National HlV Testing Network : Operational guidelines
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National HlV Testing Network :
Operational guidelines - extracted text
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National Hl^ Testing Network :
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Operational guidelines
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National AIDS Control Organization
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Government of India
Ministry of Health &, Family Welfare
1, Red Cross Road
New Delhi - 110 001
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CONTENTS
Chapter 1.
Review of the existing HIV testing programme
I
1 1 Present HIV Testing infrastructure
1
1.2 Need for decentralization oftheHIV testing activities
3
1.3 Quality Assurance and Quality Control Programmes
Chapter 2.
3
Current National HIV testing policy and strategies
5
2.1 National Policy on HIV testing
5
2.2 WHO Recommendations for selection and use of HI V
antibody tests
7
2.3 National HIV testing strategies
Chapter 3.
Structure ofthe decentralized HIV testing network
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3.1 Identification, establishment and functions of HIV
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testing facilities.
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Chapter 4.
Training programme of the staff of HIV testing facilities
Chapter 5.
Planning, Procurement, Storage and Distribution of HIV test kits
5.1
Planning
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5.2 Calculation ofthe requirement of HIV tests
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5.3 Procurement
32
5.4 Storage
33
5 5 Distribution
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Chapter 6.
Procurement, Distribution and Maintenance of Equipment
6.1 List of equipments
6.2 Procurement and distribution
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6.3 Maintenance
Chapter 7.
Quality Assurance Programme
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7.1 Necessity and importance
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7.2 Guidelines to improve quality of testing
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7.3 Proficiency testing of laboratory
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7.4 Structure of the National HIV Quality Assessment Programme
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7.5 Record keeping
7.6 Laboratory Aspects
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CHAPTER 1
Review of the Existing HIV Testing Programme
The pandemic spread of HIV and its threat for the developing countries became evident by
1985. The commercial kits for testing of HI V by this time became available. During the same
year, Indian Council of Medical Research (ICMR) started search for HIV infection in ‘ '
country as a research issue and hence the testing facility for HIV became available at two
centres (Pune and Vellore). With the evidence of infection found by 1986, the surveillance
was initiated in other geographic zones. Numerous HIV testing centres were setup in the
country which simultaneously acted for the surveillance, transfusion safety, identification of
HIV positive individual and research. At present there arc 62 surveillance centres, 150 zonal
blood testing centres, and nine referral centres in the country. In the course of time it was
realized that various objectives of HIV testing cannot be combined and different testing
procedures and test strategies should be applied for each one of them. Unlinked anonymous
HIV surveillance was implemented by the end of 80s and the advantages could be understood.
The ineffectiveness of the indiscriminate screening and testing of individuals in changing
high risk behaviour was also appreciated. In 1992, the National AIDS Control Organization
(NACO) took over the task of HIV testing from ICMR and effort for streamlining started. The
need for switching the surveillance activity from the surveillance centres to specially
identified sentinel sites was realized. On the issue of blood transfusion safety the necessity for
introduction of simple and rapid tests was considered. It was also decided to extend the 11IV
testing facilities for blood transfusion safety to every district of the country'. The Government
of India has spent nearly 2/3rd of its budget of National AIDS Control Programme between
1987 and 1992 for testing facilities for HIV and blood banking. During the current five Y carPlan, 30% of the budget allotted for AIDS Control will be spent on blood safety programme.
Since 1993 HI V-l and HIV-2 mixed kits, which have been evaluated by WHO and have
the desired sensitivity and specificity, have been used for all testing objectives except some
research areas.
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/. 1 Present HIV Testing Infrastructure
Surveillance centres
By December 1993, surveillance centres were functioning in 30 oi the 32 states and union
territories, except union territories (UT) of Daman & Diu and Dadraand Nagar Havcli. I hese
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two territories were covered by the neighbouring states. The surveillance centres equipped
with ELISA testing equipment were primarily involved in surveillance and diagnosis of cases
of AIDS.
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Zonal Blood Testing Centres
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In order to prevent transmission of HIV infection through blood, ICMR initially started
screening of blood donors in some institutions. In December, 1989 Director General of 1 Icalth
Services (DGI IS) in collaboration with ICMR and State Governments, drew up an action
plan to start zonalised blood testing in a phased manner. In the first phase 29 zonal blood
testing centres (ZBTC) started working in 4 metropolitan cities of Bombay, Madras, Delhi
and Calcutta. In addition, all the surveillance centres were also carrying out HIV testing for
blood donors and* were also identified as ZBTC. As on December, 1992 there were 128
ZBTCs in addition to 62 surveillance centres, some of them also functioning as ZBTC in
different cities.
As per decision of the Technical Advisory Committee taken in 1993, the screening ol
blood for blood safety purposes was delinked from the surveillance activities. Thus, 1 50
ZBTC in different States/UTs were identified and started functioning.
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HIV Screening for Blood Transfusion at the District Level
Once the need for screening all blood units for transfusion was accepted it was decided in
1993 to extend the facilities for HIV testing to all blood transfusion centres. All the district
hospitals where blood transfusion is carried out have been provided with rapid HIV test kits.
Regional Reference Centres
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While the surveillance centres primarily carried out ELISA testing for initial screening, nine
regional reference centres were provided, in a phased manner, the facil ities for doing Westci n
Blot (WB) test. All ELISA positive samples (excluding those detected during screening for
blood safety) were sent to these reference centres for validation of ELISA results. Surveillance
centres were attached to one of the Reference Centres.
