OperationalGuidelinesforHIV2Diagnosis

IntroductionThereare2typesofHumanimmunodeficiencyvirus(HIV)viz.HIVtypeI(HIV1)and
HIVtype2(HIV2).ThemostcommoncauseofHIVdiseasethroughouttheworldisHIV1which
comprises of several subtypes with different geographic distributions. HIV type 2 (HIV2) is
endemicinWestAfricaandhasspreadinthelastdecadetoIndiaandEurope.

NaturalhistorystudiesindicatethatHIV2islesspathogenicthanHIV1.ThoseinfectedwithHIV2
haveslowerdiseaseprogression,amuchlongerasymptomaticstage,slowerdeclineinCD4count,
lowerratesofverticaltransmission,lowerviralloadswhileasymptomaticandsmallergainsinCD4
countinresponsetoantiretroviraltreatment(ART).

ItisobservedandwelldocumentedthatinfectionwithHIV2doesnotprotectagainstHIV1and
dualinfection.Duallyinfectedpatientstendtopresentatamoreadvancedstageofdiseasethan
thosewithHIV2only.InfectionwithbothHIV1andHIV2generallycarriesthesameprognosisas
HIV1singleinfection

Information on the epidemiology of HIV2 and dual infection in India is limited. However, a few
cases of HIV2 infection have been reported. The existing national guidelines and the diagnostic
andtreatmentalgorithmsdonotallowfordiscriminationinthediagnosisofHIVinfectionbytype.
InordertoprovidefortreatmentalternativesforHIV2anddualinfectedpersons,itisimportant
to assess the characteristics as well as response to ART for HIV2 and dual infections and this
wouldrequireaccuratediagnosisofHIV2.

Although HIV1and HIV2 are related, there are important structural differences between them.
Accurate diagnosis & differentiation of HIV1 & HIV2 is crucial for treatment, as HIV2 is
intrinsically resistant to NNRTI, the pillar of national first line ART regimen. This information is
crucialfortreatmentofinfectedindividualsaswellasforunderstandingextentofHIV2infections
inIndia.DiscriminatingrapidkitsarebeingusedatICTCs.However,HIV2positivityshowninthese
testsneedsconfirmationwhichcannotbedoneatICTCs.
NACOhasestablishedanetworkoflaboratorieswhichincludesICTCs,Statereferencelaboratories
(SRLs)andNationalReferencelaboratories(NRLs).DesignatedNRLs&SRLswillberesponsibleto
confirmthepresenceofHIV2infection.

Instructions to be followed by ART centers for referring clients/patients for HIV 2 diagnosis
(RefertoFlowchart):
I.

II.
III.

IV.
V.
VI.
VII.

Clients/PatientswiththefollowingreportfromtheICTCSpecimenispositiveforHIV
antibodies(HIV1andHIV2;orHIV2alone)(Annexure8)willbereferredtothenearest
ARTcentreforregistration.
TheARTcentrewillthenreferthesaidclient/patienttothedesignatedHIV2referral
laboratoryasperAnnexure1
ThepatientmustcarryICTCreportandareferralslip(Annexure2)dulysignedbytheART
MedicalOfficeralongwithaphotoIDtothereferrallabonanyworkingdayfromMonday
toFridaybetween9:00AMto2:00PM.
TheHIV2referrallabwillcollectfreshbloodspecimen(serum+plasma)forHIVsero
statusconfirmation
SpecimenwillbetestedbyreferrallaboratoryasperthenationalalgorithmforHIV2sero
diagnosis(Annexure3).
Twocopiesofreport(Annexure4)willbesenttothereferringARTcenter(bothhard&
softcopy)within4weeks
CopyofthereporttoberetainedbythereferringARTcenter&originaltobehandedover
topatient/client

InstructionstobefollowedatHIV2ReferralLaboratories:
I.
CheckICTCreport,ReferralslipfromARTcenter,photoIDandrelateddetailsintheforms
II.
Collect5mlbloodeachintwotubesoneplainandoneEDTAvacutainertube
III. Separatetheserumfrombloodcollectedinplainvacutainer.Proceedasperthealgorithm
forHIV2asperAnnexure3
IV. StorethebloodcollectedinEDTAvacutainerat200C.Onlythosesampleswillbesendto
ApexlaboratorywhoseresultisindeterminateeitherforHIV1,HIV2orHIV1&2by
Westernblot(Annexure5:PCRrequisitionform).ThesesampleswillbetestedatApex
laboratorybyMoleculartests.
V. ReportstobesenttoreferringARTcenterbybothassoftcopy(email)andahardcopy.
Hardcopyofthereporttobepreparedintriplicate.Originalandacopytobesenttothe
referringARTcentreandonecopytoberetainedintheReferrallabforrecords.
VI. UtilizationofkitdetailstobesubmittedtoApexlaboratoryeveryquarterlyasper
Annexure6

