The document discusses evaluating the efficacy of the OraQuick rapid HIV test kit using oral fluid for HIV antibody detection in patients attending dental hospitals in India. The study found the OraQuick test to have a sensitivity and specificity of 100% compared to standard blood tests. It was found to be an effective and accurate screening tool for HIV detection using oral fluid. However, it could not distinguish between HIV-1 and HIV-2 antibodies. Further larger studies were recommended to introduce it as a routine screening procedure.

1. Nallan CSK Chaitanya,pinakapani R,
Pavan Kumar, Rajeshwari Annigeri, G
Raghu Rama Rao, Amareswar, Veena
Ramanna
Journal Of Indian Academy Of Oral
Medicine And Radiology 2011.23[3]204-
207
Presented By Dr. Priyadershini A. Kasture

2.  Detection of HIV antibodies is done by the standard blood
tests. Rapid tests provide results in few minutes.
 The OraQuick rapid HIV1/2 antibody test using oral fluid has
not been tried in resource-limited settings in India.
 The aim was to evaluate the efficacy of the OraQuick test kit
using oral fluid for HIV antibody detection in patients attending
the dental hospitals

3.  Human immunodeficiency virus type 1 and 2 are the etiological
agents of AIDS.
 A global summary of AIDS epidemic by WHO in 2008, estimated
33.4 (31.1 to 35.8) million people are living with HIV-1 worldwide,
while about 2 million have already died in 2008.
 There could be still unknown, undiagnosed cases probably living
with HIV virus.
 These estimates may mask the dynamic nature of this evolving
epidemic in relation to temporal changes, geographic distribution,
magnitude, viral diversity and mode of transmission.
. Cao H, Walker BD. Immunopathogenesis of HIV-1 infection. Clin Dermatol
2000;18(4):401-10.
2. UNAIDS report on the global AIDS epidemic
2008.http://data.unaids.org/pub/Global Report/2008/JC1511_
GR08_ExecutiveSummary_en.pdf

4. Whom to test for HIV-
 One needs to be able to correctly suspect and screen a client at risk for HIV
status. No Mandatory HIV testing should be imposed as a precondition for
employment OR for providing health care services and facilities.
 Not all Patients for Surgery(Operation) should be subjected to HIV testing
 Routine Mandatory HIV testing should not be under taken for the benefit
of Health care workers.
 “regardless of patients infection status every patients blood /body fluid is
considered to be positive/infectious”
 On accidental exposure to any patients Body fluid/potentially infectious material,
Health care worker should take necessary PEP (Post Exposure Prophylaxis)
ideally within 2 hours but certainly within 72 hours.

5. Negative HIV status of patient reported by a Laboratory, does not give
liberty to HCW to be careless(regarding their own safety while
providing their heath care service to patient ) and ignore the
principles/guidelines of Universal Safety Precaution ,as it can be a
case of False Negative HIV status reporting during Window
period where the routine screening tests (aimed at detecting
presence of HIV antibodies) are unable to detect the HIV status of
asymptomatic patients .
HIV testing of every ANC women/patient is recommended(but not
mandatory) so as to determine the risk of transmission from mother
to foetus and further to take action to prevent it (PPTCTCs) .

7.  A1 (Comb AIDS Rs)
 (Sensitivity 100% , Specificity 98. 7%)

 A1+
 A1-
 Report Negative
 A2 (SD Bioline HIV1/2 3.0 )
 (Sensitivity 100% , Specificity 99.8%)

 A1+ A2+ A1+ A2-
 A3 (HIV Tridot) A3
 (Sensitivity 99.6% for HIV1, 100% for HIV2,
 and Specificity 100%)
 A1+ A2+ A3 + A1+ A2+ A3- A1+ A2- A3 + A1+ A2- A3-
 Report Positive Indeterminate Indeterminate Report Negative
 Interpretation: A1 Non-Reactive = HIV Antibody Test Negative .
 A1 Reactive+ A2 Non-Reactive +A3 Non-Reactive= HIV Antibody Test Negative (A1 being highly sensitive).
 A1 & A2 Reactive+A3 Non-Reactive / A1 & A3 Reactive+A2 Non-Reactive = HIV Antibody Test Indeterminate .
 A1 A2 A3 Reactive = HIV Antibody Test Positive (A2 & A3 being highly specific).
 A Serum sample , showing result of the above three different ELISA or Simple & Rapid HIV Antibody test as HIV Antibody Test Positive or HIV
Antibody Test Indeterminate , should be retested by Supplemental ( Western Blot assay or Indirect Immunofluorescence ) test.