Quality Control Laboratory’
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The National AIDS Control Organization (NACO) has delegated the coordination of the
quality assurance and quality control programme to the All India Institute of Medical
Sciences, New Delhi since December, 1993. During 1994 all the Regional HIV reference
centres participated in the quality assessment programme started by the All India Institute of
Medical Sciences.
art
To conclude, the HIV testing could not be efficiently managed by the present set up of.
coordination. The situation was further worsened by the dramatic expansion of the HIV
testing facilities to almost all the district headquarters, some taluka hospitals and a number of
urban hospitals.
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CHAPTER 2
Current National HIV Testing Policy and Srategies
2.1 National Policy on HIV Testing
The following note covers some of the pertinent issues which are incorporated in the National
HIV Testing Policy document.
Any testing procedure undertaken in the country must be in accordance with and a part
of comprehensive control programme on HIV infection.
b) The choice of testing procedure, interpretation of testing results and pre-requisites of the
testing depend on the purpose or objective of HIV testing which can be any one of the
following.
a)
(i) To identify an individual with HIV infection under following circumstances:
- for the diagnosis of clinically suspected cases of AIDS;
- voluntary testing is sought by an individual for health reasons and
- non-health purposes.
(ii) To monitor the trend of HIV infection in a population or a sub-group for guidance
of intervention programme (HIV surveillance).
(jii) To test blood for transfusion safety or prospective donor of semen, tissue or organs
for ensuring safety of the recipients (transplantation safety).
(iv) Research on HIV infection/AIDS.
(v) Mandatory
c) Testing procedure must be supported by social support and means and skills for
intervention, even if the testing is refused or otherwise not done.
d) Any kind of mandatory testing, without explicit consent of the person when it tends to
identify an individual (unless otherwise required by the court), should be discouraged.
This includes testing of international travellers, refugees, women in the reproductive age
group, hospital inpatients or those seeking admission, injecting drug users, sex workers,
prison inmates, sports-men, pre- or in- service employment, screening for insurance
purposes, or any other populations.
e) Transfusion safety should be ensured in every comer of the country under any
circumstances.
0 A single ELISA/Rapid/Simplc (ERS) test for both HIV-1 and 2 is recommended for
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transfusion safety. Normally, the donor of any infected blood unit need not be traced back
and no consent is needed for testing the blood unit for HIV. Should a donor ask for his
HIV test result or for- reasons as to why his blood has been rejected, the blood bank
personnel should be adequately trained to properly interpret a single ERS positive test
result and refer the donor to a centre for voluntary HIV testing.
g) The establishment of voluntary testing centres with the facilities for supplemental testing
will be encouraged. At these centres, the persons may be offered voluntary confidential
testing along with counselling facilities. The centre should offer services to all referral
patients from the different health care settings.
h) The testing protocol using either three ERS tests, based on different antigen or principle,
orone ERS test plus WB is considered scientific for identifying an infected individual. In
view of the comparative cost of the second option which may impede the extending of
case identification facilities to the peripheral level, the three ERS tests strategy is
recommended for identification of a case.
i) Surveillance is to be designed by the State Epidemiologist/State AIDS Programme
Officer and is to be carried out by the staff of the selected sites (health institutions). This
will be done by an unlinked anonymous approach using 2 ELISA/Rapid/Simple tests for
both HIV-1 and 2. The approach of sentinel surveillance needs to be expanded in
preference to the present randomized approach of surveillance. The latter will be phased
out.
The
samples will be tested in any HIV testing facility suitably situated and easily
j)
approachable by the staff of the surveillance site.
k) Testing procedures for research are to be designed according to the specific research
objectives and could be decided by the researchers. However, all the studies undertaken
must follow the highest international standards for the scientific protocol which
primarily involves in full, explicit consent of the patient and pre-dccidcd mutually agreed
terms for any eventuality of the patient due to research activities.
There is need for legal and ethical clearance and special diagnostic criteria for the patients
undergoing any vaccine trial or introduction of any HI V antigenic component in the body.
1) A re-structuring of the existing HIV testing network will be necessary to carry out
objective-wise testing. While transfusion safety must be ensured by any laboratory that
carries out HIV testing, the identification of HIV-infected individual must be done at a
limited number of institutions (voluntary testing centres, AIDS case referral hospitals,
research institutions having well-trained staff).
m) Internal and external quality control programme must be rigorously implemented on a
regular basis which would compel any laboratory in the country involved in the HIV
testing to participate in the quality assessment programme. A centralized agency will
publish a directory of all testing laboratories in the country according to the objectives of
testing, type and number of kits used and a summary result of the quality assessment
programme.
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2.2 WHO Recommendations for the Selection
and the Use ofHIV Antibody Tests
(1) the objective of the test;
(2) the sensitivity and specificity of the test(s) being used(3) the prevalence of HIV infection in the population being tested.
