical Center and New York University School of Medicine, New York, New York
| | - Karl B Seydel
- Blantyre Malaria Project, University of Malawi College of Medicine, Blantyre, Malawi.,Department of Osteopathic Medical Specialties, Michigan State University College of Osteopathic Medicine, East Lansing, Michigan
| | - Alice Liomba
- Department of Paediatrics and Child Health, University of Malawi College of Medicine, Blantyre, Malawi.,Blantyre Malaria Project, University of Malawi College of Medicine, Blantyre, Malawi
| | - Alex Saidi
- Department of Paediatrics and Child Health, University of Malawi College of Medicine, Blantyre, Malawi.,Blantyre Malaria Project, University of Malawi College of Medicine, Blantyre, Malawi
| | - Grace Matebule
- Department of Paediatrics and Child Health, University of Malawi College of Medicine, Blantyre, Malawi
| | - Wenzhu B Mowrey
- Department of Epidemiology & Population Health, Montefiore Medical Center and Albert Einstein College of Medicine, Bronx, New York
| | - Bernadette O'Hare
- Global Health Implementation, University of St. Andrews School of Medicine, North Haugh, United Kingdom.,Department of Paediatrics and Child Health, University of Malawi College of Medicine, Blantyre, Malawi
| | - Danny A Milner
- American Society for Clinical Pathology, Chicago, Illinois
| | - Kami Kim
- Departments of Pathology and Microbiology and Immunology, Montefiore Medical Center and Albert Einstein College of Medicine, Bronx, New York.,Department of Medicine, Montefiore Medical Center and Albert Einstein College of Medicine, Bronx, New York
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Lang R, Charlton C, Beckthold B, Kadivar K, Lavoie S, Caswell D, Levett PN, Horsman GB, Kim J, Gill MJ. HIV misdiagnosis: A root cause analysis leading to improvements in HIV diagnosis and patient care. J Clin Virol 2017; 96:84-88. [PMID: 29031156 DOI: 10.1016/j.jcv.2017.10.005] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2017] [Revised: 08/27/2017] [Accepted: 10/07/2017] [Indexed: 11/26/2022]
Abstract
BACKGROUND Standard diagnostic testing for HIV infection has traditionally relied on a high sensitivity HIV antibody screening test using an enzyme-linked immunosorbent assay (ELISA) followed by a high specificity antibody confirmatory test such as a Western Blot. Recently several of the screening assays have been enhanced with an ability to identify p24 antigen thereby narrowing the diagnostic window. OBJECTIVES To explore the implications of enhanced HIV screening methods that may be leading to HIV misdiagnoses. STUDY DESIGN A patient deemed to be an HIV infected 'elite controller' was found to be misdiagnosed when undergoing detailed investigations prior to initiating antiretroviral therapy. A root cause analysis was performed to identify the causative factors of this misdiagnosis. A retrospective review of all "elite controllers" in Alberta, Canada revealed challenges of current HIV testing algorithms. RESULTS Technical and human factors were identified as being causative in this HIV misdiagnosis including (i) high rates of false reactive results on the Abbott ARCHITECT HIV-1&2 COMBO EIA, (ii) human error in reading the initial Western blot, (iii) HIV algorithmic directives in which confirmatory (Western blot) testing was not performed on a repeatedly reactive screen test. The outcome of this analysis identified opportunities for improvement, including implementation of a newly approved (automated) confirmatory assay and improved communication between the clinician and laboratory. CONCLUSIONS HIV testing remains problematic despite significant advances in HIV test performance and algorithm development, presenting new and unexpected issues. Ensuring a high-quality management system including implementation of the latest HIV technologies and algorithms along with human resources and policies are required to minimize the impact of false positive diagnoses, especially in the era of universal screening and 'test and treat' recommendations.
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Affiliation(s)
- Raynell Lang
- Department of Medicine, University of Calgary, Calgary, Canada
| | - Carmen Charlton
- Department of Laboratory Medicine and Pathology University of Alberta, Edmonton, Canada; Provincial Laboratory of Public Health, Edmonton, Canada
| | | | - Kiana Kadivar
- National HIV Reference Laboratory, National Microbiology Laboratory, Winnipeg, Canada
| | - Stephanie Lavoie
- National HIV Reference Laboratory, National Microbiology Laboratory, Winnipeg, Canada
| | - Debbie Caswell
- Saskatchewan Disease Control Laboratory, Ministry of Health, Regina, Saskatchewan, Canada
| | - Paul N Levett
- Saskatchewan Disease Control Laboratory, Ministry of Health, Regina, Saskatchewan, Canada
| | - Greg B Horsman
- Saskatchewan Disease Control Laboratory, Ministry of Health, Regina, Saskatchewan, Canada
| | - John Kim
- National HIV Reference Laboratory, National Microbiology Laboratory, Winnipeg, Canada
| | - M John Gill
- Department of Medicine, University of Calgary, Calgary, Canada; Southern Alberta HIV Clinic, Calgary, Canada.
