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Algoritma Tes HIV

1. Indonesia faces challenges in achieving its 90-90-90 targets for HIV diagnosis, treatment and viral suppression. As of 2017, only 39.9% of estimated PLHIV knew their status, 32.2% were on treatment, and viral suppression rates were unknown. 2. Key strategies for effective HIV management include early diagnosis, monitoring treatment through ART and viral load testing, initiating ART, preventing opportunistic infections, and early infant diagnosis. 3. Point-of-care CD4 and viral load testing can improve access in rural areas by making testing more portable and reducing loss to follow up compared to sending samples to centralized laboratories. Dried blood spot samples also facilitate testing in remote areas.

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117 views31 pages

Algoritma Tes HIV

1. Indonesia faces challenges in achieving its 90-90-90 targets for HIV diagnosis, treatment and viral suppression. As of 2017, only 39.9% of estimated PLHIV knew their status, 32.2% were on treatment, and viral suppression rates were unknown. 2. Key strategies for effective HIV management include early diagnosis, monitoring treatment through ART and viral load testing, initiating ART, preventing opportunistic infections, and early infant diagnosis. 3. Point-of-care CD4 and viral load testing can improve access in rural areas by making testing more portable and reducing loss to follow up compared to sending samples to centralized laboratories. Dried blood spot samples also facilitate testing in remote areas.

Uploaded by

yurdiansyah
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Algoritme pemeriksaan

HIV
Agnes R. Indrati
Divisi Imunoserologi
Dept. Patologi Klinik
FK Universitas Padjadjaran/ RS Hasan Sadikin
Bandung
HIV in Indonesia
HIV AIDS Situation in Indonesia
700000
90-90-90 Target cascade
600000

500000

400000

300000 39.9%
200000

32.2%
100000
?
0
Estimated Knew their On treatment Virally
number of HIV status suppresed ?
PLHIV

(Kemenkes RI, Maret 2017)


key strategies for effective
HIV management

Early HIV ART Early Infant


Diagnosis Monitoring Diagnostic

ART Oportunistic
Initiation Infection
HIV serological assays
Window Period based on tests method
Performance Characteristic of HIV tests
Performance Characteristic of HIV tests
HIV Test Algorithm in Indonesia
Retesting
WHO recommendations retesting is warranted for the following populations:
1. Individuals testing HIV-negative who:
• have ongoing risk for HIV infection
• pregnant, in high HIV prevalence settings; HIV-negative in the first trimester
2. Individuals whose HIV status is inconclusive
• return in 14 days for additional testing to confirm their diagnosis
3. Individuals diagnosed HIV-positive
• should be retested to verify their HIV
• Retesting is not recommended for individuals on ART

Source: WHO, 2010 (12, 57) ; WHO, 2014 (12, 57)


Confirmatory testing
The HIV-1 Western blot and HIV-1 IFA  no longer part of the recommended algorithm:
• false-negative or indeterminate results early in the course of HIV infection
• majority of HIV-2 infections misclassified as HIV-1 by the HIV-1 Western blot
• HIV-1 NAT confirmation
• additional laboratory tests (HIV-1 VL & CD4):
to confirm the presence of HIV-1 infection
to stage HIV disease
to assist in the selection of an initial ART
Common causes of false results in HIV
serological assays
Common causes of false results in HIV
serological assays
Immunological and virological events in natural
course of HIV infection
Clinical, Immunological
& Virological failure
CD4 Evaluation
Purposes

• staging & monitoring HIV patients


• initiation ART
• prophylactic therapy

POC CD4 T-cell counting devices


• compact, portable and use disposable cartridges
• venous and capillary blood
• Multiple internal quality control

Parekh et al. cmr.asm. January 2019, 32, 1.e00064-18


POCT CD4

• well-trained • improve access,

POCT
Flowcy tometry

laboratory especially for


technicians rural patients
• good sample • to reduce
transport patient loss to
systems follow-up

Parekh et al. cmr.asm. January


2019, 32, 1.e00064-18
Point-Of-Care CD4 Counting Reduces Pre-
Treatment Loss-To-Follow-Up
Percent Of Patients Receiving Percent Of Patients Returning
CD4 Test Results After Initial CD4

Source: Jani et al. AIDS (2011)


Viral Load
• a nucleic-acid-based test
• monitor response to treatment, disease progression
& predict outcome
• access is very limited in RLS
• done in centralized facilities, expensive
instrumentation, technical skill
• high costs per assay

WHO UNTAID 2012


Viral Load to HIV management

• need to scale up
VL testing • the most effective method to evaluate the response of ART

• improve access to VL testing


POC VL • improve patient care management
testing

Brook G. BMJ. Sex Transm Infect. 2018


VL POCT

benefit limitation
the cost per test is similar to
relatively easy to use most other commercial VL
assays

requires a relatively
already being used for TB
sophisticated laboratory
diagnosis
setting

plasma samples , requires


additional time and
resources
Correlation lab based vs POCT VL
• monitoring ART treatment failure
(>1000 copies/mL)
• Xpert system vs laboratory HIV
VL with plasma samples:
• 98% concordance
• 94% sensitivity
• 99% specificity

Kulkarni et al. BMC Infect Deis2017; 17: 506 Brook G. BMJ. Sex Transm Infect. 2018
Early Infant Diagnosis
• The WHO & UNICEF recommended virological testing for infant HIV
diagnosis (< 18 m of age)
• Quantitative viral RNA or qualitative proviral DNA
• Minimum sensitivity of 95% (preferably 98%) & specificity of 99%.
• Virological testing for HIV-exposed infants at 4-6 weeks of age or at the
earliest opportunity thereafter
Early Infant Diagnosis
• The most widely-used test for EID is a DNA PCR molecular test, which is
also performed on sophisticated laboratory-based instruments.
• HIV-1 DNA test detects HIV proviral DNA
• Alternatively the RNA PCR quantitative tests/ viral load
 Dried blood spot
HIV test algorithm in infant/ children <18
months
Dried Blood Spot
• Greater stability than fresh whole blood / plasma
• Simplifies samples transport
• Cost effective.
expand testing access into peri-urban & rural settings

Murtagh et al. ASLM (2013)


Usage of DBS in HIV Virology

Advantages
• easily obtained, stored, & training required is less intensive
• more stable over longer periods
• DBS are more easily transported

Disadvantages
• reduced sensitivity of viral RNA amplification
• in low viral loads, genotyping results is not accurate
• challenges surrounding the pre-extraction and analytical stages need
to be resolved
VL Comparison from Plasma & DBS
in Asia & Africa

Monleau et al. JCM (2014)


Terima
Kasih……
[email protected]

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