Review of Early Infant Diagnosis of HIV-1 in Delhi by Dr.A.K. Gupta, Additional Project Director cum Technical Lead, Delhi State AIDS Control Society, Dept. of Health & FW, Govt. of Delhi

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This presentation describes efficacy of early Infant diagnosis of HIV-1 in assessment of effectiveness of various PMTCT interventions. There is an urgent need to reduce large number of unnecessary …

This presentation describes efficacy of early Infant diagnosis of HIV-1 in assessment of effectiveness of various PMTCT interventions. There is an urgent need to reduce large number of unnecessary Cesarean Sections on HIV positive pregnant women.

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  • Data from UNAIDS shows that in 2008, 10% of all new HIV infections were in children, almost all of which occurred through mother-to-child transmission. In that same year, children made up about 6% of the total number of people living with HIV in the world. You may ask why there is such a discrepancy between these 2 numbers. Much of the reason is reflected in the third data point which shows that children accounted for 13% of AIDS-related deaths in 2008.
  • The progression of AIDS in children accelerates more quickly than in adults, leading to extremely high rates of mortality. At the bottom of this graph you will see a pink line indicating the relatively low mortality rates for children not infected with HV. Compare this now to the green line at the top of the graph which tracks the mortality rates of HIV-infected children over time. You will notice that by 1 year of age, 35% of HIV-infected infants have died. And by 2 years, that number reaches 53% and continues to climb over time.
  • But these high rates of infant mortality do not need to be accepted as inevitable. The progression of AIDS in a child can be slowed down and even paused by the timely initiation of antiretroviral therapy. Research has shown that a significant number of lives can be saved by initiating ART for HIV-infected infants immediately after diagnosis within the first few months of life. The chart here shows results from the CHER study in South Africa which demonstrated a 76% reduction in mortality when infants were started on treatment in those first 13 weeks after birth. 377 HIV infeced Infants aged 6-12 weeeks with CD4%>=25% divided in three groups & followed up for 3.5 years: (i) Immediate ART) for 40 weeks, (ii) immediate ARTfor 96 weeks, (iii) Defered ART -ART initiated on clinical or immunological progression 16% deaths when ART deferred compared to 4% deaths when ART initaited early (P=0.0002). Most deaths occurred within first 6 months (i.e., before age 10 months when ART deferred. The results of CHER trial demonstrated that early ART in HIV Infected Infants < 12 weeks of age reduced mortality by 76% and HIV progression by 75%.
  • 77 uninfected infants from South Africa, tested with Abbott ELISA. Non-breast feeding population. Antibody titers declined gradually during first 3 months, then rapidly thereafter 94.5% HIV antibody negative at 12 months. 100% HIV antibody negative at 15 months . Moodley D Ped Inf Dis J 1995;14:850
  • Trainers: Data contributed from multiple perinatal studies, primarily in the US and Europe, with formula fed populations. Include 271 HIV-infected infants. Sensitivity of DNA PCR increases substantially after the first week of life. By 28 days the sensitivity approaches 96% Sensitivity (true positives) increases during first weeks of life Sensitivity can vary with assay and laboratory; assay should be appropriate for viral subtype Theoretically, sensitivity and specificity (true positives) may vary in populations of infants receiving perinatal prevention regimens; no supportive data has been published Primarily US and European populations, subtype B populations. HIDE 90% CI 29-46 at 48 hours 76-97 at 14 d 89-98 at 28 d 7 children had negative test results after the neonatal period, the age at the last negative test ranging between 65 and 13 days.
  • p24 Assay for Early Infant Diagnosis Basis for the assay : HIV p24 antigen is normally produced at high levels within the first few weeks of infection but quickly becomes bound to specific antibodies which make it unable to be detected by standard antigen-detection serological tests. Heat treatment of the sample dissociates p24 from these complexes (the ultrasensitive method). Ultrasensitive p24 is a sensitive and highly specific marker for HIV infection and has been shown to be an accurate EID method in ELISA format. This is the first ultrasensitive POC p24 test. Planned assay design : Assay utilizes a drop of plasma which is added to a pre-filled tube and heated for 4 minutes in specially-designed heat-block to release p24 antigen from immune complexes and allowed to passively cool to room temperature Assay currently does not directly use whole blood. Hence, in the final assay design, drops of capillary whole blood from heel-sticks will be captured in specially designed sample collection modules that separate plasma from whole blood A solution of the assay probe mix containing anti-p24 antibody conjugates is added to the sample After 5 minutes incubation, a dipstick is inserted into the tube and the test and control line results are read after 30 minutes The assay is complete in under 1 hour The dipstick p24 assay is expected to undergo further clinical trials in 2010. Market release TBD.
