By Nicholas Borgert

In the 10 minutes it takes to read this article, 100 more people on Earth will be infected with HIV, the virus that can lead to AIDS. That’s one new case every 6 seconds.

Yet statistics suggest the profile of HIV/AIDS patients differs greatly between the United States and other parts of the world. The Centers for Disease Control and Prevention (CDC) estimates that between 800,000 and 900,000 Americans are HIV positive. According to the CDC, more than 300,000 US residents, are now living with AIDS; about 40,000 new cases surface each year. Nearly half of Americans living with AIDS at the end of 2001 resided in four states: New York (17%), California (14%), Florida (11%), and Texas (7%). Nearly 80% were male; almost 75% were between the ages of 35 and 55.

HIV/AIDS is at epidemic status in many underdeveloped countries. In sub-Saharan Africa, 10% of the population is infected. The Joint United Nations Program on HIV/AIDS found:

• Outside the United States, an estimated 42 million people are living with HIV/AIDS, including 3.2 million children under age 15.

• Women are increasingly at risk; worldwide, about 50% of the 38.6 million adults living with HIV or AIDS—19.2 million—are women.

The Global Fund to Fight AIDS, founded in 2002 by the United States and the United Nations, underwrites testing and treatment in 120 countries. The US contribution for fighting AIDS is more than twice that of all other donor nations combined.

Many of those who are HIV positive live for years without getting sick. HIV steadily wears down the body’s immune system making it susceptible to viruses, parasites, fungi, and bacteria that don’t cause sickness in those with healthy immune systems.

The virus is transmitted by blood, vaginal fluid, semen, and breast milk. Initial symptoms mimic those of the flu: fever, headache, sore muscles and joints, swollen lymph glands, and often a skin rash. AIDS conditions often involve serious weight loss, brain tumors, and other health problems. There is no cure for AIDS and HIV cannot be purged from the body. Prescribed drugs can slow the virus and its damage to an immune system and drugs are used to treat opportunistic infections (OIs). Newer, more potent anti-HIV drugs have also helped reduce the rates of most OIs.

A vital part of managing AIDS is tracking a patient’s CD4+ cells (also called T-helper cells). Healthy people have between 500 and 1,500 CD4+ cells in a milliliter of blood. AIDS is diagnosed when a patient has less than 200 CD4+ cells or the percentage of T-helper cells falls below 14%.

Easier Tests, Faster Results
Calypte Biomedical reports it developed the first rapid response urine test for HIV 1 and 2. Richard George, PhD, is the company’s president and CEO. Calypte has been aggressive in developing products for rapid testing of HIV/AIDS, and plans to market three rapid assays that detect antibodies to HIV-1 and HIV-2. These rapid assays can be performed using urine, oral fluid, or fingerstick blood. Results from these tests will be available in 20 minutes. Administration of the tests does not require a lab or health care professional.

The urine and oral fluid assays are noninvasive and reduce the risk of accidental infection by eliminating the use of needles. These tests are currently in field trials in two separate studies in Thailand. The studies are expected to be completed this fall. Interim study reports were presented at the Calypte booth at July’s International AIDS Conference in Bangkok, Thailand. Following approval for use in the professional market, Calypte will seek approval to sell versions of the urine and oral fluid tests as over-the-counter tests in some countries.

George says that of the three phases in the management of the disease—testing, treatment, and monitoring—treatment has, without a doubt, shown the most progress over the past few years. “Drugs are extending life and improving the quality of life. I know patients who have been infected for more than 20 years and are relatively healthy,” he says. “However, many have misinterpreted this progress to mean that there is a cure. This has resulted in a return to the old careless ways of the early 1980s for some groups.”

Another important factor is the wider availability of antiretroviral drugs, he says. Treating pregnant women can drastically reduce mother-to-infant transmission. “Generic drugs are now available that allow patients to be treated for $300 to $400 per year instead of the thousands of dollars it cost just a few years ago,” he says. “Donor countries are making money available to purchase those drugs. Agencies such as WHO, CDC, and USAID are making it their goal to get as many people on treatment as possible.”