Objectives of HIV Antibody Testing
There are four main objectives for which HIV antibody testing is performed:
(1) Transfusion/donation safety: Unlinked and anonymous screening of blood and blood
pro ucts and of serum from donors of tissues, organs, sperm or ova
( ) Sero-surveillance: Unlinked and anonymous testing ol sera for the purpose of
(3)
(4) L“XXm™n;“'Si8n\andSyn’P'0"’SS"eg“^
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Sensitivity and Specificity of Antibody Tests
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Ser°-SUrvcilla'lcc and
diagnosis of 111V infection in an
Prevalence of HIV Infection
The probability that a test will accurately determine the true infection status ofa person beine
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In general, higher the prevalence of HIV infection in a population, the greater is the
probability that a person testing positive is truly infected (i e. the greater the positive
predictive value, PPV). Thus, with increasing prevalence, the proportion of serum samples
testing false-positive decreases. Conversely, the likelihood that a person showing negative
test results is truly uninfected (i.e., the negative predictive value, NPV) decreases as
prevalence increases. Therefore, as prevalence increase, so does the proportion of samples
testing false-negative.
Strategics for HIV Antibody resting
The PPV of a test is very low when a population with low HIV prevalence is tested, even if the
specificity of the test is very high. For this reason a supplemental test is necessary to enhance
the PPV of HIV testing. All samples found reactive by the first test are retested by a second
test based on a different principle and/or a different antigen preparation (see Strategy II
below). However, in some situations a third test may be considered necessary (see Strategy
III).
At present, the most common strategy for HIV antibody testing uses a highly sensitive
enzyme-linked immunosorbent assay (ELISA) followed by the WB assay. ERS test usually
costs only Rs. 25-56 (USS 0.75-1.75) per test. The cost is further reduced when these tests are
bulk-purchased by the WHO (Table 2.1). The WB, however, may cost up to Rs. 600-1280
(USS 19-40) per test and still produces indeterminate results of uncertain diagnostic
significance. Studies have shown that combinations of ERS tests may provide results as
reliable as and in some instances even more reliable than the ELISA/WB combination at a
much lower cost WHO, therefore, recommends testing strategies for HI V antibody detection
which use ERS tests in place of ELISA/WB.
Table 2.1. Specifications of HIV test kits bulk-purchased by WHO
Test Type
HIV Specificity
Price (USS)
Number of
Manufacturers
Rapid/Simple
Rapid/Simplc
ELISA
Western Blot
HIV-1
HIV-1+2
HIV-1+2
HIV-1
HIV-2
0.65
2.00-2.30
0.70
12.40
13.80
1
2
3
2
2
*Scc page 65 for details
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Recommendations
WHO recommends three testing strategies to maximize accuracy while minimizing cost The
choice of the most appropriate strategy will depend on the objective of the testing and t ic
prevalence of HIV in the population, as shown in Table 2.2.
Table 2.2. WHO recommendations for HIV testing strategies according to the objectives and
prevalence of infection in the population
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Objective of testing
Prevalence of
infection
Testing strategy*
Transfusion/donation safety
Serosurveillance
All prevalences
> 10%
</= 10%
All prevalences
I
I
II
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> 10%
< 10%
II
III
Clinical signs/symptoms
of HIV infection/AIDS
Diagnosis
Asymptomatic
* see text for details.
Strategy I
The serum is tested with one ERS test. If it is reactive it is considered HIV antibody positive
The non-reactive serum is considered HIV antibody negative.
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Strategy 11
The serum is first tested with one ERS test. If it is found reactive, it is retested with a second
ERS based on a different antigen preparation and/or different test principle (e g. lnd‘rect
versus competitive). If it is found reactive on second test also it is considered HIV antibody
positive. Serum that is non-reactive on the first test is considered HIV antibody negative .Any
serum that is reactive on the first test but non-reactive on the second test is also considered
antibody negative.
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Strategy III
As in strategy II, the serum is first tested with one ERS assay, and any reactive sample is
retested using a different assay. Strategy III, however, requires a third test. .serum is found
reactive on the second assay. The third test in this strategy should be basecI on. a diff ent
antigen preparation and/or different test principles. A serum reactive on all the three
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considered HIV antibody positive. A scrum that is non-reactive on the first test is considered
HIV antibody negative as is serum that is reactive in the first test but non-reactivc in second.
Scrum that is reactive in the first and second tests but non-reactive in the third test is
considered equivocal (see “equivocal (borderline) tests results” below for further analysis).
In the selection of HIV antibody tests for use in strategics 1, II and III, the first test should
have the highest sensitivity, whereas the second and third tests should have higher
specificities than the first.
When diagnosis is the objective, an additional blood sample should be obtained and
tested from the person diagnosed as seropositive for the first time on the basis of one sample.
This will help to eliminate any possible laboratory or clerical error which may result in wrong
labelling/mixing of the samples.
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For all the three strategies, it is most important that quality assurance procedures be
stringently complied with so as to maximize the accuracy and reliability of the laboratory
results. Procedures for detecting both laboratory and clerical errors must be included in all
protocols. For example, procedures that guarantee the correct idenffication of HIV reactive
units of donated blood are essential for the maintenance of a safe blood supply.
Any positive test result obtained with testing strategy-I must not be used for purposes of
diagnosis of HIV infection in an individual. If a blood or tissue donor is to be notified of test
results, the testing strategies for diagnosis must be used (Table 2). Guidelines for counselling
persons regarding HIV testing, infection and disease arc available from WHO. ■
Users should note that differentiation between HIV-1 and HIV-2 infections cannot
always be achieved with the currently available antibody tests, even when the two types of
WB (HIV-1 and HIV-2) are used. WHO is currently undertaking studies aimed at the
development and evaluation of testing strategies for differentiation using ERS assays.