  • Why at six weeks of age? The vast majority of infants with in utero, intra-partum and early postnatal infection will be identified by 6 weeks of age Most infants have their first visit for immunizations and growth monitoring at 6 weeks You can start CTX at this visit also. The sensitivity of the DNA PCR test is > 96% Testing at this 4-6 weeks of age should identify all babies infected in during pregnancy, labor & delivery and during early breast feeding Note: if maternal HIV status is unknown screen with rapid antibody first. For infants older than 9 months of age at the first clinic visit , screen with a rapid antibody test first. If antibody is positive then perform DNA PCR. If antibody is negative and infant is still breastfeeding, repeat rapid antibody 6-12 weeks after cessation of breast feeding.
  • We can only diagnose HIV in the first months of life using virological tests (HIV DNA PCR, HIV RNA PCR or bDNa or NASBA or ultrasenstive p24 antigen) As it takes some time to develop HIV infection and for HIV to start replicating, testing immediately at birth will not detect all those infants who HAVE HIV. To date the HIV DNA PCR is the only testing method that can be performed using DBS specimens ( i.e. and is therefore most useful in context of PMTCT follow up. HIV RNA methods are reliable can be done on plasma and whole blood specimens and are well suited to inpatient or sick infants where specimens using DBS are not essential) For ALL methods robust QA is required. Estimation of proportion of truly infected infants detected by testing at certain ages if all infants are breastfed would produce numbers as below for South Africa , base don performance of HIV DNA testing E.G. South Africa T ot infected (BF) % missed diagnosis at time of testing of total if BF Birth 59527 70 1st week 60012 50 2nd week 60497 30 3rd week 60980 20 4th week 61463 11 6th week 61944 5 2nd month 62425 4 3rd month 64445 5 4th month 66450 5 5th month 68438 5 6th month 70410 5 The ongoing missed diagnosis reflects those who have recently acquired HIV through breastfeeding and are in the window period. Estimated numbers do not adjust for those who would have died. WHO therefore recommends to perform testing at or around 4-6 weeks for PMTCT follow up and whenever sick or HIV is suspected in infants known to be exposed.
  • The status of the 50 infants is shown here. Out of the group, eight children had died. 12 more were concluded to be lost to follow up due to incorrect or outdated contact information for the caregivers. 4 more were contacted, but the caregivers declined treatment for the infants. And the silver lining of all these efforts was an additional 26 infants were started on treatment.
  • Despite the improvement in treatment initiation in the last example, I think we can all agree that there is an unacceptable number of HIV-positive infants being lost before treatment. One of the major hurdles is getting the DNA PCR results back to families so that they can act upon that information. I won’t go into the details of the challenges in doing this, but will give a quick overview of some of the strategies employed by EGPAF in Swaziland as they support health facilities to disseminate test results to caregivers. A first step is to educate staff and caregivers about importance of prompt follow up for infant diagnosis and the possible consequences to delaying treatment for any amount of time. Parents and caregivers want what’s best for their child, but they need to be counseled on WHY this is such a critical issue. Staff need to be trained on how to thoroughly capture contact information for caregivers, with multiple phone numbers, addresses, etc so that there is no excuse for a child to be lost to follow up. Each health facility should specifically identify someone who is responsible for contacting families with results and to schedule follow-up appointments. This could be a health provider, a trained counselor, or village health worker who is assigned to this task. In order for this person to do their job, they need to have the resources to actively follow-up on each case. They should be provided mechanisms such as cell phones and airtime, a bicycle, or travel stipends to physically track down families. A register should be established that tracks the status of test result delivery so there is no confusion on if or when caregivers have been informed. Finally, sites should consider adding program indicators to track their progress on delivering results and to encourage improvement over time.


