Reporting Language for the HIV Diagnostic Testing Algorithm

2014 Webinar Series Reporting Language for the HIV Diagnostic Testing Algorithm Thursday, May 8, 2014 Speaker Christine C. Ginocchio, PhD, MT(ASCP), VP Global Microbiology Affairs, biomerieux, Durham, NC, Professor, Hofstra North Shore LIJ School of Medicine, Hempstead, NY Dr. Ginocchio is the VP of Global Microbiology Affairs for biomerieux. Dr. Ginocchio is a Clinical Professor of Medicine, Hofstra North Shore-LIJ School of Medicine, NY. Prior to joining biomérieux in February 2014 she was the Senior Medical Director and Chief, Division of Infectious Disease Diagnostics, North Shore-LIJ Health System Laboratories, NY. She is Co-Editor-in-Chief for the Journal of Clinical Virology, Dr. Ginocchio has been an invited speaker at over 200 national and international conferences, has published 9 book chapters, and more than 90 peerreviewed articles. Her awards include the President s Award and the Irving Abrahams Award for outstanding basic science research, the PASCV 2012 award in Diagnostic Virology and the ASM 2013 BD Award for Research in Clinical Microbiology. Objectives At the conclusion of this program, participants will be able to: Explain the new HIV-1/2 diagnostic algorithm and the reasons for the change. List the appropriate reporting language for the different combinations of screening and confirmatory test results. Continuing Education Credit The Association of Public Health Laboratories (APHL) is approved as a provider of continuing education programs in the clinical laboratory sciences by the ASCLS P.A.C.E. Program. Participants who successfully complete each program will be awarded 1.0 contact hours. P.A.C.E. is accepted by all licensure states except Florida. APHL is a Florida and CPH-recertification approved CE provider; each course has been approved for 1.0 contact hours. Evaluation/Printing CE Certificate Continuing education credit is available to individuals who successfully complete the program and evaluation by November 8, 2014. 1. Go to http://www.surveymonkey.com/s/588-914-14ba and complete the evaluation. 2. Select: P.A.C.E., Florida or CPH-recertification credit. 3. Complete the survey. 4. Certificate printing a. PACE or Florida Certificates: add your information in the boxes and click on Submit. If you are requesting Florida CEU, you must submit a valid Florida license number for the certificate and for us to enter your information into CE Broker. i. Please review your certificate. If you need change any information, go to the bottom of the page and click on here to go back and edit. IMPORTANT: Enable printing of background images in the print (Firefox) or page setup (Internet Explorer) dialog options. ii. Certificates are available only by selecting the Print button. They will not be emailed or mailed. 1. Print the certificate. 2. We recommend that you also print the certificate to an adobe file and save. There is a $15 fee if you request a duplicate certificate later. Webinar certificates will no longer be saved in the Continuing Education Center (CEC). b. CPH-recertification credit: you must submit a valid certification number on the evalulation. Your information will be forwarded to the National Board of Public Health Examiners. At the end of the evaluation, you will be able to print a Certificate of Attendance. Copy the Certificate of Attendance URL to you browser, then in the next screen print your certificate. Archived Program The archived streaming video will be available within one day after the live program. Anyone from your site can view the Web archived program and/or complete the evaluation and print the certificate for free. New this year! Registration is not necessary for the archive program. For Live or archived site registrations, the URL will be sent to the site representative who is responsible for distributing the URL. Comments, opinions, and evaluations