FlowchartForreferringthePatientforHIV2Testing

Clients/Patients
(withICTCReportSpecimenispositiveforHIVantibodies(HIV1andHIV2;orHIV2alone)
andReferralslip]

ARTCenter

DesignatedHIV2referrallaboratory

Collectfreshbloodspecimen

TestasperthenationalalgorithmforHIV2serodiagnosis

ReportingtoreferringARTcenter(bothhard&softcopy)

RetainacopyofreportatARTandhandoveroriginalreporttopatient

Annexure1:DesignatedHIV2referrallaboratories
Sr.No. ReferringARTcenters
Nameoflaboratory
ContactName&Address
NARI,Pune
Dr.A.R.Risbud
1
Maharashtra,Mumbai,
ScientistF
Dadra&NagarHaveli,
NationalAIDSResearchInstitute
Daman&Diu,Goa
NACOlaboratory
PlotNo.73,GBlock,MIDC,
Bhosari,Pune411026
Ph.No:02027331200Ext.
Email:nrl.nari1@gmail.com
Dr.BhaswatiBandopadhyay
SchoolofTropical
2
Bihar,WestBengal,
NRLIncharge
Medicine(STM),
Jharkhand,Sikkim,
Dept.ofVirology,4thFloor,
Kolkata

SchoolofTropicalmedicine,108,C.R.Avenue
Kolkata700073.
Ph.No:03322198538
Email:nrl.stm1@gmail.com
Dr.R.L.Icchpujani
3
Delhi,Haryana,Himachal NationalCentrefor
DiseaseControl
NRL Incharge, Centre of AIDS & Related
Pradesh,Jammu
(NCDC),Delhi
Diseases,NationalCentreforDiseaseControl,
&Kashmir,Punjab,

22ShamnathMarg,NewDelhi110054.
Chandigarh,Rajasthan
Tele/Fax:01123934517
Email:nrl.nicd@gmail.com
4
AndhraPradesh
IIPM,Hyderabad
Dr.UmaDevi

NRLIncharge
InstituteofPreventiveMedicine,
BSQCDepartment,Narayanguda,NearYMCA
Hyderabad500029
Ph.No:04027568167
Email:nrl.ipm@gmail.com
5
UttarPradeshand
NIB,Noida
Dr. RebaChabra
Uttaranchal
NRLIncharge
NationalInstituteofBiologicals
A32,Sec62,NOIDA(UP)201307
Ph.No:01202400022/2400072
Ext.2380/2173
Email:nrl.nib@gmail.com
6
Assam,Meghalaya,
Guwahati
Medical Dr.NabaKr.Hazarika
ArunachalPradesh
College&Hospital
Dept.ofMicrobiology,
GauhatiMedicalCollege&Hospital,
Guwahati781032
Ph.No:03612529457
Email:srl.assam.gmc@gmail.com

10

11

Odisha

SCBMedicalCollege&
Hospital,Cuttack

Karnataka

NIMHANS,Bangalore

Dr.AshokaMahapatra
SCBMedicalCollege&Hospital,
Cuttack,Orissa751007
Ph.No:06712410041
Email:srl.orissa.scbmc@gmail.com
Gujarat
BJMedicalCollege,
Dr.M.M.Vegad
Ahmedabad
Head&Prof.Dept.ofMicrobiology,
B.J.MedicalCollege,Asarwa,
Ahmedabad,Gujarat380016
Ph.No:07922683721
Email:srl.gujarat.bjmc@gmail.com
Kerala,Lakshwadweep
TD medical college, Dr.AnithaMadhavan
Alapuzha
SRL,DepartmentofMicrobiology.