  • 1. Presented By DR A K Gupta, MD (Pediatrics) Additional Project DirectorDelhi State AIDS Control Society Govt of Delhi
  • 2. This presentation will:Recapitulate Key concepts in diagnosing HIVinfection in infants and young childrenExplain the National algorithms for diagnosingHIV in infants and young children Review the Performance of EID programme Discuss Lessons Learnt/Challenges / Issueswhich need to be addressed Explain new strategy to ensure enrollment of allnew HIV exposed for EID Inform about Scale up of EID programme during2012-13 Discuss Effectiveness of current PMTCTInterventions Explain Adapting WHO (2010) PMTCT protocol 2
  • 3. Recapitulate Key concepts of EID
  • 4. Children constitute: 10% of new HIV infections each year o (280,000 out of 2.7 million) 6% of the persons living with HIV o (2 million out of 33 million) 13% of HIV/AIDS deaths each year o (270,000 out of 3 million) o 90% in sub-Saharan AfricaSource- UNAIDS, 2008 4
  • 5.  Rapid HIV progression and higher risk of death in infected infantsWithout Anti Retroviral treatment:By age 1, one-third of all HIV-infected children will haveDiedBy age 2, half of all HIV-infected children will have died CD4 and viral load are poor predictors of disease progression in infants
  • 6. 1 Year = 2 Years = 35% 53%Newell ML Newell ML et al Lancet 2004; mortality mortality364: 1236-43 6
  • 7. The results ofCHER trialdemonstratedthat early ARTin HIVInfectedInfants < 12weeks of agereducedmortality by76% and HIVprogressionby 75%. From the Children with HIV Early Antiretroviral Therapy Study (CHER), Violari, NEJM 2008 7
  • 8. All infants under 24 months of age withconfirmed HIV infection should be started onantiretroviral therapy, irrespective of clinical orimmunological stage.
  • 9. NVP No infant or triple maternal ART ARV exposure PI triple Sd NVP or NNRTI containing ART ART# MTCT ARV Exposure NVP Non NNRTI exposure triple ART Unknown infant maternal MTCT NVP Exposure triple ART# If no PI is available use NVP triple ART
  • 10. To identify the HIV-infected child early, prior to the development of clinical disease during the first months of life. The goal is NOT to exclude infection in infants.Diagnosis should be early enough so interventions and Anti Retroviral treatment can be startedStart ART in all confirmed HIV Infected infants irrespective of clinical or immunological status to reduce pediatric mortality and morbidity 10
  • 11. Methods of Early Infant diagnosis
  • 12. 100 90 Rapid Ab can be used 80 to exclude infection 70 around 12-18 months of age 60% antibody 50 positive 40 30 20 10 0 birth 1 3 6 9 12 15 18 months of life Moodley D, PIDJ 1995;14:850 12
  • 13. 100 90 At 4-6 weeks of age 80 sensitivity of 70 DNA PCR is 96- 60 98%sensitivity % 50 40 30 20 10 0 48 hrs 2-7 days 7-14 days 28 days daysDunn D, AIDS 1995, 9:F7 13
  • 14. Limitations of RNA PCR for Infant Diagnosis
  • 15. Point-of-Care Testing for Early Infant Diagnosis
  • 16. a. Whole blood from pricking skin, Dried on filter paperb. Easy to store & Easy to transportc. Required supplies for DBS collection Gloves Pen Lab forms DBS card Lancet or glucolet Disinfectant for skin Gauze or cotton wool
  • 17. 5-10kg infants1. Warm the area2. Wash hands, put on gloves3. Position baby with foot down4. Clean area, dry 30 sec5. Press lancet into foot, prick skin6. Wipe away first drop7. Allow large drop to collect8. Touch blood drop to card9. Fill entire circle with drop10. Fill at least 3 circles11. Clean foot, no bandage <5kg infants Overhead 4-5
  • 18. Overhead 4-34
  • 19. circles not filled clotted/layered Scratched/abradedNot Dried before sending Serum Ring around
  • 20. Don’t touch or smear the blood spots.Allow the specimen to air dry horizontally for at least 3 hours.Keep away from direct sunlight, dust, and bugs.Do not heat, stack or allow DBS to touch anything during the drying process. Lay them on a flat surface or drying rack.
