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1 Guidelines for UsingHIV testing Technologiesin SurveillanceUNAIDS/WHOW orking Group on Global HIV/AIDS/STI SurveillanceWHOUNAIDSWHO/CDS/CSR/ : GeneralOriginal: English Guidelines for UsingHIV testing Technologiesin surveillance :Selection, Evaluation, andImplementationCenters for Disease Control and Prevention World Health Organization(WHO) WHO/CDS/CSR/ : GeneralOriginal: English ii Global surveillance of HIV/AIDS and sexually transmitted infections (STIs) is a joint effortof the World Health Organization (WHO) and the Joint United Nations Programme onHIV/AIDS (UNAIDS). The UNAIDS/WHO Working Group on Global HIV/AIDS and STI Sur-veillance, initiated in November 1996, is the main coordination and implementationmechanism for UNAIDS and WHO to compile the best information available and toimprove the quality of data needed for informed decision-making and planning atnational, regional and global and UNAIDS express their gratitude to those who have contributed their time andexperience and provided precious inputs and suggestions for the development of theseGuidelines.

2 The Centers for Disease Control and Prevention (CDC), Atlanta, USA, deserves specialcredit for having prepared these Guidelines. The key professional staff, Dr. ChristopherMurrill and Dr. Rebecca Martin, should be congratulated for their efforts in producing thisdocument, with editorial assistance from Ms. Sadhna Patel and Ms. Beatrice thanks should be given to Dr. Gaby Vercauteren and Dr. Susan Best, WHO, andDr. Mark Rayfield and Mr. Tim Granade, CDC, for providing scientific and technical exper-tise as well as for undertaking critical reviews of the draft work was supported and made possible by the Center for Population, Health andNutrition, Global Bureau, United States Agency for International Development (USAID),Washington, World Health Organization and Joint United Nations Programme on HIV/AIDS, 2001 WHO/CDS/CSR/ ISBN 9173-92-063-7 This document is not a formal publication of the World Health Organization (WHO) or theJoint United Nations Programme on HIV/AIDS (UNAIDS), and all rights are reserved.

3 Thedocument may, however, be freely reviewed, abstracted, reproduced or translated, in partor in whole, but not for sale or use in conjunction with commercial purposes. The viewsexpressed in documents by named authors are solely the responsibility of those mention of specific companies or of certain manufacturers' products does not implythat they are endorsed or recommended by WHO or UNAIDS in preference to others of asimilar nature that are not mentioned. Errors and omissions excepted, the names ofproprietary products are distinguished by initial capital letters. iii HIV testing Technologiesfor surveillance Table of Contents Executive Summary _____1 _____2 of HIV testing in HIV Serosurveillance of HIV testing testing Approaches HIV Incidence _____9 Used in HIV testing Selection and Disadvantages of Whole Blood, Serum, and Plasma and Disadvantages of Urine and Oral Collecting, Processing, and Storing Blood Specimens Whole Blood, Serum.

4 And Plasma Blood Collected by Venipuncture Serum and Plasma Collected by Venipuncture Blood by Finger Stick and Storing a Dried Blood Spot for an HIV Test Collecting and Storing Urine and Oral Fluids Urine and Oral Fluids Fluids Urine and Oral Fluids and Logging Collected Specimens Specimens _____16 iv hiv testing technologies and Strategies Used in surveillance hiv testing technologies of HIV testing Immunoassays Description Characteristics of EIAs Performing an EIA Tests General Description Characteristics of Rapid Performing a Rapid Test HIV testing Strategies for Surveillance_____22 and Evaluation of hiv testing technologies Used in HIV surveillance to Select Tests Evaluation of Selected Tests _____28 Quality Assurance and Safety Quality Assurance Quality Assurance Phase Phase Phase Procedures _____32 Appendix Universal Precautions for Prevention of Transmission of HIV, Hepatitis B Virus, and Other Bloodborne Pathogens in Health-Care Settings _____33 Glossary _____35 References _____37 List of Figures/Table/Boxes Figure Unlinked Anonymous HIV testing _____6 Figure Linked Confidential and Anonymous HIV Testing_____8 Figure 4 UNAIDS and WHO HIV testing Strategies _____23 Figure 5 How to Select an HIV Test _____26 Table A Comparison of hiv testing technologies : Enzyme Immunoassays and Rapid Tests __21 Box 1 Three different epidemic states _____2 Box 2 Linked and unlinked HIV testing _____5 Box 3 General outline for a country evaluation of hiv testing technologies _____29 1 Guidelines for Using hiv testing technologies in surveillance .