Govt.TDmedicalcollege,
Alapuzha,Kerala688005
Ph.No:04772282015
Email:srl.kerala.mc2@gmail.com
Madhya Pradesh & Gandhi
Medical Dr.DeepakDube
Chattisgarh
College,Bhopal
SRLIncharge,DepartmentofMicrobiology,
GandhiMedicalCollege,
BarakktullahVishwavidyalaya,
SultaniaRoad,Bhopal462001.
Ph.No:07552730502
Email:srl.mp.gmc@gmail.com

12

Manipur,Nagaland,
Tripura,Mizoram

RIMS,Imphal

13

TamilNadu&
Pondicherry,Andaman&
Nicobarislands

MadrasMedical
College,Chennai

Dr.AnitaDesai
AssistantProfessor
Dept.ofNeurovirology,NIMHANS,
HosurRoad,Bangalore560029.
Ph.No:08026995778Ext.
Fax:08026564830
Email:nrl.nimhans8@gmail.com
Dr.Ng.BrajachandSingh
NRLIncharge
DepartmentofMicrobiology,
RegionalInstituteofMedicalScience,P.O.
Lamphelpat,Imphal(west),Manipur795004
Ph.No:03842414750Ext181
Email:nrl.rims1@gmail.com
Dr. Vasanthi
Prof&OfficeIncharge,HIVNRLLaboratory,
TowerBlock1,RoomNo.106,
MadrasMedicalCollege,Chennai600003
Ph.No:04425383445Ext.
Email:nrl.mmc@gmail.com

Annexure2:ReferralSlipforHIV2testing

TobefilledinduplicatebyARTI/C/SMO/MO.Originalcopytobesentto
HIV2referrallaboratoryClient/patienttocarryICTCHIVreport&photoID

Name:Surname___________Middlename____________Firstname___________________

Date:_________________(DD/MM/YY)Gender:M/F/TGAge:_________Years

ICTCPID#___________PreARTReg.no.______________

NameandpostaladdressofreferringARTcenter:

EmailIDofreferringARTcenter/MOincharge:

Name&SignatureofMedicalOfficerARTcenter:

Annexure 3: National HIV 2 Testing Algorithm

TestKitstobeusedatthereferrallab:

Rapid1:DetermineHIV1/2(FDAApproved)HIV1WesternBlot:NewLAVBlot1
Rapid2:HIVTridotHIV2WesternBlot:NewLAVBlot2
Rapid3:ImmunocombBispotHIV1&2

TestingAlgorithmforHIV2samples

S.NO.

T1

T2

T3

DETERMINE

HIVTRIDOT

IMMNOCOMB

Actionrequired

ResultsWB
HIV1

Results
WBHIV2

FinalInterpretation

Negative

SCREENING

HIV1

HIV2

HIV1

HIV2

NEG

FollowupwithICTC
throSRL

POS
TESTBYBOTH
HIVTRIDOT
AND
IMMUNOCOMB

NEG

Nofurthertesting
requiredasboth
differntiatingrapid
testsaregivingHIV1
result

POS

NEG

POS

ReportasHIV1positive

POS

POS

POS

POS

POS

NEG

POS

POS

NEG

POS

NEG

NEG

POS

POS

POS

PerformHIV1&HIV2
WB(ToconfirmHIV
type)

PerformHIV2WB(To
confirmHIV2status)

PerformHIV1&HIV2
WB(ToconfirmHIV
type)

POS

NEG

HIV1

NEG

POS

HIV2

POS

POS

HIV1+2

NEG

NEG

Negative

POS

IND

IND

POS

IND

IND

SamplesgivingIndeterminate
resultswithWBberefferedto
ApexLabforHIV1and/orHIV2
PCRasperthecase

NEG

Negative

POS

HIV2

IND

RepeatTesting

POS

NEG

HIV1

NEG

POS

HIV2

POS

POS

HIV1+2

NEG

NEG

Negative

POS

IND

IND

POS

IND

IND

SamplesgivingIndeterminate
resultswithWBberefferedto
ApexLabforHIV1and/orHIV2
PCRasperthecase

POS

POS

NEG

NEG

POS

NEG

POS

NEG

NEG

NEG

PerformHIV1&HIV2
WB(ToconfirmHIV
type)

PerformHIV1WBonly
forconfirmation

POS

NEG

HIV1

NEG

POS

HIV2

POS

POS

HIV1+2

NEG

NEG

Negative

POS

IND

IND

POS

IND

IND

SamplesgivingIndeterminate
resultswithWBberefferedto
ApexLabforHIV1and/orHIV2
PCRasperthecase