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Equivocal (Borderline) Test Results
If the test results in strategy-I 11 are equivocal, the scrum should be retested. On retesting, if the
results are again equivocal, testing with WB may be considered, especially for persons from
low-prevalence populations (^ 1%). A second blood sample should be obtained after a
minimum of two weeks following the first sample and both samples should be retested using
the appropriate strategy. If the second serum sample also produces an equivocal results, the
person is considered to be HIV antibody negative.
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Equivocal results obtained during sero-survcillance studies must be discarded, as must
units found reactive.
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11IV Antibody Tests Selected for Bulk Purchase
WHO has recently started to bulk-purchase HIV tests in order to provide member countries
with tests giving the most accurate results at the lowest possible cost.
Table 1 summarizes the specifications and cost of rapid/simple HIV tests, ELISA and
WB assays selected by WHO for bulk purchase and available to countries through WHO
during 1992. Guidelines on selecting tests for use with the strategies outlined in Table 2 are
available from the Diagnostics Unit, Office of Research, Global Programme on AIDS.
Tests other than those bulk-purchases by WHO are also suitable for use with the testing
strategies shown in Table 2. Information concerning their selecting is available upon request.
2.3 National HIV Testing Strategies
On September 10, 1993 the National AIDS Control Programme Technical Advisory
Committee recommended implementation of the HIV testing strategy by the National AIDS
Control Programme. This strategy underlines the following:
For transfusion purposes, only one highly sensitive, reliable, economically feasible and
technically easy ERS test for both HIV-1 and HIV-2 antibodies should be carried out by
the Zonal Blood Testing Centres/Blood Banks and if the results indicate that antibodies
are present, the blood should be discarded and no further test needs to be done on this
blood sample.
ii) For anonymous unlinked surveillance purposes, HIV-1 and HIV-2 combination kits
conforming to the one used for the blood safety purposes, will be used by the surveillance
centres. For the purpose of surveillance, all sera are first tested with one ERS test. Any
serum found reactive on the first assay is retested with a second ERS assay based on a
different antigen preparation or principle. If it is found reactive by the second assay also,
it is considered antibody positive. Any serum which is reactive on the first test but nonreactive on the second test is considered antibody negative.
iii) HIV testing for diagnostic purposes will depend on the clinical status of the patient. For
asymptomatic persons, all samples are first tested with one ERS test. Any reactive
sample is tested further with a second ERS test based on a different antigen preparation
or principle. Samples found reactive by the second test are then subjected to a third ERS
test based on different antigen prparation or principle. The serum reactive on all three
tests is considered HIV antibody positive. Serum that is non-reactive on the first test is
considered HIV antibody negative. Scrum that is reactive in the first test but non-reactive
in the second test is also considered negative. I he serum that is reactive in the first and
second tests and non-reactive in third test is considered to be equivocal/borderlme
positive. These sera will be tested by the western blot assay. All patients with clinical
i)
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signs and symptoms of HI V infection/AIDS as per WI IO case definition are to be tested
X teSsTbeXrdo8yiWff1,Ch h3S bCCn ad°P,ed f°r SUrVeiilance Proses as above i.e. two
ERS tests based on different antigens or based on different principle
1V and fCSenCh PUT0SeS’the serum samPles for i n v antibody will be confirmed by WB test
and facility can be provided at some of the identified research institutions only
Note:
i)
For transfusion purposes, the ERS test selected should be of a very high sensitivity and a
good spec.fic.ty to ensure almost negligible false negative reports and considerably
reduced number of wasted blood units respectively.
ii) For anonymous surveillance purposes, the first ERS selected should be of a very hieh
sens.t.vjty and a good sepcificity and a second ERS should be of a very high spe^fichy
few
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iii) For diagnostic purposes, the first ERS should be of a very high sensitivity and a good
the third ERS should be of a good sensitivity and specificity to ensure negligible false
negative as well as false positive reports.
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CHAPTER 3
Structure of the Decentralized HIV resting Network
According to the national legislation, the states and union territories are rcspons.bkH'or the
matters related to the health. States are also implementing the National AIDS Contra
Programme though it is sponsored by the Central Government. In line with this policy
according to the proposed decentralisation of the HIV testing network the state healt
administration would assume all responsibilities related to the planning and monitoring the
state HIV testing network. NACO, the representative of the Central Government, will support
the states financially and technically. It will also help the state governments in the
procurement and supply of HIV test kits and related equipments. The states will periodically
report to NACO on these developments.
It is proposed to create a network of different types of HIV testing laboratories and to
establish quality assurance programme of HIV tests in all states of Republic of India. In
addition, it is envisaged to provide training to all categories of staff so that all laboratories
perform at the same level of competence and proficiency. It is also proposed to identify
laboratories forevaluation of HI V test kits to be used for National AIDS Control Programme.
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3.1 Identification, Establishment and Eunctions of HIV Testing Facilities
The structure of the decentralized HIV testing network is shown in figure 3.1. It includes four
categories of institutions:
i) HIV Screening Laboratory, level 1 and level 2
ii) HIV Testing Laboratory
iii) State HIV Reference Centre
iv) National HIV Reference Centre
The proposed activities of these laboratories and their relation to NACO and the State
AIDS Programme Officer (SAPO) are shown in figure 3.1 and table 3.1.
i
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The National HIV Reference Centre (NHRC) at the national level will be responsible to
NACO and will interact with the State HIV Reference Centres (SHRC). The SHRC’s will be
under the operational control of SAPO and will interact with HIV testing laboratories (H fL)
and HIV screening laboratories (HSL) on one hand and with NHRC on the other hand.
