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WHO Recommendations on the Diagnosis of HIV Infection in Infants and Children. Geneva: World Health Organization; 2010.

Cover of WHO Recommendations on the Diagnosis of HIV Infection in Infants and Children

WHO Recommendations on the Diagnosis of HIV Infection in Infants and Children.

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ANNEX 1Summary of findings and quality of evidence evaluation for the use of virological testing

Applying the grades of recommendation assessment, development and evaluation (GRADE) methodology, specific questions were identified and formulated according the population targeted, intervention, comparator, outcome and time (PICOT) framework as follows:

  1. Should HIV infection in infants be diagnosed by performing an HIV DNA polymerase chain reaction (PCR) test at age 4–6 weeks compared with the gold standard?
  2. Should HIV infection in infants be diagnosed by performing an HIV RNA nucleic acid amplification test (NAT) at age 4–6 weeks compared with the gold standard?
  3. Should HIV infection in infants be diagnosed by performing an ultrasensitive p24 antigen (Us p24 Ag) test at age 4–6 weeks compared with the gold standard?
  4. Is HIV DNA PCR using dried blood spots (DBS) reliable for diagnosing HIV in infants at age 4–6 weeks compared with liquid samples?
  5. Is RNA NAT using DBS samples reliable for diagnosing HIV infection in infants at age 4–6 weeks compared with liquid samples?
  6. Is the Us p24 Ag test using DBS samples reliable for diagnosing HIV infection in infants at age 4–6 weeks compared with liquid samples?

A review of the literature was performed using the following sites and search engines: PubMed, MEDLINE, American Family Physician, Bandolier, The Journal of Family Practice, BMJ Clinical Evidence, The Cochrane Library, SUM search, National Guideline Clearinghouse, Institute for Clinical Systems Improvement, TRIP Database, abstracts from the Conference on Retroviruses and Opportunistic Infections (CROI) 2005–2008, and abstracts from the conference of the International AIDS Society (IAS) 2005–2008. Different combinations of the following search terms were used: HIV infection, HIV infant diagnosis, HIV virological test, HIV NAT test, HIV DNA assay, HIV RNA assay, p24 Ag assay, dried blood spots. Language or date of publication was not a restriction.

The paper selection process was performed according to the GRADE approach and studies were considered as ‘valid’ only if the following criteria were met:

  • Population of interest (infants <18 months exposed to HIV)
  • Uncertain diagnosis (infection status of the population being tested was unknown)
  • Consecutive enrolment
  • Comparison with an appropriate reference standard.

Therefore, valid studies of diagnostic test accuracy included representative and consecutive patients in whom legitimate diagnostic uncertainty existed; they involved a comparison between the test under consideration and an appropriate reference (‘gold’) standard. The studies were then listed and briefly described in simple summary tables (Tables A–1 to A–18).

Table A–1. Summary of evidence for the use of HIV DNA PCR assay.

Table A–1

Summary of evidence for the use of HIV DNA PCR assay.

Table A–2. Summary of findings for the use of HIV DNA PCR assay.

Table A–2

Summary of findings for the use of HIV DNA PCR assay. Question: Can HIV DNA PCR be used at 6 weeks to diagnose HIV in HIV-exposed infants?

Table A–3. GRADE profile for the use of HIV DNA PCR for diagnosis of HIV infection in infants.

Table A–3

GRADE profile for the use of HIV DNA PCR for diagnosis of HIV infection in infants. Question: Should HIV infection in infants be diagnosed by an HIV DNA PCR test at 4–6 weeks? Population group: Infants exposed to HIV (i.e. infants <18 (more...)

Table A–4. Summary of evidence for the use of HIV RNA NAT assay.

Table A–4

Summary of evidence for the use of HIV RNA NAT assay.

Table A–5. Summary of findings for the use of HIV RNA NAT.

Table A–5

Summary of findings for the use of HIV RNA NAT. Question: Can HIV RNA NAT be used at 6 weeks to diagnose HIV in HIV-exposed infants?

Table A–6. GRADE profile for the use of HIV RNA nucleic acid amplification testing (NAT) for diagnosis of HIV infection in infants.

Table A–6

GRADE profile for the use of HIV RNA nucleic acid amplification testing (NAT) for diagnosis of HIV infection in infants. Question: Should HIV infection in infants be diagnosed by performing an HIV RNA NAT test at 4–6 weeks? Population group: Infants (more...)

Table A–7. Summary of evidence for the use of HIV ultrasensitive p24 antigen (Us p24 Ag) assay.

Table A–7

Summary of evidence for the use of HIV ultrasensitive p24 antigen (Us p24 Ag) assay.

Table A–8. Summary of findings with the use of HIV ultrasensitive p24 antigen (Us p24 Ag) assay.

Table A–8

Summary of findings with the use of HIV ultrasensitive p24 antigen (Us p24 Ag) assay. Question: Can HIV Us p24 Ag assay be used at 6 weeks to diagnose HIV in HIV-exposed infants?

Table A–9. GRADE profile for the use of HIV ultrasensitive p24 antigen (Us p24 Ag) on plasma samples for diagnosis of HIV infection in infants.

Table A–9

GRADE profile for the use of HIV ultrasensitive p24 antigen (Us p24 Ag) on plasma samples for diagnosis of HIV infection in infants. Comparison: Is Us p24 Ag test using DBS samples reliable for diagnosing HIV infection in infants at 4–6 weeks? (more...)