expressed in this program do not constitute endorsement by APHL. The APHL does not authorize any program faculty to express personal opinion or evaluation as the position of APHL. The use of trade names and commercial sources is for identification only and does not imply endorsement by the program sponsors. This program is copyright protected by the speaker(s) and APHL. The material is to be used for this APHL program only. It is strictly forbidden to record the program or use any part of the material without permission from the author or APHL. Any unauthorized use of the written material or broadcasting, public performance, copying or re-recording constitutes an infringement of copyright laws. The Association of Public Health Laboratories (APHL) sponsors educational programs on critical issues in laboratory science. For more information, visit www.aphl.org/courses

Faculty Disclosure Suggested Reporting Language for the HIV Diagnostic Testing Algorithm The Association of Public Health Laboratories adheres to established standards regarding industry support of continuing education for healthcare professionals. The following disclosures of personal financial relationships with commercial interests within the last 12 months as relative to this presentation have been made by the speaker(s): Christine C. Ginocchio, Ph. D., M. T. (A.S.C.P.) VP, Global Microbiology Affairs biomerieux, Durham, NC Professor, Hofstra North Shore-LIJ School of Medicine, NY Christine C. Ginocchio, PhD, MT(ASCP) Nothing to disclose. Association for Public Health Laboratories Webinar 5/8/2014 1 2 Objectives Explain the new HIV-1/2 diagnostic algorithm and the reasons for the change List the appropriate reporting language for the different combinations of screening and confirmatory test results Distinguished Contributors Bernard M. Branson, MD Division of HIV/AIDS Prevention, National Center for HIV/AIDS, Viral Hepatitis, and TB Prevention S. Michele Owen, PhD Division of HIV/AIDS Prevention, National Center for HIV/AIDS, Viral Hepatitis, and TB Prevention Laura G. Wesolowski, PhD Division of HIV/AIDS Prevention, National Center for HIV/AIDS, Viral Hepatitis, and TB Prevention Berry Bennett, MPH Association of Public Health Laboratories, Silver Spring, Maryland Florida Bureau of Public Health Laboratories, Jacksonville, Florida Barbara G. Werner, PhD Association of Public Health Laboratories, Silver Spring, Maryland Massachusetts Department of Public Health Bureau of Infectious Disease, Boston, Massachusetts Kelly E. Wroblewski, MPH Association of Public Health Laboratories, Silver Spring, Maryland Michael A. Pentella, PhD Association of Public Health Laboratories, Silver Spring, Maryland Massachusetts Bureau of Laboratories, Boston, Massachusetts 3 4 HIV Statistics as of 2010 History of CDC Guidelines An estimated 1.1 million persons in US were living with HIV Estimated 181,000 were unaware of their infection Approximately 49,000 new HIV diagnoses are reported to CDC each year As of 2009, an estimated 83 million adults aged 18 to 64 years reported they had been tested for HIV Accurate laboratory diagnosis of HIV is essential to identify persons who could benefit from treatment, to reassure persons who are uninfected, and to reduce HIV transmission 1989: Guidelines for the serodiagnosis of HIV Type 1 infections 1992: Guidelines for testing for antibodies for HIV Type 2 infections 2004: Protocols for confirmation of reactive rapid antibody test results Employed only tests for HIV antibodies 5 6