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7. HIV Screening Laboratory (HSL)
This is a laboratory facility for the primary screening of blood samples for HIV from blood
units collected for transfusion purpose. HIV screening laboratory may be based at any
hospital or medical institution and has staff which may be trained to carry out HIV tests. There
will be two levels of HIV screening laboratories (HSL):
a) HSL level I (HSL-I) : These laboratories will test donated blood only from their own
blood bank/transfusion centres for HIV antibodies by Rapid/Simple test. They will be
equivalent to the present day District Hospital Blood Bank testing centres which have an
yearly load of less than 3,000 tests.
b) HSL level II (flSL-II): These laboratories will take up the function of Zonal Blood Testing
Centres (ZBTC). They will generally test donated blood unit by ELISA. In addition, they
will be able to test blood units of either their own blood banks or the blood banks attached
to them in case of emergency by Rapid/Simple test.
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Criteria for New HSL
Need for establishing HIV testing facilities will be based on the following criteria:
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HSL-I
I
a) The institution must be interested in hosting a facility for HIV testing.
b) The medical institution to host the facility is either involved or can potentially be involved
in blood transfusion and there is no HIV testing laboratory existing in its premises.
c) The yearly collection of the blood bank/transfusion centre must be 3,000 or less blood
donations.
d) The institution should have a medical laboratory as well as the staff trained in HIV testing.
-
HSL-II
a) The institution must be interested in hosting a facility for HIV testing.
b) The medical institution to host the facility is either involved or can potentially be involved
in blood transfusion and there is no HIV testing laboratory existing in its premises.
c) The yearly collection of the blood bank/trans fusion centre must be more than 3,000 blood
donations.
d) The institution should have a medical laboratory as well as the staff trained in HIV testing.
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The State AIDS Programme Officer (SAPO) will circulate these conditions among various
medical/health institutions in the state for selecting HSL I and II. The hospitals and other
health institutions which meet the criteria will be offered full support in establishing HIV
testing facilities.
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NATIONAL AIDS CONIROL PROGRAMME
NATIONAL AIDS
CONTROL
ORGANIZATION
NATIONAL HTV/AIDS REFERENCE
CENTRE
STATE AIDS
PROGRAMME OFFICER
(State AIDS Control CeU)
STATE HIV/AIDS
REFERENCE CENTRE
HIV TESTING
LABORATORY
3MO/CMO/CIVIL SURGEON
DISTRICT MEDICAL
OFFICER*
HIV SCREENING
LABORATORY I
HIV SCREENING
LABORATORY II .
* Officer responsible for various health programmes in the district
Structure of the decentralized National HIV Testing Network
Figure 3.1
.c: ■
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Table 3.1
NATIONAL AIDS CONTROL PROGRAMME
Summary of the activities performed by various
Institutions of the National HIV Testing Network (NHTN)
ACTIVITY
national/regional
INSTITUTIONS
NACO
NHRC
itial evaluation of HIV Test
is aimed for use by NHTN
entification and assessment of
•tential institutions for NHTN
s
STATE INSTITUTIONS
SAPO
SHRC
HTL
HSL 1 & 2
For the whole
country
1
NHRC, SHRC
(assists SAPO)
SHRC
(assists SAPO)
SHRC,HTL,HSL
HTL,HSL
(assists SAPO)
SAPO
(operational
aspects)
SHRC stall’
(technical
aspects)
SHRC
staff
(operational
aspects)
HTL staff
HSL staff
(technical
aspects)
pplies & Equipment
I Procurement/Reccipt
For NHRC and
States
self
) Distribution
For NHRC and
States
From NACO
For NHTN,
HTL, HSL
Through NACO
and self
From SAPO & self From SAPO and From SAPO
for sclfHTL &
SHRC
and self
HSL.
From SAPO and
From SAPO
From SAPO
self for self,
* Maintenance
From NACO
and self for
SHRC, HTLHSL
From NACO
for SHRC,
HTL and HSL
For State
net work
aining
From NACO and
&
HSL staff
(optional)
I
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Through SAPO
Through SAPO
Through SAPO
: National HTV Reference Centre
: State HIV Reference Centre
: HIV Testing Laboratory
: HTV Screening Laboratory
: ELISARapid/Simple Tests •-*
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1
a
Table 3.1 (Contd.)
3
ACTIVITY
5. HIV test kits provision
(a) Planning test kits supply
(b) Procurement
i
NATIONAL/REGIONAL
INSTITUTIONS
NACO
NHRC
Assist SAPO
technically
for the State
From SAPO for
selLHSL & HTL
For self, HTL
and HSL
From SAPO for
HTL and HSL
For itself
For itself
From SAPO or
SHRC for self
For self.
From SHRC or
SI IRC for self
For self
From SAPO
for self.
From SAPO
for self
Single test
Single test
Single test
Three ERS.WB
TwoERS
One ERS
From NACO
for self
For self
From NACO
for State
From NACO
for SHRCJITL,
HSL
For NHRC and
SAPO/SHRC
Single test
Three ERS, WB
Of HTL & HSL of
the state
OfSHRC
Of HTL, HSL
Of SHRC
9. Monitoring
National HIV Reference Centre
State HIV Reference Centre
HIV Testing Laboratory
HTV Screening Laboratory
ELISA/Rapid/Simple Tests4-*
HSL 1 & 2
For NHTN
8. Quality Assessment
NHRC
SHRC
HTL
HSL
ERS
HTL
For the
State
7. Testing (Complementary)
I
SHRC
Assists NACO
technically
6. Screening
10. Reporting
SAPO
Summary of
State requests
(c) Storage
(d) Distribution/transportation
of the test kits
STATE INSTITUTIONS
To Central
Government
To NACO
To NACO
To SAPO
To SHRC/SAPO To SHRC/SAPO
I
B
E
!