  • 21. HOW TO PACKAGE & TRANSPOPRT DBS CARD Add desiccant packets (minimum 10 packets per bag)Add humidity card, Keep packaged DBS (in sealablepress air out of bag, plastic bags) refrigerated untiland seal bag transported to reference laboratory. Shipping
  • 22. At 4-6 weeks of life or At first visit (if >6 weeks of age)Why at six weeks of age? The sensitivity of the test is > 96% Testing at this 4-6 weeks of age should identify all babies infected in during pregnancy, labor & delivery and during early breast feeding It correspond to first immunizations visit Cotrimoxazole prophylaxis is initiated at this age. 23
  • 23. 90 2005 n=79 78 80 76 2006 n=108 70 2007 n=109 In 2007: 60 • only 8% of HIV 50 47 exposed infants 40 tested in 1st 2 30 months of life 30 23 17 • only 4 % started 20 on co-trimoxazole 10 0 Number of countries using dired blood Number of countries with a policy on spots for virological testing provider initated testing and counselling for infants and young childrenTowards Universal Access: Scaling up priority HIV/AIDS interventions in the health sector,WHO/UNAIDS/UNICEF 2008
  • 24. Missed Opportunties for Early Infant Diagnosis
  • 25. Low weight and/or Lymphadenopathy growth failure Parotid glandPneumonia, swelling including PCP Recurrent earOral candidiasis infections (thrush) after 6 Persistent weeks of age diarrhoea Tuberculosis
  • 26. Risk of transmitting HIV to the infant during breastfeeding is greater when:  The woman has a high viral load or low CD4 count (new infection or advanced HIV disease)  The woman has mastitis, a breast abscess, nipple sores or other breast problem  The infant or child has ulcers or open sores in the mouth  The child is mixed fed
  • 27. Mixed feeding in first 6 months increasesrisk of HIV - If breastfed infant is given formula, risk doubles - If breastfed infant is given solid foods the risk of HIV infection is eleven times as high as the exclusively BF infant
  • 28. To minimize risk of MTCT, HIV-infected mothers should discontinue breastfeeding when infant is 6 months of age, if replacement feeding is AFASS Transition from breast milk to replacement feeding should take place over 2-3 days to 2-3 weeks
  • 29. Pneumocystis Jiroveci Pneumonia (PCP) is a severe and rapidly progressive pneumonia in HIV infected infants  Peak incidence is between 3-6 monthsProphylactic cotrimoxazole therapy significantly reduces the risk of PCP, other bacterial infections and malaria and reduces infant deaths. 33
  • 30.  The CPT should be given from 6 weeks onwards to the weight of the infant/Child. Weight( Kg) Child dispersible tablets( 20mg TMP/100mg smx) X Once daily <5 1 tablet 5-10 2 tablet 10-15 3 tablet 15-22 4 tablet Give CPT until HIV has been ruled out and mother is no longer breast feeding In BF - dispersed in expressed breast milk. In RF- disperse in 1-2 TSF of boiled water
  • 31. CTX is generally very well tolerated in children  Check for tolerance and adherence at every visitSide effects and toxicities are more common in  Adults > children  Advanced disease > early stages of disease  HIV-infected > HIV-exposed childrenIf a child develops severe reaction to CTX Dapsone can be used for prophylaxis (2mg/kg/dose daily, maximum 100mg daily) 35
  • 32. Reviw of Performance of EID programme during 2011-12 What proportion of pregnant women testing HIV+ get their HIV-exposed infants tested and at what age? How long does it take for an EID sample to reach the lab, and for the result to reach the site? the family? Among HIV-exposed infants receiving EID testing, what percent of mothers/caregivers receive their infant’s result? Among all confirmed HIV-infected infants, what proportion initiates ART and at what age? Among those initiated ART, proportion initiated correct regimen as per National Guidelines?
  • 33. What proportion of pregnant women testingHIV+ get their HIV-exposed infants tested and at what age?
  • 34. How long does it take for an EID sample to reach the lab, and for the result to reach the site?
  • 35. Among HIV-exposed infants receiving EID testing, whatpercent of mothers/caregivers receive their infant’s result? 9 DBS DNA PCR Positive infants died before Whole Blood PCR Test 51 (25.5%) DBS DNA PCR negative infants LFU 9 (37.5%) Confirmed HIV positive infants LFU
  • 36. Among all confirmed HIV-infected infants, what proportion initiates ART and at what age?None of 15/24 (62.5%)infant confirmed HIVcould be Infected Infantsinitiated Initiated on AntiART by 3 Retroviralmonths of Treatmentage Delayed start of ART resulted inIn 3 infants OIs in 5/15tested at 6 (33.3%) childrenweeks ofage ART Nine (37.5%)was children could notinitiated at be initiated ART.4 mth, 9 -One Died in pre-mth and 11 ART,mth of age. -6 were LFU -2 parents refused
  • 37. Among those initiated ART, proportioninitiated correct regimen as per National Guidelines?