8. Screening (E/R/S) tests
a) ELISA
b) Rapid tests
- Dot blot assays
- HIV spot and comb tests
- Fluorometric microparticle technologies
c)Simple tests -Also based on ELISA principle but takes 1-2 hours
- Particle agglutination(gelatin, RBC, latex,
microbeads)
Supplemental tests
a). Western blot assay
b).Immunofluorescence test
Confirmatory tests
a).Virus isolation-Cocultivation with lymphocytes and Interleukin-2
b).Detection of p24 antigen
c). Detection of viral nucleic acid
- In situ hybridization
- Polymerase chain reaction

9.  The window period is the time from infection until a test can
detect any change.
 Average window period for HIV-1 is 25 days & HIV-2 is 16
days.
 ELISA- ’wet-lab’ type analytic biochemistry assay[EIA] to
detect the presence of an antigen in blood sample.
 Western Blot- ‘protein immunoblot’ used to detect specific
proteins in a sample of solid tissue or its extract.

10.  Bio- saliva HIV test is a non-invasive, accurate way to test for HIV-1/2
antibodies without blood needle or lancets.
 It tests the HIV antibodies not the disease.
 Test kit is having a swab and a device with a test strip.
 After taking swab of oral fluid,then device is placed in a vial that holds an
enzyme solution which reacts to any antibody-antigen binding.
 If positive strip shows red line, if no line then its negative.
 Require 20 min for one test.

11.  Repeated tests should be done for confirmation.
 Ora Sure-uses oral mucosal transudate present in buccal and
gingival area.
 OraQuick-saliva test kit
 86% accuracy
 Rapid HIV test results from the OraQuick are slightly
more accurate than blood samples.
www.usatoday.com, www.aidsmeds.com, www.home-hiv-tests.com

12.  The demographic features of spread of HIV in Asia are
different from elsewhere.
 India stands second in the world with respect to people living
with HIV.
 UN estimates project that India’s adult HIV prevalence will
peak at 1.9% in 2019. About 2.3 million people are living with
HIV infection by 2007.
 There is a declining trend in the epidemic in South Indian
states.
Rajendran R, Sivapathasundaram B. Viral infections of oral cavity. Shafers’s
textbook of oral pathology (5th ed). Elsevier publications 2006;488-98.
NACO guidelines: Annual HIV Sentinel Surveillance Country Report 2006.
http://www.nacoonline.org National_AIDS_Control_Program/Surveillance

13.  The early detection assumes paramount importance at the
present scenario. Diagnosis of HIV infection is based on the
detection of specific antibodies, antigens or both. Serological
tests are employed for the screening purposes.
 The CDC recommends that diagnostic HIV testing and opt out
HIV screening be a part of routine clinical care in all health care
settings, while maintaining the individual concerned for not
opting the testing for optimal clinical and preventive care.
Sierra S, Kupfer B, Kaiser R. Basics of the virology of HIV-1 and its replication. J Clin Virol
2005;34(4):233-44.
Hahn EK. Incorporating the CDC recommendations for adolescent HIV screening into
practice. Journal for Nurse Practitioners 2009;5(4):265-73.
Rothman RE, Merchant RC, Talan DA, Moran GJ, Pinner R.Update on emerging infections
from the centers for disease control and prevention. CDC update 2007;49(5):575-77.

14.  Technological advances in the diagnosis of HIV infection
provide the clinicians with greater opportunities to reduce HIV
transmission rates.9 It estimates that increased awareness of
serological status will decrease the number of new infections
mainly by behavior modification of HIV-positive people and
treatment that decreases viral loading in infected individuals. 9
Doughty M, Locksmith GJ. New rapid diagnostic tests for HIV infection.
Ob/Gyns 2003;10(3):131-34.

15.  To date, only traditional ELISA was available for detection of anti-HIV
antibodies in serum.
 Overtime there have been improvements of performance of ELISAs from
usage of viral lysates to usage of recombinant antigens, synthetic
peptides or combination of these both.
 This has led to better sensitivity and specificity of these assays. The
ELISA more recently has been employed to detect HIV antibodies in
whole blood, urine and salivary samples.
 The Westernblot remains a gold standard in HIV antibody conformation.
 None of the test samples had shown false-positive and false- negative
results when compared with the reference tests.
Urassa W, Godoy K, Killewo J, Kwesigabo G, Mbakileki A Mhalu F, et al. The accuracy of an
alternative confirmatorytrategy for detection of antibodies to HIV-1: Experience from a
regional laboratory in Kagera, Tanzania. J Clin Virol 1999;14(1):25-29.
King SD, Winter SH, Bain BC, Brown WA, Johnston JN, Delk AS. Comparison of testing
saliva and serum for detection of antibody to human immunodeficiency virus in Jamaica,
West Indies. Journal of Clinical Virology 2000;19(3):157-61.