Location
HSL-I ’ These may be located in the laboratory premises of any medical or health institution.
The present day district or taluka hospital blood banks/transfirsion centre will fall under this
category.
HSL-I1: These may be located in the laboratory premises ofany medical of health institution, 1 he
present day zonal blood testing centre and surveillance centre will fall under this category.
Capacity
HSL-I : with work load of3,000 or less tests per year will perform Rapid/Simple tests only On
the other hand, HSL-II shall be able to perform more than 3,000 single HIV antibody tests per
year by ERS. *
Staff
The staffing pattern ofHSL-I and HSL-II will vary according to the work load. In HSL-I, with
the work load less than 3,000 tests per year, the tests will be carried out by the existing staff
of the institution if possible. Otherwise, one technician may be provided to carryout HIV
testing. This laboratory will be under the control and supervision of blood bank officer. HSL11 may have HIV laboratory specialists and support staff. The pattern will be determined
individually for each laboratory by SAPO. However, it must have at least two laboratory
technicians and should be under the supervision of the blood-bank officer.
Staff Salary
The post of technicians in HSL 1 & Il will be on a consolidated salary on contract basis as
decided by NACO from time to time. The requirement of qualification and experience will be
as per State Government rules. The SAPO will be the appointing authority
Functions
^**1
Both HSL I and II are responsible for the primary screening of blood samples by single HIV
test. They are meant to carry out tests according to the strategy-! recommended by the
Technical Advisory Committee of NACO for HIV testing.
StafFTraining
HSLs will send their staff for training organized by the S APO at the.
(i)
(ii)
nearest HIV Testing Laboratory, or
State HIV References Centre, or
IS
1 .
'-
<
‘
...
c
(iii) National HIV Reference Centre, or
(iv) any other recoginized laboratory in the country.
Administrative and Technical Control
Administratively HSLs will be under the control of the institution hosting these laboratories
whereas, technically these have to comply with the National HIV Testing Pohey. Irladd.tm
these must follow periodic instructions and circulars 1Ssued by the SAPO or the SHRC
work c>f the HSLs will be monitored by the SAPO. They will subm.t report on them HIV
activity to SAPO. However, SHRC will ensure quality control programme at HSLs
Supplies and Equipment
HSLs will submit their requests for the supplies and equipments, to the SAPO/SHRC and
receive supplies from the SAPO/SHRC. The HSLs will be respons.ble for the storage o
test kits and other reagents required by them.
Contingency
.^d-.
Contingency grant to each HSL will depend on the w.ork load and will be decided by the
NACO in consultation with SAPO.
2. HIV Testing Laboratory (HTL)
This is the second line of HIV testing facility which, in addition to primary screening for HIV
would have the provision for a second ERS test for survedlancecand
Pb7;Xalent
further validation, if necessary, they may refer the sample to SHRC. They will equr
to present day surveillance centres with different activities.
Location
These ^..one, - ^.ed
SXs *2'h^
SXXncTdJaboraiofy sendees in open.ion They are required io have st least one
trained laboratory staff members for the HIV testing.
^4
Criteria for New HTL
Need for establishing new HTL will be based on the following critena:
19
--'
•
1. Inadequate existence ofvoluntary HIV testing centre(s) for the population in the city/town,
2. AIDS case diagnosis,
3. Serosurveillance of HIV infection/AIDS.
Functions
HTL will carry out supplementary tests by a second and a third ERS for sentinel surveillance
and identification of infected individuals, respectively. In other words, it should be able to
perform HIV tests according to strategies II and III for HIV testing.
Csl
Staff
I
Each HTL will be provided with two technicians. They will be on a consolidated salary on a
contract basis as decided by NACO from time to time. The requirement of qualification and
experience will be as per State Government rules. The SAPO will be the appointing authority.
HTL will be under the supervision of a trained medical microbiologist/immunologist.
Staff Training
These laboratories will participate in the staff training organized by the SHRC.
Administrative and Technical Control
If located in a hospital/health institution, the HTL will be under the administrative control of
that hospital/health institution. Technically it will be under the supervision of SHRC. All
activities of HTL will be monitored by SHRC. It will be financially supported by SAPO and
will submit report to him/her.
Supplies and Equipment
^,■-4 *
HTL will submit its requests for the supplies and equipment to the SAPO and will receive
supplies from SHRC under instructions of SAPO. It will be responsible for storage of ERS
kits for primary screening as well as supplementary testing for validation of the results of
, primary screening.
Contingency
Contingency grant to each HTL will depend on the work load and will be decided by the NACO
in consultation with S APO.
20
'si-
C2
3. State HIV Reference Centre (SHRC)
The SHRC will be the technical headquarter for the HIV laboratory network in the State. The
present day regional reference centres in different states should be rccoginized as SHRC. There
will be only one SHRC in a state. The SHRC will be created/identified by the NACO on the
recommendation of state government.