Table A–10. Summary of evidence for the use of HIV DNA PCR on dried blood spot (DBS) samples.

Table A–10

Summary of evidence for the use of HIV DNA PCR on dried blood spot (DBS) samples.

Table A–11. Summary of findings for the use of HIV DNA PCR on dried blood spot (DBS) samples.

Table A–11

Summary of findings for the use of HIV DNA PCR on dried blood spot (DBS) samples. Question: Can HIV DNA testing on DBS samples be used at 6 weeks to diagnose HIV in HIV-exposed infants?

Table A–12. GRADE profile for the use of HIV DNA PCR using DBS samples for diagnosis of HIV infection in infants.

Table A–12

GRADE profile for the use of HIV DNA PCR using DBS samples for diagnosis of HIV infection in infants. Question: Is HIV DNA PCR using DBS reliable for diagnosing in infants at 4–6 weeks? Population group: Infants exposed to HIV (i.e. infants <18 (more...)

Table A–13. Summary of evidence for the use of RNA nucleic acid amplification testing (NAT) on dried blood spot (DBS) samples.

Table A–13

Summary of evidence for the use of RNA nucleic acid amplification testing (NAT) on dried blood spot (DBS) samples.

Table A–14. Summary of findings for the use of RNA nucleic acid amplification testing (NAT) on dried blood spot (DBS) samples.

Table A–14

Summary of findings for the use of RNA nucleic acid amplification testing (NAT) on dried blood spot (DBS) samples. Question: Can HIV RNA NAT on DBS samples be used at 6 weeks to diagnose HIV in HIV-exposed infants?

Table A–15. GRADE profile for the use of RNA nucleic acid amplification testing (NAT) on dried blood spots (DBS).

Table A–15

GRADE profile for the use of RNA nucleic acid amplification testing (NAT) on dried blood spots (DBS). Comparison: Is RNA NAT using DBS samples reliable for diagnosing HIV infection in infants at 4–6 weeks? Population group: Infants exposed to (more...)

Table A–16. Summary of evidence for the use of ultrasensitive p24 antigen (Us p24 Ag) assay on dried blood spot (DBS) samples.

Table A–16

Summary of evidence for the use of ultrasensitive p24 antigen (Us p24 Ag) assay on dried blood spot (DBS) samples.

Table A–17. Summary of findings for the use of ultrasensitive p24 antigen (Us p24 Ag) assay on dried blood spot (DBS) samples.

Table A–17

Summary of findings for the use of ultrasensitive p24 antigen (Us p24 Ag) assay on dried blood spot (DBS) samples. Question: Can HIV Us p24 Ag on DBS samples be used at 6 weeks to diagnose HIV in HIV-exposed infants?

Table A–18. GRADE profile for the use of HIV ultrasensitive p24 antigen (Us p24 Ag) on dried blood spot (DBS) samples for the diagnosis of HIV infection in infants.

Table A–18

GRADE profile for the use of HIV ultrasensitive p24 antigen (Us p24 Ag) on dried blood spot (DBS) samples for the diagnosis of HIV infection in infants. Question: Is the Us p24 Ag test using DBS samples reliable in diagnosing HIV infection in infants (more...)

Five studies were selected to assess the DNA PCR assay performance on liquid samples (Tables A–1 to A–3). Data collected on the use of this assay were published between 1993 and 2005. The studies were conducted mainly in high-income countries, and the performance indicators showed significant variation over time as technologies improved (1, 2, 3, 4, 5)

For the use of RNA NAT assays on plasma, the evidence used was based on four studies (Tables A–4 to A–6) (4, 6, 7, 8) published between 1997 and 2003. Good consistency of results was found across the studies. Only one study (Young et al.) (7) was conducted in a low–middle income country.

Data regarding the use of first-generation p24 Ag assay were excluded, given the superiority of the Us p24 Ag assay (Tables A–7 to A–9); nine studies (9, 10, 11, 12, 13, 14, 15, 16, 17) provided evidence on the performance of this assay and all but one (Fiscus et al.) (15) were conducted in low–middle income countries.

The use of DBS samples was reported by seven studies for HIV DNA PCR (Tables A–10 to A–12) (18, 19, 20, 21, 22, 23, 24), two studies for RNA-NAT (Tables A–13 to A–15) (24, 25, 30) and four studies for Us p24 Ag assay (Tables A–16 to A–18) (26, 27, 28, 29). The studies provide a comparison of the same assay performed on liquid samples or with the current gold standard.

In order to assess the sensitivity (Sn), specificity (Sp), positive predictive value (PPV) and negative predictive value (NPV) as accuracy indicators, a 2×2 contingency table was obtained from each study restricting data to the performance at age 4–6 weeks, wherever possible. Subsequently, the 2×2 contingency tables were pooled together and accuracy indicators were calculated for each of the assays considered.

Accuracy indicators were defined as surrogate outcomes while preparing the GRADE profile and, for each of the four indicators, valid studies were assessed for limitations using the Quality in Diagnostic and Screening tests (QUADAS) checklist. In addition, the presence of indirectness, inconsistency and impreciseness was assessed, and the final quality of evidence obtained (GRADE profiles).

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