Appearance of Laboratory Markers for HIV Infection HIV RNA (plasma) HIV Antibody Why change the testing algorithm? HIV p24 Ag Clinical Considerations Eclipse Acute 22 HIV Infection Established HIV Infection 0 10 20 30 40 50 60 70 80 90 100 Days Infection Seroconversion Window 7 Modified after Busch et al. Am J Med. 1997 8 Definitions Plasma Viral Load and HIV Transmission Risk Seroconversion window period: interval between infection with HIV and the first detection of antibodies Acute HIV infection: interval between the appearance of detectable HIV RNA and the first detection of antibodies Duration depends on the design of the antibody immunoassay and the sensitivity of the immunoassay during seroconversion Established HIV infection: characterized by a fully developed IgG antibody response sufficient to meet the interpretive criteria for a positive Western blot or IFA Rakai (Uganda) 453 HIV disc. couples 11.6 % TR / year % partners infected 30 20 10 0 <400 400 3500 3500 10'000 10'000 50'000 HIV RNA load (cp/ml) >50000 9 Quinn 2000, NEJM 342:921 10 HIV-1 Viral Loads at Initial Detection Increased Risk of Sexual Transmission of HIV 10 9 8 7 6 5 4 3 2 1 0 Log HIV RNA cp/ml Median Viral Loads 29,347 Established HIV+ (n=66) 209,183 Acute HIV+ (n=21) HIV RNA in Semen (Log 10 copies/ml) 5 4 3 2 1/30 1/200 Virus 75 750 times more infectious 1/1000 1/10,000 1/500 1/2000 1/100 1/1000 Pilcher C et al. N Engl J Med 2005;352:1873-1883 11 Cohen MS, et al. J Infect Dis. 2005 12

Reduction in Prevalence (%) Reduction in Risk Behaviors Once Seropositive Status is Known Reduction in Prevalence of Unprotected Intercourse Relative to HIV Positive Persons Unaware of Serostatus 53% HIV Positive Persons Aware of Their Own Serostatus 68% HIV Positive Persons Aware of Their Own Serostatus and HIV Negative Partner Summary: Clinical Recognition that risk of HIV transmission from persons with acute and early infection is much higher than that from persons with established infection Recent indications for the clinical benefits from antiretroviral treatment (ART) of all persons with HIV infection, including acute infection Placement in HIV medical care Evaluation that includes additional tests (HIV-1 viral load, CD4+ T-lymphocyte determination, and an antiretroviral resistance assay) to confirm the presence of HIV-1 infection, to stage HIV disease, and to assist in the selection of an initial antiretroviral drug Marks G, et al. JAIDS. 2005;39:446 453. 13 14 Benefits of Routine Screening Standardizes HIV screening Increases awareness of HIV status Reduces the risk of HIV transmission Reduces late diagnoses Reduces the stigma associated with the disease Increases survival when HIV-infected patients are placed on treatment Grade A US Preventive Services Task Force recommendation Why change the testing algorithm? Technical Considerations Source: CDC. MMWR Morb Mortal Wkly Rep. 2006;55(RR-14):1-17 Ann Int Med: 159:1, 51-60. 15 16 Diagnostic Algorithm: 1989 Screening test has been repeatedly reactive (i.e., greater than or equal to two tests) on the same specimen A supplemental, more specific test such as the Western blot or IFA has been used to validate those results 17 Antigen 1 st and 2 nd Generation EIA Plasma/serum Plasma/serum (1 h/37 o C) 1 st - Viral lysate 2 nd Recombinant proteins or synthetic peptides Detects HIV IgG Color reagent IgG HIV antibody Enzymedetection enzyme anti-human IgG 18

Antigen: 3 rd Generation Sandwich EIA Recombinant proteins or synthetic peptides Detects HIV IgM or IgG Plasma/serum Color reagent IgG HIV antibody IgM enzyme HIV antigen 19 HIV antigen p24 antibody Detects IgM or IgG antibody or p24 antigen 4 th Generation Combo Assay Plasma/serum Enzymedetection Enzymedetection Color reagent HIV antibodies p24 antigen HIV antigen p24 antibody 20 1987 Vironostika EIA 1985 Abbott HIV-1 EIA Timeline 1991 Cambridge Western blot 1992 Abbott HIV-1/HIV-2 EIA 1992 Fluorognost IFA 2000 Genetic Systems HIV- 1/HIV-2 Peptide EIA 1998 Genetic Systems rlav (HIV-1) 2002 OraQuick HIV-1/HIV-2 Rapid Test 2003 GS HIV-1 HIV-2 Plus O EIA 2003 Unigold Reveal HIV-1 Rapid Tests 3 rd & 4 th gen lab screening tests 2004 Multispot HIV-1/HIV-2 Rapid Test 2008 Ortho Vitros HIV 1+2 CIA 2006 Advia Centaur 1/O/2 CIA 2006 Aptima Qualitative RNA 2011 Bio-Rad Ag/Ab Combo EIA 