Location
It should preferably be located in the state capitrJ or in any city which has a better transport
and communication links with other towns of the state than the capital of that state. The
SHRC will be a part of a reasonably well developed medical laboratory in the city.
■
♦
:
<2^
i
Staff
I
■
It should have three technicians to look after all aspects ofHI V-testing. The technicians will be
appointed on a consolidated salary on a contract basis as decided by NACO from time to time.
The requirement for the qualifications and experience will be according to the State Government
rules.
Functions
...Tl'
a) Perform HIV testing as outlined for strategies II and III:
',;’a
i) ■ for serosurveillance purposes (strategy II),
ii) for diagnosis of HIV infection/AIDS (strategy 111).
iii) for revalidation of problematic sera by WB assay.
.* ;4
..
i
. 'i
b) Training of laboratory staff of all laboratories in ;he state including its own;
c) Establishing HIV testing network and conducting quality assurance programme in the
state;
d) Technical supervision and monitoring the work of all HSLs and HTL in the state;
e) Reporting on all HIV testing activities excluding HIV-test reports from HSLs & HTL in
the state to S APO;
f) Participate in the National quality assessment/proficiency programme conducted by NHRC.
g) Assist SAPO to identify and establish HTLs and HSLs throughout the state.
h) Assist SAPO in implementation of requests from all state laboratories for supplies, equipment
and HIV test kits.
I
.^1
21
/>!
• ‘ J ‘
jsj
<.'■.
■■('■
I
—
..•J
Administration
Administratively, SHRC will be under the host institution. I lowev-r, operationally it will be under
the SAPO while technically it will be coordinated by NHRC. SAPO, in consultation with the
administration ofthe institution hosting the SHRC, should identify a professional microbiologist or
immunologist as the incharge of SHRC who will also be the State Coordinator of HI V testing
(SCOHT). He will be responsible for:
4^
< -2.
4
4
a) State level management of HIV testing network,
b) Assessment of the requirement and type of kits in HSLs and HTL,
c) Identifying laboratories in the state for different objective of HIV testing;
d) Quality Assurance programme in the state HIV laboratories;
c) Training of staff of all state peripheral laboratories;
f) Supervision and monitoring of the HIV testing programme in the State, and
g) Reporting-on HIV testing activities excluding HIV-test reports from HSLs and HTLs to
SAPO.
In addition, he will prepare a list of all laboratories in the state that can potentially
participate in HIV testing and also those reporting increasing number of HIV infection/AlDb
cases which may be considered for establishing HIV testing facilities.
An assessment form (page 25-26) will be circulated by him/her to review the existing
operational situations and capacity of the laboratories. Willingness of the institution to
participate in the State HIV testing network and communication facilities will be two
important criteria for the selection.
He/She will also submit a budgetary estimate for the staff needed, their training,
equipment etc. to the SAPO for funding.
Contingencies
Contingency grant to each SHRC will depend on the work load and will be decided by the
NACO in consultation with SAPO.
.-cawfl
■«9S^
4. State AIDS Programme Officer (SAPO)
State AIDS Programme Officer will be the incharge of AIDS Control activity in the state. He must
have a basic M B B.S. degree with postgraduate qualification in public health/microbiology
pathology/medicine/venereal diseasesfimmunohematology and blood banking recognized by the
22
Medical Council of India and must belong to the central or state inedical/health sei vices. 1 le will be
appointed as per state government rules.
.5.' I
Location
He will be located in the state capital.
Function
... ’ 4
•. ,d
a) SAPO will be responsible for the HIV testing network in his state.
b) He will interact with the NACO on behalf of the State Government for implementation of
HIV testing network in his state.
He
will be responsible for the identification and assessment of potential institutions and
c)
laboratories for setting up SHRC, HTL and HSLs. He will be assisted by the SHRC for
setting up'HTLs and HSLs in the state.
He
will determine the staffing pattern of HSLs, HTLs and SHRC.
d)
e) He will be the appointing authority of the laboratory staff in the HSLs which is not located
in any institution.
He
will be responsible for the operational aspects, eg. training of the staff of HSLs, HTLs
9
and SHRC in his state.
g) He will monitor the work of HSLs, HTLs and SHRC.
h) He will be responsible for the procurement of HIV kits from NACO, their appropriate
storage under him and further distribution to SHRC, HTLs and HSLs according to their
requirement.
i) In case of purchase of HI V kit for use in his state, he will take help of NACO and NHRC.
J) He will be responsible for the timely distribution of funds to all HSLs, HTLs and SHRC
in his state.
k) He will be responsible for the procurement of equipments required for HIV testing at
HSLs, HTL and SHRC from NACO.
I) He will be responsible for identifying an appropriate firm for the service maintenance of
all equipments required for HIV antibody testing and located in the SHRC, HTLs and
HSLs.
m) He will be responsible for establishing QA/QC programme in the SHRC, HTLs and
HSLs.
n) He will ensure that SHRC of his state will participate in the National HIV Quality
Assessment Programme of the NHRC.
Administrative Control
■J
Administratively SAPO will under State Government (Health Ministry/Director of State Health
Services)
23
.<>.'>■•
J- ;l.;-rl>. J •■.■I"
5. National HIV Reference Centre (NHRC)
National HIV Reference Centre will be the apex institution for laboratory diagnosis of HIV
infection. It will provide technical support to NACO on all aspects of HIV testing,
monitoring, quality assurance and training. It will be located in one of the national
laboratories and will have the most advanced laboratory facilities for carrying out different
immunological and virological HIV tests and studies. One of the nine regional reference
centres will be recoginized as NHRC by NACO on the basis of expertise available at the
centre. The regional references centres other than those recoginized as either NHRC or SHRC
will be involved in the national quality assessment programme (page 47) as National Participating
Centres. The budget for this purpose will be made available with the budget ofNHRC.