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Towards more accurate HIV testing in sub-Saharan Africa: a multi-site evaluation of HIV RDTs and risk factors for false positives. J Int AIDS Soc 2017; 19:21345. [PMID: 28364560 PMCID: PMC5467586 DOI: 10.7448/ias.20.1.21345] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
Abstract
Introduction: Although individual HIV rapid diagnostic tests (RDTs) show good performance in evaluations conducted by WHO, reports from several African countries highlight potentially significant performance issues. Despite widespread use of RDTs for HIV diagnosis in resource-constrained settings, there has been no systematic, head-to-head evaluation of their accuracy with specimens from diverse settings across sub-Saharan Africa. We conducted a standardized, centralized evaluation of eight HIV RDTs and two simple confirmatory assays at a WHO collaborating centre for evaluation of HIV diagnostics using specimens from six sites in five sub-Saharan African countries. Methods: Specimens were transported to the Institute of Tropical Medicine (ITM), Antwerp, Belgium for testing. The tests were evaluated by comparing their results to a state-of-the-art reference algorithm to estimate sensitivity, specificity and predictive values. Results: 2785 samples collected from August 2011 to January 2015 were tested at ITM. All RDTs showed very high sensitivity, from 98.8% for First Response HIV Card Test 1–2.0 to 100% for Determine HIV 1/2, Genie Fast, SD Bioline HIV 1/2 3.0 and INSTI HIV-1/HIV-2 Antibody Test kit. Specificity ranged from 90.4% for First Response to 99.7% for HIV 1/2 STAT-PAK with wide variation based on the geographical origin of specimens. Multivariate analysis showed several factors were associated with false-positive results, including gender, provider-initiated testing and the geographical origin of specimens. For simple confirmatory assays, the total sensitivity and specificity was 100% and 98.8% for ImmunoComb II HIV 12 CombFirm (ImmunoComb) and 99.7% and 98.4% for Geenius HIV 1/2 with indeterminate rates of 8.9% and 9.4%. Conclusions: In this first systematic head-to-head evaluation of the most widely used RDTs, individual RDTs performed more poorly than in the WHO evaluations: only one test met the recommended thresholds for RDTs of ≥99% sensitivity and ≥98% specificity. By performing all tests in a centralized setting, we show that these differences in performance cannot be attributed to study procedure, end-user variation, storage conditions, or other methodological factors. These results highlight the existence of geographical and population differences in individual HIV RDT performance and underscore the challenges of designing locally validated algorithms that meet the latest WHO-recommended thresholds.
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47
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A public health approach to addressing and preventing misdiagnosis in the scale-up of HIV rapid testing programmes. J Int AIDS Soc 2017. [DOI: 10.7448/ias.20.7.22290] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
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A public health approach to addressing and preventing misdiagnosis in the scale-up of HIV rapid testing programmes. J Int AIDS Soc 2017; 20:22190. [PMID: 28872270 PMCID: PMC5625588 DOI: 10.7448/ias.20.7.22190] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
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Johnson CC, Fonner V, Sands A, Ford N, Obermeyer CM, Tsui S, Wong V, Baggaley R. To err is human, to correct is public health: a systematic review examining poor quality testing and misdiagnosis of HIV status. J Int AIDS Soc 2017; 20:21755. [PMID: 28872271 PMCID: PMC5625583 DOI: 10.7448/ias.20.7.21755] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2016] [Accepted: 03/07/2017] [Indexed: 11/19/2022] Open
Abstract
INTRODUCTION In accordance with global testing and treatment targets, many countries are seeking ways to reach the "90-90-90" goals, starting with diagnosing 90% of all people with HIV. Quality HIV testing services are needed to enable people with HIV to be diagnosed and linked to treatment as early as possible. It is essential that opportunities to reach people with undiagnosed HIV are not missed, diagnoses are correct and HIV-negative individuals are not inadvertently initiated on life-long treatment. We conducted this systematic review to assess the magnitude of misdiagnosis and to describe poor HIV testing practices using rapid diagnostic tests. METHODS We systematically searched peer-reviewed articles, abstracts and grey literature published from 1 January 1990 to 19 April 2017. Studies were included if they used at least two rapid diagnostic tests and reported on HIV misdiagnosis, factors related to potential misdiagnosis or described quality issues and errors related to HIV testing. RESULTS Sixty-four studies were included in this review. A small proportion of false positive (median 3.1%, interquartile range (IQR): 0.4-5.2%) and false negative (median: 0.4%, IQR: 0-3.9%) diagnoses were identified. Suboptimal testing strategies were the most common factor in studies reporting misdiagnoses, particularly false positive diagnoses due to using a "tiebreaker" test to resolve discrepant test results. A substantial proportion of false negative diagnoses were related to retesting among people on antiretroviral therapy. Conclusions HIV testing errors and poor practices, particularly those resulting in false positive or false negative diagnoses, do occur but are preventable. Efforts to accelerate HIV diagnosis and linkage to treatment should be complemented by efforts to improve the quality of HIV testing services and strengthen the quality management systems, particularly the use of validated testing algorithms and strategies, retesting people diagnosed with HIV before initiating treatment and providing clear messages to people with HIV on treatment on the risk of a "false negative" test result.