2010 Abbott Architect Ag/Ab Combo CIA 2009 Avioq HIV-1 EIA 1 st gen confirmatory tests 2 nd gen rapid tests 2010 INSTI HIV-1 Rapid Test 2013 Alere Ag/Ab Combo Rapid 21 Cumulative frequency of positive tests Relative Seroconversion Sensitivity 1.00 0.90 Genprobe 0.80 Architect 4th BioRad 4th 0.70 Advia 3rd Vitros 3rd 0.60 Abbott 3rd 0.50 BioRad 3rd Insti 0.40 Multispot Reveal 0.30 Statpak Complete 0.20 Unigold 0.10 Oraq Adv 0.00-50 -40-30 -20-10 0 10 20 30 days before positive Western blot 26 seroconverters were analyzed with 14 tests 17 seroconverters with WB positive used for cumulative frequency analysis 22 APTIMA (-26) Sequence of Test Positivity Relative to Western Blot Architect Ag/Ab Combo (-20) Bio-Rad Ag/Ab Combo (-19) Determine Ag/Ab Combo (-15) Advia (-14) Vitros (-13) GS 1/2+O (-12) INSTI (-9) DPP (-8) Multi-Spot (-7) Reveal G3, Avioq (-6) COMPLETE HIV-1/2 (-5) HIV-1/2 STAT-PAK (-5) Unigold (-2) OraQuick (-1) WB positive Vironostka (+2) HIV-2 Infection Remains uncommon in U.S., but Does not respond to NNRTIs, some PIs (first line therapy) Undetectable by HIV-1 viral load tests Misclassification by HIV-1 Western blot: 54/58 (93%) HIV-2 patients tested had positive HIV-1 WB (NYC) * 97/163 (60%) HIV-2 cases reported had positive HIV -1 WB (CDC) ** 25 20 15 10 5 Days before WB positive 0 HIV-2 often diagnosed after immunologic deterioration in patient with negative viral load Modified from Masciotra et al, J Clin Virol 2011 and Owen et al, J Clin Micro 2008 23 *Torian et al, Clinical Infectious Disease 2010 **MMWR July 2011 24

Summary: Technical Improved HIV assays allow detection of HIV sooner after infection Antigen/antibody combo tests now FDA-approved that can detect most antibody-negative persons during highly infections acute infection stage Western blot or indirect immunofluorescence assay (IFA) for confirmation of reactive initial immunoassay results can produce false-negative or indeterminate results early in the course of HIV infection Because of cross-reactivity, >60% of persons with HIV-2 infection misclassified as HIV-1 by Western blot Collaborative Effort CDC and Association of Public Health Laboratories (APHL) Recommendations based on: HIV tests approved by the FDA as of December 2012 Scientific evidence Laboratory experience Expert opinion collected from 2007 through December 2013 Updated recommendations include tests for HIV antigens and HIV nucleic acid antibody testing alone might miss a significant percentage of HIV infections detectable by virologic tests 25 26 Scope of Guidelines Algorithm HIV Testing Guidelines Intended only for testing of serum or plasma specimens from adults and children 2 years of age or older Specific recommendations to establish the presence or absence of the diagnosis of HIV infection in infants are described elsewhere Because maternal antibodies against HIV might be present in uninfected infants born to HIV-infected Do not address methods or strategies for screening blood or organ donors for HIV infection FDA and U.S. Public Health Service (USPHS) have issued separate guidance and recommendations on this topic None of the assays in the updated recommended algorithm are FDA-approved for use with oral fluid or dried blood spot specimens 27 28 Appearance of Laboratory Markers for HIV Infection HIV RNA (plasma) HIV p24 Ag HIV Antibody Abbott Architect 4 th Generation Ag/Ab Combo Assay Chemiluminescent immunoassay Detects p24 antigen and HIV antibody Eclipse Acute 22 HIV Infection Established HIV Infection 0 10 20 30 40 50 60 70 80 90 100 Days Infection Time to result: 29 minutes NAAT Ag 4th gen Ab 3 rd gen Ab 2 nd gen Seroconversion Window Ab 1 st gen Modified after Busch et al. Am J Med. 1997 29 FDA-approved June 22, 2010 30