POS

HIV1

NEG

Negative

IND

RepeatTesting

Annexure4:ReportFormattobeusedbyHIV2ReferralLaboratories
Tobefilledintriplicate.TwocopiestobesendtoreferringARTcenter
(oneforPatientandoneARTrecord)
NameoftheReferralLaboratory

Name:Surname___________Middlename____________Firstname____________________

Date:_________________(DD/MM/YY)Gender:M/F/TGAge:_________Years

ICTCPID#___________PreARTReg.no.______________

LaboratorySampleID___________________

NameofreferringARTcenter:

Dateofsamplecollection(DD/MM/YY)

Dateofsampletesting(DD/MM/YY)

TestName
Rapid
Rapid
Rapid1
HIV1WB HIV2WB
2
3
Nameofthekit

Result

FinalInterpretationofTestResult:

SignatureoflaboratoryInchargeDate:

POS:Positive,Neg:Negative,IND:Indeterminate,ND:NotDone,WB:WesternBlot

***ENDOFREPORT***

Annexure5:PCRRequisitionForm

NameoftheReferralLaboratoryrequestingPCR:

Name:Surname___________Middlename____________Firstname____________________

Dateofsamplecollection:_________(DD/MM/YY)Gender:M/F/TGAge:_________Years

ICTCPID#___________ PreARTReg.no.______________

LaboratorySampleID___________________

NameofreferringARTcenter:

AddressofreferringARTcenter:

Serologicaltestresultatthereferrallaboratory:

SignatureoflaboratoryIncharge:

Annexure6:Inventoryforkitutilization
(TobesentquarterlytoApexlaboratorybyemail)

Date:
Nameofkit

BatchNo./
Expirydate

DetermineTMHIV1/2

HIVTridot

ImmunocombBispot
HIV1/HIV2

NewLavBlot1

NewLavBlot2

SignatureofLaboratoryIncharge:

No.ofkits
received

No.ofkits
used

Balance

Annexure7: HIV2ReferralLaboratoryCumulativeMonthlyReportingFormat

NameofHIV2ReferralLaboratory:

HIV2ReferralLaboratorycumulativeMonthlyReportingFormat
Number
Number
Number Number Number
thatare
Number
Number
Number
thatare
Number
ofART
of
thatare thatare
referred
of
of
both
thatare
primary only
only
toApex
samples
Month/Year centers
HIV1&
patients
HIV
referring
samples HIV1 HIV2
labfor
thatare
received
HIV2
Negative
further
patients
collected Positive Positive
rejected
Positive
testing

SignatureofLaboratoryIncharge:

Annexure8:ICTCHIVTestReportingFormat
HIVTESTREPORTFORM

NameandaddressofICTCcentre:(Formtobefilledinduplicate)

Name:Surname___________Middlename____________Firstname____________________

Gender:M/F/TGAge:_________YearsPID#___________LabID#_____________

Dateandtimeblooddrawn:____________________(DD/MM/YY)________________________(HH:MM)
TestDetails:
Specimentypeusedfortesting:Serum/Plasma/WholeBlood
Dateandtimespecimentested:___________(DD/MM/YY)___________(HH:MM)
Note:
Column2and3tobefilledonlywhenHIV1&2antibodydiscriminatorytest(s)used
Nocellhastobeleftblank;indicateasNAwherenotapplicable.

Column1
Column2
Column3
Column4
Reactive/Nonreactive(R Reactive/Nonreactive
Reactive/Nonreactive
NameofHIVtestkit /NR)
for
HIV1 (R/NR) for HIV2
(R/NR)forHIVantibodies
antibodies
antibodies
TestI:

TestII:

TestIII:

Interpretationoftheresult:Tick()relevant
SpecimenisnegativeforHIVantibodies
SpecimenispositiveforHIV1antibodies
*SpecimenispositiveforHIVantibodies(HIV1andHIV2;orHIV2alone)
SpecimenisindeterminateforHIVantibodies.Collectfreshsampleintwoweeks.
*ConfirmationofHIV2serostatusatidentifiedreferrallaboratorythroughARTcentres

Name&SignatureName&Signature
LaboratoryTechnicianLaboratoryIncharge
Endofreport