  • 38. 1. When HIV-1 is transmitted despite PMTCT with > 2 ARV drugs, or mothers ART, prevalence of NRTI or NNRTI resistance in infant HIV will be > 30%.2. When HIV-1 is transmitted despite PMTCT with NVP alone, the prevalence of major mutations associated with NNRTI resistance in infant HIV will be 50% or greater3. NNRTI Resistance may decrease with time by 20% in many infants after a long period of non- exposure to ARVs.Source- Diane Bennett et al, Global AIDS Programme , CDC Atlanta
  • 39. WHO 2010 Revised Guidelines for EID and ART
  • 40.  Ensuring Entry of all HIV exposed infants in the EID cascade Ensuring testing at 6 weeks of age of all HIV exposed infants to serve the very purpose of EID Training of pediatric providers on PICT and referral of symptomatic cases who missed opportunity of EID. Reducing Turn Around Times of DNA PCR testing- change in national guideline of only 2 days /month of sending samples to reference lab. Better coordination between ICTC and ART centers regarding NVP exposure status Improving follow up of BF first DBS negative exposed infants Early Initiation of ART in confirmed HIV infected infants before signs / symptoms of HIV develop ie by 12 weeks of age
  • 41. Scale up of EID programme during 2012-13
  • 42. Exisitng and New facilities
  • 43. Strategyto Address the issues
  • 44. Ensuring Adherence to CPT
  • 45. Day 1-3 : Ensure first DBS DNAPCR test at 6 weeks of age &Send sample to NCDC within 2days (ICTC/PPTCT)Day-10 Ensure result of DBStest is collected within 7 daysof test (ICTC/PPTCT)Day-17 Ensure infant reachesARTC for Whole Blood Test(ICTC/PPTCT)Day -17/18: Ensure wholeblood sample is collected andsent to NCDC on same dayDay 23/24: ARTC to ensurethat result of Whole bloodtest is collected on 4th day ofsubmitting sample.Day 31/32: ART Centre callparents to start ART inconfirmed HIV +ve infantswithin 7 days ie < =12 weeks
  • 46. Swaziland Expérience (2010)-Makaria Reynolds et al Active Follow up through Phone Calls• Phone calls were effective• Staff invested significant time in calling patients• Many clients had incorrect information recorded• Some infants had died 50 HIV Infected Not Contacted coming For ART 50
  • 47. ICTC/ARTC Counselor must ensure following:• Emphasize parent /caregivers the need of prompt follow up for diagnosis and treatment• Record correct contact information of parent / caregiver• Contact families for follow-up by phone call and if reqd. home visit, may also take help of ORWs. DSACS will provide travel allowance.• Record in Register when result was provided to /parent caregiver.• Add program indicators on % PCR results given to families and percent of PCR positive initiating treatment 51
  • 48. PMTCT Interventions – Assessing efficacy through EID
  • 49. Provision of Antiretroviral Drugs 55% of pregnant women not receiving PMTCT drugs 68% of HIV-exposed infants not receiving PMTCT drugsWHO, UNAIDS, UNICEF - Towards Universal Access: Progress Report 2009
  • 50. Delhi PMTCT Cascade (2011-12)
  • 51. Infant feeding Counselling is it really happening ?
  • 52. MCTC Rates Overall MCTC rate = 24/234 (10.25%) But if all DBS Positive Children 53/234 are included in analysis then MCTC rate = 22.6%The Current PMTCT Intervention is only 50% effective
  • 53. New WHO PMTCT Protocol
  • 54. ARV Prophylaxis Antepartum Intra-partum Post-partumand dosingTDF 300mg once Start at 14 Continue Continue triple ARVdaily weeks or as triple ARV prophylaxis until 1 week3TC 150mg twice soon as prophylaxis after all infant exposure todaily possible breast milk has ended *EFV 600mg once thereafterdaily * When the Option-B regimen is stopped, stop EFV and continue with 7-day TDF+ 3TC tail
  • 55. Maternal Status Intra-partum Post-partumPresenting in sd-NVP 200 mg once AZT 300 mg + 3TC 150 mgactive labour, no at onset of labour twice daily x 7 daysprior ARV withprophylaxis AZT 300 mg + 3TC 150 mg at onset of labour and every 12 hours until delivery