Bio-Rad GS 4 th Generation HIV Combo Ag/Ab EIA Multispot HIV-1/HIV-2 Antibody Differentiation Assay Microwell plate EIA 3 rd generation format: HIV-1: gp160 HIV-2: gp36 Group O p24 antigen Reactive Control Recombinant HIV-1 FDA-approved July 25, 2011 Peptide HIV-2 Peptide HIV-1 31 32 APTIMA Qualitative HIV-1 RNA Assay Aid to HIV-1 diagnosis Diagnosis of acute HIV-1 infection in antibodynegative persons Confirmation of HIV-1 infection in antibody-positive persons when it is reactive FDA-approved July 2006 33 34 Study Sites The Screening Targeted Populations to Interrupt On-going Chains of HIV Transmission with Enhanced Partner Notification (STOP) study in New York, New York, North Carolina, and San Francisco, California Arizona Department of Health Services in collaboration with Maricopa Integrated Health Systems 35 36

Phoenix ED Screening July 2011 through February 2013 4 th gen screening of patients who had blood drawn 15% of patients declined testing 13,014 patients tested 37 (0.3%) new HIV infections diagnosed 12 (32.4%) had acute HIV Infection (antibody negative) Median viral load: 3.6 million copies/ml 25 (67.6%) had established HIV infection: Median viral load: 27,125 copies/ml 18 false-positive 4 th gen (Architect) Specificity 99.86%, PPV 67% 37 Patient Gender HIV Infection Status Differentiation IA Western Blot HIV-1 Viral Load Patient 7 Acute Non Reactive Negative >10,000,000 Male Patient 8 Male Acute Non Reactive Negative 5,370,318 Patient 11 Male Acute Non Reactive Inconclusive 1,141,782 Patient 19 Female Acute Non Reactive ND >10,000,000 Patient 25 Male Acute Non Reactive ND >10,000,000 Patient 36 Male Acute Non Reactive ND >10,000,000 Patient 23 Male Acute Non Reactive ND 4,357,922 Patient 39 Male Acute Non Reactive ND 691,343 Patient 57 Male Acute Non Reactive ND 382,628 Patient 31 Female Acute Non Reactive ND 309,139 Patient 27 Male Acute Non Reactive ND 64,163 Patient 3 Male Acute HIV-1 Reactive Negative 2,914,430 Patient 13 Male Established HIV-1 Reactive Positive 86,910 Patient 6 Male Established HIV-1 Reactive Positive 29,476 Patient 5 Female Established HIV-1 Reactive Positive 18,822 Patient 4 Male Established HIV-1 Reactive Positive 15,608 Patient 12 Male Established HIV-1 Reactive Positive 11,209 Patient 2 Male Established HIV-1 Reactive Positive 6,460 Patient 40 Female Established HIV-1 Reactive ND < 40 Patient 56 Male Established HIV-1 Reactive ND 764,498 Patient 32 Male Established HIV-1 Reactive ND 690,951 Patient 16 Male Established HIV-1 Reactive ND 632,488 Patient 59 Male Established HIV-1 Reactive ND 602,878 Patient 42 Male Established HIV-1 Reactive ND 130,248 Patient 28 Female Established HIV-1 Reactive ND 78,084 Patient 58 Male Established HIV-1 Reactive ND 67,808 Patient 61 Male Established HIV-1 Reactive ND 65,105 Patient 29 Male Established HIV-1 Reactive ND 49,873 Patient 24 Male Established HIV-1 Reactive ND 44,816 Patient 48 Female Established HIV-1 Reactive ND 27,125 Patient 41 Male Established HIV-1 Reactive ND 20,692 Patient 38 Male Established HIV-1 Reactive ND 14,925 Patient 30 Male Established HIV-1 Reactive ND 9,519 Patient 22 Female Established HIV-1 Reactive ND 4,334 Patient 37 Male Established HIV-1 Reactive ND 1,537 Patient 49 Female Established HIV-1 Reactive ND 1,225 Patient 47 Female Established HIV-1 Reactive ND 757 38 Benefits of the New Algorithm New Testing Algorithm More accurate laboratory diagnosis of acute HIV-1 infection Equally accurate laboratory diagnosis of established HIV-1 infection More accurate laboratory diagnosis of HIV-2 infection Fewer indeterminate results Faster turnaround time for most test results 39 40 3. HIV-1 RNA assay 1. Nonreactive Negative for HIV-1 antigen and HIV-1/HIV-2 antibodies. 2. HIV-1 reactive 2. HIV-2 reactive 2. Non-reactive or indeterminate 3. RNA not detected No laboratory evidence of HIV infection. If acute HIV infection is suspected, consider testing for HIV-1 RNA. Positive for HIV-1 antibodies. Laboratory evidence consistent with established HIV-1 infection is present. Positive for HIV-2 antibodies. Laboratory evidence of HIV-2 infection is present. HIV antibodies were not confirmed and HIV-1 RNA was not detected. No laboratory evidence of HIV-1 infection. Reporting this test result is not required. Report test results: 1 and 2 Report test results: 1 and 2 Reporting this test result is not required. 