HIV TESTING STRATEGIES

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1 HIV TESTING STRATEGIES Ralph R. Frerichs, D.V.M., Dr.P.H. Professor UCLA Department of Epidemiology EPI 227, 11 am - Noon, May 24, 2004 Background on Testing Issues 1

2 Estimated No. of Adults Infected with HIV By WHO Region, Source: WHO. World Health Report, 2004 Life Expectancy in Africa With and Without HIV/AIDS, 2002 Source: WHO. World Health Report,

3 HIV Treatment with Anti-retroviral Drugs Who to treat and at what cost? Estimated Global Coverage with Antiretroviral Therapy End of 2003 Need HIV testing before being able to find and treat asymptomatic HIV/AIDS Source: WHO. World Health Report,

4 4

5 Path of HIV Infection To limit HIV transmission, need testing, contact tracing and partner notification How determine? Source: Los Angeles Times, April 17, Increased public pressure for mandated HIV testing 5

6 HIV Infection in the United States in Years Gone By The group that transmits the disease 40,000 incident cases per year 400,000 prevalent disease cases Few if any Cures 40,000 deaths per year Following years of infection, the person with HIV dies. 400,000 prevalent carriers created 40,000 new infections each year Current HIV Infection in the United States The group that transmits the disease 40,000 incident cases per year 1,000,000 prevalent disease cases Few if any permanent cures 14,400 deaths per year (effective therapy) Following infection, persons remain alive due to effective therapy but still harbor the virus, serving as potential transmitters 1,000,000 prevalent carriers create 40,000 new infections each year 6

7 Testing and Avoidance Infected blood Universal testing Probability of becoming infected.6.4 Blood Transfusion.2 0 Test and avoid contaminated blood Testing and Avoidance Occasional testing Probability of becoming infected Infected partner Monogamous anal sex for one year 0 Test and avoid or always use condom 7

8 Testing and Avoidance Probability of becoming infected Routine testing If infected and unaware mother Offspring 0 Tested, treated and no breastfeeding Probability of becoming infected Testing and Avoidance Infected partner Occasional testing Monogamous vaginal sex for one year Test and avoid or always use condom 8

9 Test result HIV+ HIV- HIV- HIV Testing HIV+ A True positives C False negatives Truth B False positives D True negatives High sensitivity implies few false negatives High specificity implies few false positives Sensitivity = A A + C Specificity = D B + D Usual HIV Testing Strategy in the United States Assay One ELISA Results in 1-2 weeks Test + Test - Assay Two Negative Western Blot Results in 1-2 weeks Test + Test? Test - Positive* Indeterminate** Negative Potential transmitters *If newly positive, confirm with another sample **retest in two weeks High Specificity (few false positives) 9

10 Planned HIV Testing Strategy in the United States Assay One Rapid Test Results in < 20 min. Test + Test - Assay Two Negative Western Blot Results in 1-2 weeks Test + Test? Test - Positive* Indeterminate** Negative Potential transmitters *If newly positive, confirm with another sample **retest in two weeks High Specificity (few false positives) Personal Screening for HIV (now available in USA) Home Collection (with telephone counseling) Pharmacy Laboratory (1) (3) (2) (4) Telephone counseling and referral 10

11 Personal Screening for HIV (not yet available in USA) Home Collection (with no telephone counseling) Pharmacy (4) Laboratory (1) (3) (5) (2) No counseling, but informed with brochures and posters and by the general media Personal Screening for HIV (not yet available in USA) Home Testing Pharmacy Initial screening for HIV infection is done in the privacy of the home (1) Saliva strip or whole blood strip No counseling, but informed with brochures, posters and the general media 11

12 The Safe Light Testing blood Providing therapy Offering condoms Sensitive counseling Deploring discrimination Testing mothers and children The difficult darkness widespread testing HIV reporting personal screening partner notification monogamy/abstinence Conclusion Transmission Because of the low infectivity (i.e., ability to lodge and multiply) of HIV, transmission of the virus should be easy to prevent, if infection status is known. Universal and continued condom use with at risk partners is good in principal but appears to be too much to expect of many people. HIV testing has been highly effective in preventing transfusionbased transmission and passage from mother to offspring. An individualize prevention strategy that relies on personal screening holds promise, but only if inexpensive rapid tests are made widely available. 12

13 Conclusion Treatment HIV detection is a necessary first step before administering antiretroviral therapy Fear of testing and therapy cost are two major deterrents of increased HIV/AIDS treatments in the developing world An individualize detection and treatment strategy that relies on personal screening to identify and lead to treatment holds promise, but only if inexpensive rapid tests are made widely available. 13

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