3/15/2017

Comparison of 3rd and

4th Generation HIV
Testing on False
Positivity Rate
28 MAR 2017

2d Lt Cedric Walters
TSgt Mary Ann Caso
Public Health and Preventive Medicine Dept
Epidemiology Lab
U.S. Air Force School of Aerospace Medicine

Integrity  Service  Excellence

Cleared, 88PA, Case # 2017-0320, 30 Jan 2017. 1

Disclaimer

The views expressed are those of the author

and do not necessarily reflect the official policy
or position of the Air Force, the Department of
Defense, or the U.S. Government.

Cleared, 88PA, Case # 2017-0320, 30 Jan 2017. 2

Overview

• HIV Program Background

• Advantages/recommendations to switching to 4th
gen
• 3rd and 4th generation HIV immunoassay background
• Specificity and False Positives
• Review cumulative HIV positivity data
• Evaluate actual performance to manufacturer’s
claims
• Summary

Cleared, 88PA, Case # 2017-0320, 30 Jan 2017. 3

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HIV Program Background

• AF HIV Program
• Force screening – every 2 years for AD/ARC
• New applicant screening
• Pre-deployment testing
• Clinical indications

Cleared, 88PA, Case # 2017-0320, 30 Jan 2017. 4

Advantages/Recommendations of
4th Gen Screening

• June 2014 CDC and APHL recommends 4th

gen screen
• FDA approval of improved HIV assays allowing
sooner detection
• Risk of HIV transmission from persons with acute
infection is much higher
• Indications for clinical benefits from antiretroviral
treatment of all persons with HIV, including those
with acute infection

CDC and APHL, Laboratory Testing, June 2017

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Advantages/Recommendations of
4th Gen Screening

• Retrospective study in HIV-1 RNA positive/

HIV-1 western blot negative samples
• 3rd gen sensitivity – 20-37%
• 4th gen sensitivity – 62-83%

CDC and APHL, Laboratory Testing, June 2017

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Advantages/Recommendations of
4th Gen Screening

• Epi Lab conducts verification of new assay based on

claims:
• More accurate for acute HIV-1 infection, lower false-
negative rate
• Equally accurate for established HIV-1 infection
• High specificity test won’t detect HIV in disease-free
population
• No control bracketing required

CHIV SIEMENS, Package Insert

Cleared, 88PA, Case # 2017-0320, 30 Jan 2017. 7

3rd Generation HIV Screen

• Chemiluminometric Immunoassay
(Antigen/Antibody Sandwich)

• HIV 1/O/2
• Detects antibody only (IgM/IgG)

• Antibody production begins approx 22 days after

HIV infection
• 95% of individuals will show detectable antibodies to
HIV at 4-6 weeks
• 99% of individuals seroconvert by 3 months
EHIV SIEMENS, Package Insert

Cleared, 88PA, Case # 2017-0320, 30 Jan 2017. 8

4th Generation HIV Screen

• Chemiluminometric Immunoassay
(Antigen/Antibody Sandwich)

• “Combo” Assay
• Detects antibodies to HIV 1/O/2
• Monoclonal antibody allows detection of p24 antigen

• p24 antigen appears approx 17 days after infection

• Allows detection of more acute HIV infections

CDC and APHL, Laboratory Testing, June 2017

Cleared, 88PA, Case # 2017-0320, 30 Jan 2017. 9

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HIV Testing Algorithm

Cleared, 88PA, Case # 2017-0320, 30 Jan 2017. 10

HIV Sequence of Markers

Cleared, 88PA, Case # 2017-0320, 30 Jan 2017. 11

Specificity and False Positives

• Specificity (true negative rate)-Percentage of

healthy people who are correctly identified
as not having the condition
True Negatives

True Negatives + False Positives

• 50 person disease free population

• 45 True Negative, 5 False Positives
• 5 are falsely measured as having the disease
• 45/(45+5)=90% Specificity
Cleared, 88PA, Case # 2017-0320, 30 Jan 2017. 12

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Air Force Epi Lab Numbers

6-Month 3rd Gen Period

• 1 Apr 2015 – 30 Sep 2015
• 180,625 3rd gen screens
• 203 repeatedly positive (0.11%)
• 60 positive by confirmation testing (0.033%)
• 70% of repeatedly positive specimens were false
positive
• Negative by Multispot and HIV-1 RNA
• Specificity – 99.92%

Cleared, 88PA, Case # 2017-0320, 30 Jan 2017. 13

Air Force Epi Lab Numbers

6-Month 4th Gen Period

• 1 Oct 2015 – 30 Mar 2016
• 172,437 4th gen screens
• 240 repeatedly positive (0.14%)
• 53 positive by confirmation testing (0.031%)
• 78% of repeatedly positive specimens were false
positive
• Negative by Multispot and HIV-1 RNA
• Specificity – 99.89%

Cleared, 88PA, Case # 2017-0320, 30 Jan 2017. 14

Air Force Epi Lab Numbers

Number Tested True Positives* False Positives Specificity
3rd Gen 180,625 60 143 (70%) 99.92%
4th Gen 172,437 53 187 (78%) 99.89%

True Negatives

True Negatives + False Positives

(180,625-203)
3rd Gen Specificity = = 99.92%
(180,625-203)+(143)

(172,437-240)
4th Gen Specificity = = 99.89%
(172,437-240) + (187)
*Includes first time positives only

Cleared, 88PA, Case # 2017-0320, 30 Jan 2017. 15

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Evaluating Manufacturer’s Claims

Number True False Specificity

Tested Positives Positives

3rd Gen 6011 2 5 (71%) 99.90%

Claim
3rdGen 180,625 60 143 (70%) 99.92%
Epi Lab
4th Gen 6140 2 17 (89%) 99.72%
Claim
4th Gen 172,437 53 187 (78%) 99.89%
Epi Lab

EHIV SIEMENS, Package Insert

CHIV SIEMENS, Package Insert

Cleared, 88PA, Case # 2017-0320, 30 Jan 2017. 16

Summary

• 3rd gen vs. 4th gen screen detection of p24

antigen
• Advantages – greater sensitivity/earlier
detection of virus
• HIV testing algorithm/presence of markers
• Specificity and False Positives
• Epi Lab data – lower false positive rate in 3rd
gen vs. 4th gen screens
• Comparing Epi Lab data to manufacturer’s
claims

Cleared, 88PA, Case # 2017-0320, 30 Jan 2017. 17

Cleared, 88PA, Case # 2017-0320, 30 Jan 2017. 18

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References

Centers for Disease Control and Prevention and Association of Public

Health Laboratories. Laboratory Testing for the Diagnosis of HIV
Infection: Updated Recommendations. Available at
http://stacks.cdc.gov/view/cdc/23447. Published June 27, 2014.

HIV 1/O/2 Enhanced (EHIV) SIEMENS ADVIA Centaur/XP [Package Insert]

HIV Ag/Ab Combo (CHIV) Assay SIEMENS ADVIA Centaur/XP [Package

Insert]

Cleared, 88PA, Case # 2017-0320, 30 Jan 2017. 19

Thank You

Questions?

Cleared, 88PA, Case # 2017-0320, 30 Jan 2017. 20