Lecture 9 : Laboratory Diagnosis of HIV Infection.

9.0. Introduction.

Many cases of HIV infection may not present with symptoms and when symptoms do occur they may be
those of infections that may affect even those who are not infected with the virus such as tuberculosis.
For this reason it is important to have a dependable way of making a diagnosis of HIV infection so that it
is not confused with other diseases. In HIV as in many other diseases it is with the help of laboratory
tests that it becomes possible to reach a conclusion that an individual is infected with HIV. This lecture
will discuss the various tests that are conducted on people being screened for HIV infection such as
Voluntary Counselling and Testing clients as well as those who are tested because they have some
symptoms that are suspected to be associated with HIV infection.

9.1 Unit Objectives

By the end of this lecture you should be able to:

1. Describe the various tests that are used to identify HIV infection using laboratory tests,
2. Distinguish between antibody based-tests and antigen- based tests and give examples
of each.
3. Explain the advantages and disadvantages of each type of tests.
4. Identify other tests that are important in the treatment and follow-up of HIV infected
people.

9.2. Laboratory Diagnosis and Monitoring of HIV Infections

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infections may be the first ones that bring the patient to a health facility. As noted in the previous section common
illnesses that appear in HIV-infected people include skin rashes and boils, Herpes Zooster (shingles), Tuberculosis,
diarrhea and respiratory tract infections including pneumonia. All these are infections that may occur in people who
are not infected with the HIV virus so that their appearance in a person is not synonymous with HIV infection.
However, the occurrence of these illnesses is reason enough to suspect HIV infection and undertake tests to confirm
or array this suspicion. It is the role of Laboratory tests to establish conclusively whether an individual who is
apparently healthy has been exposed to HIV (screening) or one who is unwell is so because of HIV infection
(diagnosis).
9.3.Laboratory tests are useful in the following HIV related situations:

• Screening apparently healthy people who are interested in knowing their HIV status (Voluntary
Counselling and Testing- VCT)
• Screening blood for transfusion to improve safety of the recipient
• Routine screening of special groups such as Antenatal clients (pregnant mothers) and those treated for
other Sexually Transmitted infections
• Those being considered for post- exposure prevention where Antiretroviral medicines are given to
individuals who have been exposed to risk of HIV in order to prevent infection.
• Diagnostic purposes in suspected HIV infections where an individual has symptoms that may be related to
HIV infection

In addition to HIV tests, other laboratory tests are done for purposes of:

• Assessing the severity of HIV infection through CD4 counts and viral load measurements which helps in
making treatment decisions.
• Assessing effectiveness of treatment by doing CD4 counts, viral loads and viral culture

Doing baseline tests before starting ARV treatment – Haemogram– which measures haemoglobin, red blood cells,
white blood cell and platelet count, Liver and kidney functions tests.

9.4.Diagnosis

Antibody- Based Tests

These are the commonly used tests for diagnosis and depend on their ability to detect the presence of antibodies to
the HIV virus in the blood of the person being tested. There are many tests available with a high sensitivity as well
as specificity with brands such as Determine, First Response, Bioline and Unigold being in common use.

Rapid tests use fairly simple kits consisting with a strip or disc that has an area for putting a drop of blood, On the
strip there are the testing areas and the control area. A coloured line appears at the testing area usually marked with
a “T” if a person is infected with HIV. A similar line always appears in the control area usually marked with a “C”

Advantages of Rapid tests.

• Simple to perform
• give results within a short time usually 20 minutes hence the name” Rapid”
• Suitable for screening large numbers of samples
• Affordable kits that cost less than a hundred Kenya shillings per test are available

Widely available in Voluntary Counseling and Testing centers as well as health facilities.

Disadvantages of Rapid tests.

• Can miss early infection when the individual is in the “Window Period” and has not developed levels of the
antibodies that can be detected with the kits.
• On rare occasions can give false positive results.
 • They cannot be used to diagnose HIV in babies born to HIV positive mothers. This is because most of them
will be born with HIV antibodies inherited from the mother. However, only a fraction of them will be infected
while the others will be false positive. Inherited maternal antibodies take up to 18 months to be cleared from
the baby’s blood stream.

Given the important consequences of a HIV diagnosis it is crucial that the possibility of getting a false positive result
for a patient is kept to the minimum possible. For this reason all positive results must be confirmed by other test
methods as explained in the testing strategy given by the World Health Organization (WHO) This strategy is
explained below but guidelines change with time and this strategy is just an example and may not apply for ever
situation.