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Affiliation(s)
- Cheryl C. Johnson
- Department of HIV, World Health Organization, Geneva, Switzerland
- Department of Clinical Research, London School of Hygiene and Tropical Medicine, London, UK
| | - Virginia Fonner
- Department of Psychiatry and Behavioral Sciences, Medical University of South Carolina, Charleston, SC, USA
| | - Anita Sands
- Department of Essential Medicines and Health Products, World Health Organization, Geneva, Switzerland
| | - Nathan Ford
- Department of HIV, World Health Organization, Geneva, Switzerland
| | - Carla Mahklouf Obermeyer
- Department of Epidemiology and Population Health, American University of Beirut, Beirut, Lebanon
| | - Sharon Tsui
- Department of International Health, Johns Hopkins University, Bloomberg School of Public Health, Baltimore, MD, USA
| | - Vincent Wong
- US Agency for International Development, Washington, DC, USA
| | - Rachel Baggaley
- Department of HIV, World Health Organization, Geneva, Switzerland
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50
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Nguyen VTT, Best S, Pham HT, Troung TXL, Hoang TTH, Wilson K, Ngo THH, Chien X, Lai KA, Bui DD, Kato M. HIV point of care diagnosis: preventing misdiagnosis experience from a pilot of rapid test algorithm implementation in selected communes in Vietnam. J Int AIDS Soc 2017; 20:21752. [PMID: 28872279 PMCID: PMC5625549 DOI: 10.7448/ias.20.7.21752] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2016] [Accepted: 06/19/2017] [Indexed: 11/18/2022] Open
Abstract
INTRODUCTION In Vietnam, HIV testing services had been available only at provincial and district health facilities, but not at the primary health facilities. Consequently, access to HIV testing services had been limited especially in rural areas. In 2012, Vietnam piloted decentralization and integration of HIV services at commune health stations (CHSs). As a part of this pilot, a three-rapid test algorithm was introduced at CHSs. The objective of this study was to assess the performance of a three-rapid test algorithm and the implementation of quality assurance measures to prevent misdiagnosis, at primary health facilities. METHODS The three-rapid test algorithm (Determine HIV-1/2, followed by ACON HIV 1/2 and DoubleCheckGold HIV 1&2 in parallel) was piloted at CHSs from August 2012 to December 2013. Commune health staff were trained to perform HIV testing. Specimens from CHSs were sent to the provincial confirmatory laboratory (PCL) for confirmatory and validation testing. Quality assurance measures were undertaken including training, competency assessment, field technical assistance, supervision and monitoring and external quality assessment (EQA). Data on HIV testing were collected from the testing logbooks at commune and provincial facilities. Descriptive analysis was conducted. Sensitivity and specificity of the rapid testing algorithm were calculated. RESULTS A total of 1,373 people received HIV testing and counselling (HTC) at CHSs. Eighty people were diagnosed with HIV infection (5.8%). The 755/1244 specimens reported as HIV negative at the CHS were sent to PCL and confirmed as negative, and all 80 specimens reported as HIV positive at CHS were confirmed as positive at the PCL. Forty-nine specimens that were reactive with Determine but negative with ACON and DoubleCheckGold at the CHSs were confirmed negative at the PCL. The results show this rapid test algorithm to be 100% sensitive and 100% specific. Of 21 CHSs that received two rounds of EQA panels, 20 CHSs submitted accurate results. CONCLUSIONS Decentralization of HIV confirmatory testing to CHS is feasible in Vietnam. The results obtained from this pilot provided strong evidence of the feasibility of HIV testing at primary health facilities. Quality assurance measures including training, competency assessment, regular monitoring and supervision and an EQA scheme are essential for prevention of misdiagnosis.
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Affiliation(s)
| | - Susan Best
- Australian National Serology Reference Laboratory, Melbourne, Australia
| | - Hong Thang Pham
- HIV Department, National Institute for Hygiene and Epidemiology, Hanoi, Vietnam
| | | | - Thi Thanh Ha Hoang
- HIV Department, National Institute for Hygiene and Epidemiology, Hanoi, Vietnam
| | - Kim Wilson
- Australian National Serology Reference Laboratory, Melbourne, Australia
| | - Thi Hong Hanh Ngo
- HIV Department, National Institute for Hygiene and Epidemiology, Hanoi, Vietnam
| | - Xuan Chien
- HIV Laboratory, Dien Bien Provincial AIDS Centre, Vietnam
| | - Kim Anh Lai
- Can Tho Preventive Medicine Centre, Can Tho City, Vietnam
| | - Duc Duong Bui
- Viet Nam Authority for HIV/AIDS Control, Ministry of Health, Hanoi, Vietnam
| | - Masaya Kato
- World Health Organization, Vietnam Country Office, Hanoi, Vietnam
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