5 Selection, Evaluation, and Implementation Guidelines for Using hiv testing technologies in surveillance As the HIV/AIDS epidemic imposes an ever-larger burden globally, surveillance for HIV becomes more critical in order to understand thetrends of the epidemic and to make sound decisions on how best torespond to it. This is especially true in developing countries, whichaccount for a disproportionate share of new and long-standing help countries focus their surveillance activities in the context of theirepidemic state (low-level, concentrated, or generalized), the World HealthOrganization (WHO) and the Joint United Nations Programme on HIV/AIDS (UNAIDS) have developed a conceptual framework to improve HIVsurveillance second generation HIV surveillance . Guidelines for secondgeneration HIV surveillance suggest approaches to make better use of datato increase and improve the response to the HIV epidemic. As biologicalsurveillance (serosurveillance) is an important component of most HIVsurveillance activities, an understanding of current HIV testing technolo-gies is the context of second generation HIV surveillance , these labora-tory guidelines suggest methods for selecting, evaluating, and implement-ing hiv testing technologies and strategies based on a country slaboratory infrastructure and surveillance needs.

6 The guidelines providerecommendations for specimen selection, collection, storage, and testingand for the selection and evaluation of appropriate HIV testing strategiesand technologies to meet surveillance objectives. Quality assurance issuesare also technical guidelines are written for HIV surveillance coordi-nators and other health professionals involved in HIV testing for surveil-lance purposes in developing countries. They are part of a series ofoperational guidelines for second generation HIV surveillance systems. executive summary 2 Guidelines for Using hiv testing technologies in surveillance :Selection, Evaluation, and Implementation Introduction The Joint United Nations Programme on HIV/AIDS (UNAIDS) and the World Health Organi-zation (WHO) recommend the use of second generation HIV surveillance to improve collection,analysis, and use of data essential to AIDS control programs. The use of second generation HIVsurveillance is also promoted to help national and international institutions monitor the epidemicand guide their responses to it (UNAIDS/WHO 2000).

7 Using second generation HIV surveillanceapproaches, surveillance systems should be flexible in order to change with a country s needs andstate of the epidemic: low-level, concentrated, or generalized (Box 1) (UNAIDS/WHO 2000). Ascountries develop or enhance their surveillance programs using the principles of second genera-tion HIV surveillance , the surveillance data collected can be better used for the purposesdescribed above. summary Topics Addressed in These Guidelines Specimen Selection, Collection, Storage, and testing hiv testing technologies and Strategies Selecting and Evaluating testing technologies Quality Assurance Measures Box 1. Three different epidemic states Low-level epidemic: The epidemic state in which HIV has never spread to significant levels in any subpopulation, although HIV infection may have existed for many years. (HIV prevalence has not consistently exceeded 5% in any defined subpopulation.) Concentrated epidemic: The epidemic state in which HIV has spread rapidly in a defined subpopulation but is not well-established in the general population.

8 (HIV prevalence is consistently >5% in at least one defined subpopulation and is <1% in pregnant women in urban areas.) Generalized epidemic: The epidemic state in which HIV is firmly established in the general population. (HIV prevalence is consistently >1% in pregnant women.) introduction 3 Guidelines for Using hiv testing technologies in surveillance :Selection, Evaluation, and Implementation Second generation HIV surveillance relies on data collected from biological surveillance (serosurveillance), behavioral surveillance , and other sources ( , HIV/AIDS case surveillance ,death registration, sexually transmitted infection surveillance , tuberculosis surveillance ) todescribe a country s HIV epidemic and respond effectively. It aims to improve integration of datafrom these sources. It also supports continuous research into new epidemiologic tools; improvedmethods for building estimates and modeling the epidemic; and better ways for using data foradvocacy, planning, monitoring, and evaluation.

9 HIV serosurveillance data are used to estimate HIV prevalence rates and geographic distri-bution of infection, monitor trends over time in specific population groups, and identify subpop-ulations at increased risk for infection. This information is then used to assist countries efforts toset HIV policy and priorities, plan and evaluate prevention programs, and evaluate the effective-ness of the countries response to the biological surveillance is the primary method for determining HIV prevalence rateslocally or nationally, accurate HIV testing is critical for second generation HIV surveillance . Withadvances in diagnostic immunology, hiv testing technologies have improved greatly. Currentlyavailable enzyme immunoassays (EIAs) are more accurate than earlier generations of EIAs, andthe latest generation of HIV rapid tests can provide results similar to EIAs in less than 45 minuteswith minimal experience and no equipment. These rapid tests enable testing for HIV surveillanceactivities in areas where testing could not previously occur ( , areas with limited laboratoryresources) and for hard-to-reach populations ( , female sex workers) who may not be accessiblethrough clinical services.

10 These guidelines provide guidance on types of specimens to collect and how to store andtest them. They describe HIV testing strategies recommended by WHO, which are based on HIVprevalence rates, and existing hiv testing technologies used for biological surveillance . They alsoinclude information regarding strategies and technologies for use in diagnostic testing since datafrom diagnostic testing may also be used as a source of surveillance information. They outlinemethods for selecting and evaluating testing technologies appropriate to a country s epidemicstate and needs. Because accurate results are important in biological surveillance for HIV, qualityassurance measures are also addressed. The guidelines also include a glossary of terms used in thedocument. These technical guidelines are written for HIV surveillance coordinators and otherhealth professionals involved in HIV testing for surveillance purposes in developing are part of a series of operational guidelines for second generation HIV surveillance systems.