8.5. WHO Testing Strategy- The World Health Organization has a strategy for minimizing risk of having a false
Positive report.

The strategy advocates for the use of three different kits in HIV testing, where one test is used as the Test Kit. If this
Test Kit gives a negative report it is reported as such. Where an individual who is negative has had a recent risky
exposure such as unprotected sex he or she should be advised on a repeat test after two weeks and at three months
to take care of the “Window Period”.

Where the test kit gives a positive test then the second kit is used to confirm these results. If the two kits agree then
the results are reported as positive. However, if the second kit is negative then there is a tie with one saying positive
and the other saying negative. In such a situation, a third kit is used as a Tie- breaker.

If the Tie-breaker test is positive then the results are issued as positive. If the tie breaker is also negative these are
indeterminate results. It is recommended that a repeat test on another sample is done in two weeks .If still
indeterminate a follow up retest after up to 1 year. If still indeterminate consider negative.

Where possible the person can also go for hospital- based tests such as ELISA or Western Blot. Antigen based tests
such as the PCR can also be used where they are available.

False negatives can occur in situations such as:

• Recently acquired infection where the individual is still in the “window period”
• Atypical host response such as in people who have a condition called Agammaglobulinemia where there
is inadequacy of the proteins that make antibodies.
• Where the patient is infected with Type N and O strains of HIV 1 strains or HIV 2 subtype
• Advanced end stage disease where antibodies are depleted by antigen
• Technical error

Antigen Based Tests

These are tests that look for components of the HIV virus such as the P24 protein, the Glycoprotein 120 and even the
viral RNA genome. These viral components are referred to as antigens. Antigen based tests include:

• Polymerase chain reaction (PCR) The polymerase is an enzyme that facilitates DNA replication. The test
uses the technique of DNA amplification to enable the identification of the viral genome as confirmation of
infection.
 • Viral load measurement- measures the number of HIV viruses present in a patient’s sample. They are
reported in viral copies per milliliter of blood
• P24 antigen assay- A measure of the presence and levels of the viral protein that form the viral core or
capsid
• Viral culture where the virus is grown in laboratory settings

The main advantages of Antigen based tests include:

• They are highly accurate in identifying HIV infection

• They are not affected by the Window Period
• They can be used to diagnose HIV infection in babies
• They are important in assessing response to treatment
• Development of resistance in children below 18 months

The disadvantages of these type of tests include:

• They are expensive,

• They are available only in a few, highly specialized laboratories
• They require high levels of training for those doing them and are therefore not generally used.

Lab Monitoring The following are other laboratory tests that are important for people infected with the HIV
virus:

• CD4 counts- These include the absolute count as well as the percentage
• Normal 500-1400 cell/ml of blood
• Less than 350 cells/ml of blood has been used as a threshold for starting patients on ARVs

Note: Effective Antiretroviral treatment achieves the median increase of CD4 cells of 100-150 cells per year

The test is usually done every 6 months during follow up of patients.

Tests for other Sexually Transmitted Diseases

Those who have been diagnosed with HIV infection should also be screened for other sexually transmitted diseases.
This is because the risk factors for contracting these disease are similar to those of HIV.
SUMMARY

This lecture discusses the role of laboratory testing in the diagnosis of HIV infection. The test
can be done for purposes of screening well people for exposure to HIV infection as well as
for those who are unwell and whose symptoms may be associated with HIV infection. The
lecture has discussed the two main groups of tests the antibody- based and the antigen-
based tests as well as highlighting the advantages and disadvantages of each. Other tests that
are important in the management and follow-up of people living with HIV have also been
mentioned.

Place here the unit summary, forming the body of this unit.

NOTE

Antibody- based tests are susceptible to the “Window Period” source of error where individuals
who have recently acquired infection can test false negative. This is a challenge even for blood
donor services where infected donors in this stage may be missed by the screening.
ACTIVITIES

Visit a nearby Voluntary Counselling and Testing(VCT) Center and discuss with the
VCT Counsellor the use of Rapid Tests in screening of clients in that clinic. As such
health workers may be busy you may have to make an appointment booking and politely
explain the purpose of your interview. You may also make your own screening part of
the process.

SELF-TEST QUESTIONS

1. Discuss the role of antibody tests in screening for and diagnosis of HIV infection.
2. What are the advantages and disadvantages of antigen- based tests as applied in a
developing country such as Kenya?

Place here the self-test questions for this unit.

FURTHER READINGS