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Infant human immunodeficiency virus diagnosis in resource-limited settings: issues, technologies, and country experiences

https://doi.org/10.1016/j.ajog.2007.03.002Get rights and content

Diagnosing human immunodeficiency virus (HIV) infection in infants is difficult because maternal HIV antibodies cross the placenta, causing positive serologic tests in HIV-exposed infants for the first several months of life. Early definitive diagnosis of HIV requires virologic testing such as polymerase chain reaction (PCR), which is the diagnostic standard in resource-rich settings but has been too complex and expensive for widespread use in most countries with high HIV prevalence. Early PCR testing can help HIV-infected infants access treatment, provide psychosocial benefits for families of uninfected infants, and help programs for prevention of mother-to-child transmission of HIV monitor their effectiveness. HIV testing, including PCR, is increasingly available for infants in resource-limited settings, but there are many barriers and complex policy decisions that need to be addressed before universal early testing can become standard. This paper reviews challenges and progress in the field and suggests ways to facilitate early infant testing in resource-limited settings.

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Why test young infants?

Early HIV testing can help HIV-infected infants access treatment, provide reassurance for families of uninfected infants, and help PMTCT programs monitor their effectiveness. In settings with high HIV prevalence, a substantial proportion of infants who are ill may have HIV, and diagnosing symptomatic HIV cases on inpatient wards and in outpatient clinics is a critical priority for HIV treatment programs. Testing infants of known HIV-infected mothers through routine screening before they become

Barriers to testing infants

Early infant testing is becoming more available, but significant barriers still exist. Many clinicians believe that antibody tests have no value in infants; virologic tests are expensive and require sophisticated laboratory facilities. The expense of creating a laboratory with appropriate quality control and assurance to perform virologic testing is substantial, as are ongoing costs of test reagents. Laboratory technicians are in short supply in many resource-limited countries, and highly

Identifying infants for testing

The most obvious and accessible population requiring HIV testing is hospitalized and ill outpatient infants, who will have a high prevalence of HIV in any highly HIV-affected country. When available, PCR testing should be applied in hospital settings to confirm the HIV status of infants and direct their long-term medical management. In hospital settings in high-prevalence areas, routine HIV screening for all people with symptoms suggestive of HIV, quick access to HIV test results, and/or

HIV deoxyribonucleic acid (DNA) PCR

HIV DNA PCR is the standard method for virologic diagnosis of HIV in infants in the developed world. It has been used for many years, is the diagnostic test of choice recommended by the American Academy of Pediatrics and the WHO, and has excellent sensitivity and specificity.22, 23, 24 HIV infection can often be detected at birth, and essentially all perinatal infections are detectable by 4 weeks of age.25 Infections acquired postpartum (ie, through breast-feeding) can be detected by 4-6 weeks

Summary

Advances in technology and increases in funding for pediatric HIV have made early infant diagnosis of HIV infection more accessible than ever before. Despite this, most HIV-exposed infants in resource-limited settings in 2007 will not be tested for HIV. Although definitive virologic testing is the gold standard for infant diagnosis of HIV, it is important for programs without immediate capacity for virologic testing to recognize that the judicious use of basic clinical assessment and antibody

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    The findings and views expressed herein are those of the authors and do not necessarily represent the views of the Centers for Disease Control and Prevention.

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