16.  Rapid point of care HIV tests greatly aid in knowing sero-
status by providing faster and accurate results in minutes.
 This can be used in areas with limited laboratory resources
and they provide convenience in testing on site results by
allowing the delivery of definite negative or provisional reactive
results greatly enhancing interventional programs.
 There are rapid HIV tests using oral fluid and whole blood.
The efficacy of these tests has been evaluated individually and
also by comparing both the tests.
Holguín A, Gutiérrez M, Portocarrero N, Rivas P, Baquero M. Performance of OraQuick advance rapid HIV-1/2
antibody test for detection of antibodies in oral fluid and serum/plasma in HIV-1+ subjects carrying different HIV-1
subtypes and recombinant variants. J Clin Virol 2009;45(2):150-52.
24. Ménard D, Maïro A, Mandeng MJ, Doyemet P, Koyazegbe T, Evaluation of rapid HIV testing strategies in under
equipped laboratories in the Central African Republic. Journal of Virological Methods 2005;126:75-80.

17.  In this study, the OraQuick test demonstrated high sensitivity and specificity
of 100% with oral fluid specimens as claimed by the manufacturer.
 These findings are in accordance with a previous study done in rural
population in India, although there were conflicting reports of lower sensitivity
and specificity of oral fluid-based tests elsewhere with high incidence of
false-positive and false-negative results.
 This study shows that OraQuick test using oral fluid seemed to be of patient’s
preference than the blood-based test as it was a painless, simple and
noninvasive procedure. It was also the test administrator’s preference over
the conventional blood-based tests as it was rapid, safe with least
occupational exposures, easier sample collection and simple to perform.
Mylonakis E, Paliou M, Lally M, Flanigan TP, Rich JD. Lab testing for infection with the HIV: Established and novel
approaches. Am J Med 2000;109(7):568-76.
Reynolds SJ, Muwonga J. OraQuick advance rapid HIV-1/2 antibody test. Expert Rev Mol Diag 2004; 4(5):587-91.

18.  This was also the test administrator’s preference over the conventional
 blood-based tests as it was rapid, safe with least occupational
exposures, easier sample collection and simple to perform. 28,29 The
test offers an immense benefit in pregnant patients without prenatal care
and also in case of occupational exposures.
 Dentists and emergency care providers are most commonly prone for
infections from contact with patient’s blood and oral fluids.
 Due to lack of adequate sterilization measures and detection facilities,
there is a greater chance of not only acquiring infection but also
spreading it among other patients unwittingly.Thus, incorporating this
simple to perform test kit, using noninvasive means, can greatly reduce
the risk of transmitting the infection.
31. Vernillo AT, Caplan AL. Routine HIV testing in dental practice: Can we cross the rubicon? J Dent Educ
2007;71(12): 1534-39.
32. White DA, Cheung PT, Scribner AN, Frazee BW. A comparison of HIV testing in the emergency
department and urgent care. J Emerg Med 2009;20

19.  There is a more recent study on this oral fluid-based test kit which
demonstrated its utility for detecting infections due to HIV-1 subtypes
and recombinants.
 Although the present study demonstrated the usefulness of the oral
fluid-based OraQuick rapid HIV-1 and 2 antibody test, the lies in its
inability to specify whether the sample contained HIV-1 or HIV-2
antibodies specifically, HIV-2 being less prevalent than HIV-1.
Holguín A, Gutiérrez M, Portocarrero N, Rivas P, Baquero M. Performance of OraQuick advance rapid
HIV-1/2 antibody test for detection of antibodies in oral fluid and serum/plasma in HIV-1+ subjects
carrying different HIV-1 subtypes and recombinant variants. J Clin Virol 2009;45(2):150-52.

20.  Although the present study demonstrated the usefulness of the oral fluid-
based OraQuick ® rapid HIV-1 and 2 antibody test, the disadvantage lies in
its inability to specify whether the sample contained HIV-1 or HIV-2
antibodies specifically, HIV- 2 being less prevalent than HIV-1.
 We conclude that this test kit is efficacious as an effective screening device
of HIV antibody detection; further studies are nm warranted in larger group
of population involving the dental set-up, emergency care units, pregnant
patients and high-risk groups directed at its diagnostic accuracy and to
introduce it as a routine office screening procedure.