41 3. HIV-1 RNA assay 2. Nonreactive 3. RNA detected 2. HIV-1 and HIV- 2 reactive 2. Nonreactive or indeterminate Positive for HIV-1. Laboratory evidence consistent with acute HIV-1 infection is present. Positive for HIV antibodies. Laboratory evidence of HIV infection is present. HIV antibodies could not be differentiated as HIV-1 or HIV-2. Additional testing for HIV-1 RNA or HIV-2 RNA should be performed if clinically indicated. HIV-1 antibodies were not confirmed and HIV-1 RNA testing was not performed. Testing of this specimen is incomplete. Follow-up testing for HIV antibodies and HIV-1 RNA is recommended as soon as possible. Report test results: 1, 2 and 3 Report test results: 1 and 2 Report test results: 1 and 2 42

Screening Test Issues Recently approved 4 th generation rapid test: Alere Determine Not included in the algorithm as data was not available Necessitates retesting with 4 th generation IA first Point of care and sites that only do rapid tests: prohibits rapid release of a confirmatory Multispot Control Antigen Antibody Rapid Testing: Follow up Laboratories should use this same testing algorithm, beginning with an antigen/antibody combination immunoassay, with serum or plasma specimens submitted for testing after a reactive (preliminary positive) rapid HIV test result. 43 44 LIS Reporting Issues Cannot link testing algorithm results beyond positive screen for Multispot Cannot add in the need to do RNA Cannot link serology to RNA results Need to report all DOH will need to link data All results should be on a single page format Confirmatory Testing Issues Serum sample for serologic testing Prefer EDTA for RNA (stability) Do you test serum with a disclaimer or collect EDTA on everyone? How do you store, locate, with so many samples? 1 test approved for HIV-1 diagnosis (Aptima) Most labs have HIV-1 viral load assays but not approved for diagnosis of HIV Need for extensive laboratory validation None for HIV-2 (rare sites can do HIV-2 RNA) 45 46 Testing Recommendations Carefully review manufacturer s instructions in package inserts to determine requirements for acceptable specimen types (serum, plasma), volume, collection tubes, anticoagulants, cell separation, storage and shipping requirements, and timeframes Communicate these specific requirements to the persons who submit specimens for testing with the assays to be performed Request collection of another specimen from a second venipuncture if all tests cannot be performed on the same specimen Moving Forward Anticipating continued improvements in laboratory diagnostic techniques, CDC and APHL will monitor the introduction and FDA approval of diagnostic assays for HIV infection and update these recommendations when necessary. CDC and APHL will continue to monitor the performance of the laboratory testing algorithm and review the performance of the recommended algorithm at least every five years. Confirm handling, storage, and shipping requirements before sending specimens to reference laboratories for additional testing 47 48

Summary Guidelines and new algorithm are a major (MAJOR) improvement in the diagnosis of HIV infections My opinion: No laboratory should be doing a 3 rd generation screening assay Ongoing evaluation of new 4 th generation of rapid tests needs be reviewed and added to guidelines to improve the rapid diagnosis of HIV Critically important for POC sites, clinics, EDs where loss to follow up is a major issue 2010 HIV Diagnostics Conference published on line in JCV in 2011 2012 HIV Diagnostics Conference published on line in JCV in 2013 Reference Articles All are open access 49 50 Thank you Questions 51