Advances in treatment have been accompanied by improvements in HIV/AIDS testing, George says. Today’s new generation of rapid tests are far more accurate, less costly and easier to perform than first-generation tests. Instead of days, rapid tests make it possible to produce a test result within minutes.

Rapid tests used with noninfectious body fluids make testing safer for health care workers who perform the tests. The tests can be administered in almost any setting. To identify those who are HIV positive and require therapy, millions must be screened, he says. New rapid tests can be taken to those who need it instead of waiting for them to come to the traditional testing sites.

Calypte’s oral fluid and urine rapid tests require no needles, syringes, infectious blood, or other sharp utensils that pose risk to health care workers. Calypte’s tests are simple enough that trained nonmedical personnel can conduct them.

“We also make a test called the HIV incidence test,” George says. “Developed by the CDC, the test was licensed to Calypte. It is used to identify populations where infections are occurring at the highest rates.”

Screening a population with conventional tests will indicate how many people are HIV positive, he says, but physicians won’t know when they were infected. A population could have been saturated years ago and no new infections are occurring. The new incidence test reveals how many of those infections occurred in the past 6 months.

This test is invaluable for targeting populations with a high incidence of HIV infections for intervention studies and for identifying populations that would be preferred for vaccine trials. It can also be used to evaluate the effectiveness of intervention efforts by showing either a negative or positive change in the incidence of infections following the intervention effort. The use of this test permits the efficient use of prevention dollars.

Another FDA-approved Calypte test detects HIV antibodies in urine. This assay is approved as a screening diagnostic test. Calypte makes two FDA-approved Western blot assays. One of these Western blot confirmatory tests is used to test urine samples and the other tests serum and plasma. The serum Western blot was the first Western blot approved in the United States. Among organizations using it is the American Red Cross.

George believes any successful HIV/AIDS program must include education, testing, counseling, and treatment. Efforts to stop the spread of HIV by education alone have not been successful; neither have testing programs that fail to educate.

“I think the proper emphasis is a massive education program about how to protect yourself from infection as the first step,” he says. “This would convince people they need to be tested and, if infected, treated. It would also permit them to behave responsibly and not infect other people.”

He credits the use of nucleic acid testing for reducing the window of detection to just a few days following infection. The United States has virtually eliminated HIV infected blood from the blood supply. And what about the next 5 to 10 years? “I sincerely hope that we will see a cure, a vaccine, or both,” says George.

Working With the Clinton Foundation
For Beckman Coulter, HIV monitoring continues to be a key interest. As HIV/AIDS diagnosis and treatment moves forward, the monitoring of treatment and disease progression is vital, especially in light of the development of drug-resistant strains of the virus.

The company has partnered with others to supply HIV/AIDS testing and monitoring equipment to developing countries, including efforts with a foundation formed by President Clinton. Beckman Coulter’s first shipment to South Africa in March featured CD4 monitoring tests and equipment, including the COULTER® EPICS™ XL flow cytometer introduced as the FlowCARE™ PLG CD4 System. Beckman Coulter expects to ship as many as 400,000 CD4 tests by year’s end; up to 15 million tests over the next 5 years.

HIV/AIDS has reached epidemic proportions in Africa, the Caribbean, South America, India and parts of the Far East, according to Bonnie Anderson, vice president of Beckman Coulter’s Translational Solutions Business Center. While incidences in Russia and China are not well documented, both countries are actively pursuing programs aimed at containing the disease.

Anderson says much of the money going toward HIV/AIDS recently has gone into prevention. Yet the impact of these funds has been disappointing. “Now, most countries are turning their attention to care and treatment programs,” she says. “One of the hopeful outcomes will be reduced viral levels that also impact transmission.”

The Clinton Foundation program blends business interests with humane concerns. “For diagnostic companies, there is significant investment required to establish the infrastructure in developing countries for instrument installations, training, education, and support,” Anderson says.