22.  In four separate studies, we compared the accuracy of the rapid test
performed on whole blood and oral fluid specimens with the results
of conventional HIV tests.
 Oral fluid and whole blood from persons of unknown HIV status
recruited from clinics, labor and delivery units, and outreach venues
were tested with the OraQuick Advance rapid HIV-1/2 antibody test.
Kevin P Delaney, Bernard M Branson, Apurva Uniyal, Peter R Kerndt,
Patrick A Keenan, Krishna Jafa, Ann D Gardner, Denise J Jamieson, Marc
Bulterys AIDS 09/2006; 20(12):1655-60

23.  Sensitivity and specificity were compared with results of the enzyme
immunoassay (EIA) and Western blot algorithm used by the study sites.
 OraQuick sensitivity was 99.7% with whole blood and 99.1% with
oral fluid from 327 persons who were HIV antibody positive by the
conventional algorithm.
 OraQuick specificity was 99.9% with whole blood and 99.6% with
oral fluid from 12 010 HIV-negative persons.

24.  EIA specificity was 99.7%. A cluster of 16 false-positive oral
fluid tests occurred in one study, in which specificity was lower
(99.0%) than in the other three studies (99.6-99.8%).
 In diverse settings in four studies, the OraQuick test showed
high sensitivity and specificity for HIV antibody in whole blood
and oral fluid specimens.
 Slightly more false-positive and false-negative results
occurred with oral fluid than with whole blood, but
performance with both specimen types was similar to, or
better than, that of conventional EIAs.

25.  To date, no data had been published on the use of OraQuick Advance
Rapid HIV-1/2 Test (OraQuick) in the UK. He reported preliminary findings
of an ongoing evaluation of OraQuick in UK genitourinary (GU) medicine
clinics.
 A total of 820 samples from patients in high-risk groups for HIV were tested
with OraQuick and results were compared with standard HIV antibody
testing.
Kevin P Delaney, Bernard M Branson, Apurva Uniyal, Peter R Kerndt
AIDS 09/2006; 20(12):1655-60. · 6.41

26.  HIV prevalence (enzyme immunoassay [EIA]) was 5.73%, sensitivity
of OraQuick was 93.64% (95% CI 82.46-98.66%), specificity 99.87%
(99.28-100%), positive predictive value 97.78% (88.27-99.94%) and
negative predictive value 99.61% (98.87-99.92%).
 This included three false-negatives considered to be due to observer
error and now rectified by further training. It increased test sensitivity
to 100%.

27.  The observed test performance of OraQuick compares well
with EIA and with other rapid tests.
 They also believed that simple, non-invasive antibody
detection tests such as OraQuick can increase HIV testing
and diagnosis in UK GU medicine and community settings.

28.  Food and Drug Administration (FDA)–approved OraQuick Advance
Rapid HIV-1/2 Antibody Test (OraSure Technologies, Bethlehem, Pa.)
is diagnostic for HIV infection.
 It claims only to screen for the presence of antibodies to HIV-1 in
saliva. These antibodies suggest HIV-1 infection, but the assay is not
robust enough to prove it.
 A confirmatory test (OraSure HIV-1 Western Blot,OraSure
Technologies) is required to actually diagnose HIV-1 infection.

29.  The two tests are designed to work together, with a rapid, convenient and
inexpensive saliva-based screening step followed by a validated, accurate,
laboratory based Western-blot assay for confirmation.
 Saliva and its constituents, together with the test’s noninvasiveness, were
better suited for disease screening and risk assessment than for diagnostic
purposes.
 In addition to HIV, for which there is an FDA-approved autoantibody
detection test, infectious diseases of local origin (caries and periodontal
diseases) and systemic origin (human papillomavirus and hepatitis C virus)
will be detectable in saliva.

30.  WHO have identified four distinct categories of HIV testing: Diagnostic
testing, Voluntary counselling and testing (VCT), Routinised testing in
specific setting, and Mandatory testing.
 Diagnostic HIV testing is testing undertaken where signs and symptoms
related to an HIV infection are observed in any individual.
 Testing is carried out to ensure timely clinical diagnosis, and to ensure the
provision of adequate clinical support and services.
 People with certain diseases, such as tuberculosis and any other sexually
transmitted disease, are also tested for HIV infection on a regular basis.

31.  There are several limitations in that oral fluid assays may be unlikely to
detect those in early stages of HIV infection or with reduced viral load,
and have shown altered accuracy in pregnancy; however, such
 limitations also apply to other rapid assays.
 Research has suggested that in adults the most important factors in
HIV testing are test accuracy, time to results and privacy of results.
 Studies have also suggested that patients express a preference for
oral testing over venepuncture sampling since it is rapid and less
invasive, although preferences may vary in different settings.

32.  It seems that saliva specimens can be easily collected under difficult field
conditions with minimal training and provide a valuable alternative to
testing blood for HIV-seroprevalence studies.
 Salivary testing for HIV may be a convenient and potentially accurate
epidemiological tool.
 But it should be used with caution since single test systems may be less
appropriate to diagnose HIV infection in an individual without follow-up
testing.