Participants such as Beckman Coulter must possess the financial stability to make a substantial up-front investment and to provide continued support of services required for monitoring in the years ahead. “This is actually quite different from the drug providers whose higher volumes drive costs down significantly,” Anderson says.

The Beckman Coulter technology, first developed by researchers at South Africa’s National Health Laboratories and now exclusively licensed by Beckman Coulter, uses a unique approach that isolates and identifies the CD4+ cell population using flow cytometry. This approach requires fewer parameters than other methods and works well on samples up to 5 days old.

Beckman Coulter will not enter the treatment segment, preferring to concentrate on tools for monitoring HIV treatment, according to Anderson. The company launched a point-of-care CD4 monitoring system called the PointCARE™ System at July’s AIDS Conference in Bangkok. It expects to begin shipping systems this month to Africa, the Caribbean, and other areas where monitoring of HIV treatment is in high demand.

An alternative to much larger flow cytometry systems found in central laboratories where FlowCARE will be sold, the PointCARE system identifies cells using gold-coated microparticles. PointCARE is ideally suited for remote testing areas where resources and highly trained operators are limited. This system enables the collection and analysis of samples in the clinic where patients are being treated. This product will soon be available as part of the company’s offering under the Clinton Foundation program as well.

Trinity Biotech’s Uni-Gold Recombigen HIV test detects antibodies to HIV in human serum, plasma, and whole blood.

Genetically Engineered Recombinant Proteins
Founded 12 years ago on the strength of its HIV POC test, Trinity Biotech has emerged as a major supplier of HIV test kits to sub-Saharan Africa, says Joe Randolph, Trinity’s marketing manager of HIV.

In December 2003, the FDA approved Trinity’s Uni-Gold™ Recombigen® HIV test, and the company was granted a CLIA waiver in June. The waiver allows the test to be run in as many as 200,000 test sites in the United States, including physician’s office labs and STD clinics. The test detects antibodies to HIV in human serum, plasma, and whole blood and provides results in 10 minutes. In general, no specialized training or education is required of the individual running the test.

Most infectious disease assays test for antibodies and employ antigens that bind with a patient’s antibody, Randolph says. The antigen is generally tagged or linked to another reagent that will produce color, or some type of signal that can be read, and ultimately represents a positive test when the antigen and antibody combine.

While traditional HIV assays use whole viral lysate as an antigen source, the Uni-Gold Recombigen HIV test features genetically engineered recombinant proteins as its antigen source. Because the proteins are engineered, only the specific portions desired are produced. The result: these proteins can be reproduced without variation in a basically unlimited supply. “Recombinant proteins provide better sensitivity and specificity while also allowing for a product that has very little lot-to-lot variation,” Randolph says.

In general, the United States is doing well in its fight against the spread of AIDS. The annual number of AIDS cases (about 40,000) and deaths (nearly 16,000) has remained stable since 1998. The increased prevalence of persons living with HIV and AIDS reflects the success of medical therapies and treatments. It also presents challenges for planners and providers of medical, prevention, and social services, as well as the affected individuals. For example, antiretroviral drug resistance is likely to increase, requiring new therapies and regimens to maintain health. “Because those with HIV are surviving longer, emphasis on strategies to help infected persons prevent transmission and encouraging people to learn their HIV status, are necessary to decrease incident infections,” Randolph says.

Finding More Sensitive Tests
Researchers at the University of Maryland’s Institute of Human Virology (IHV) recently unveiled a real-time immuno-PCR test. This ultra-sensitive technique can detect HIV infections earlier and at much lower levels than earlier tests. Combining a traditional ELISA approach and polymerase chain reaction technology, the new test is 25 times more sensitive than previous technologies, IHV estimates. Conventional testing has been able to detect HIV about 12 days after infection. By detecting HIV earlier, the new method can improve protection of the blood supply and expand available options for treatment of the virus. Institute researchers developed a 5-lb portable, battery-operated HIV monitoring system that can be powered from a car battery. That’s a major advantage in poor countries where a lack of electricity and extreme temperatures can hinder a central lab’s performance.

Nicholas Borgert is a contributing writer for Clinical Lab Products.