•
The institution/laboratory acting as NHRC should have specially trained staff for carrying
out the activities of the national reference centre. It should also have expertise for evaluation
of test kits, quality assurance and quality control programmes. The NHRC should be provided
with form technicians on a consolidated salary on a contract basis as per guidelines of the
Indian Council of Medical Research.
Functions
,<S0<
jfiesi
.4
*
-
a) Evaluation of HIV test kits to be used in National AIDS Control Programme;
b) Developing draft policy documents and operative guidelines for the National HIV testing
network and laboratories participating in it;
c) Plan and assist SHRC for HIV testing quality assurance and quality control programme,
d) Train staff of the SHRC,
e) Provide technical support to NACO, SAPO and SHRC for the procurement of equipment
and material, reagents etc;
f) Provide facilities for confirmation of laboratory findings of SHRC;
g) Monitoring the HIV testing activity in the country.
h) Report on the HIV testing activities to NACO.
i) NHRC will assist SAPOs of various states in identification and establishment of SHRC
in their state.
NHRC will be under operational control of NACO whereas, administratively it will be
under the hosting institute. NACO will provide necessary funds for its activity
■■3
24
I
gin
NATIONAL AIDS CONTROL, INDIA
assessment report
•
Eor hospital and blood bank laboratory facility
.4^!
I.
Identification of Institution:
City
District
1. State
2. Name of the hospital which plans to accommodate HIV testing facility:
.4jsss|
3. Average number of blood transfusions inthe hospital per month
tfSSfl
4. Location of laboratory:
(Name)
In hospital
-■
(Name)
In blood bank
Other
(Where)
5. It if is out of hospital, distanccfrom the hospital
II.
Km.
Minimum requirements for IIIV testing iacilily:
1. Room or space available > 8 Sq. Mtrs. Yes
■
No
3. Electricity available for 24 hours Yes
4. Sourccof electricity: Main supply
Protected well
Others
6. Sewerage system: Septic tank
7. Working table (bench) with drawers Yes
8. Shelve medium size Yes
Both
Generator
5. Source of water supply: Municipal
No
25
cI
Airconditioner
Two
2. Ventilation: Window One
No
No
9. Chairs or stool available Yes
No
No
10. Separate tank with tap water Yes
11. Refrigerator adjustable, 2-8°C of 250+liters Yes
No
No
12. Incubator adjustable, medium size Yes
13. Electric centrifuge medium size Yes
No
14. Sterilization equipment:Autoclave
Hot air oven
'OH '
15. Water distilator with capacity of one liter/hour or more Yes
40
''
III. Incinerator available: Yes
No
No
IV. Daily load of the laboratory:
1. Number of tests
2. Number of lab technicians
V. Additional remarks on the laboratory facilities:
01
Recommendations:
a) Type and number of HIV tests to be provided per month:
b) Stafftrainingrequirements:
c) Equipment to be supplied:
Assessed by
On
199
I
(Signature)
26
/
CHAPTER 4
.-•■■-I
fl
Training Programme for the Staff of HIV Laboratories
*
■4
There are two aspects of this programme in relation to the functions of the decentralised HIV
testing network.
•
1
'^s
i) Operational'Aspect: This will help the participating institution to understand the structure
of the network in relation to the state and central government, administration, supplies,
monitoring, reporting etc. Such guidelines will be prepared by NACO. The initial training
on the operational guidelines will be conducted by NACO and SAPO for NHRC and
SHRC respectively. Eventually it will be integrated into the training programme on the
technical aspect.
ii) Technical Training Aspect: A person should be identified at the national & state level to
develop and implement training programmes. This individual may be a whole time officer
or a consultant on contractual basis. The NACO will identify this officer at national level
& SAPO will identify at the state level in consulation with NACO.
Objectives
The objectives of this technical training will be to create capabilities for:a) HIV testing: performance and interpretation ofELlS/VRapid/Simple tests. Also to know
the principles of other tests.
b) Quality Assurance/quality control programme and quality assessment programme or
proficiency testing.
c) Evaluation of HIV test kits.
Three types of training programme will be conducted to achieve these objectives:
a) Training ofMicrobiologists/Immunologists and 7 echnicians in the Evaluation
of Test Kits & Quality Assurance Programme.
3^^
I
Three to four workshops may be planned for training of staff from SHRC (microbiologists/
immunologists and laboratory technicians). Each workshop should be of two weeks duration.
The number of participants may be restricted to 10-15. Faculty for training may be drawn by
and large from the expertise available in the country. Experts from other countries may be
inducted if necessary. These workshops will be held at N1 IRC.
I
27
. .
>;
I
1 j
b) Training ofMicrobiologisls/Jmmunologists for 11IV testing.
Training workshops for the microbiologists/immunologists from SURC for HIV antibody
testing by ERS tests and WB assay and interpretation of the results may be planned. Each
workshop will be of 5 days duration. The number of participants will be restricted to 15. I he
faculty will be drawn from NHRC and other centres in the country. These workshops will be
.roan .!
s
held at NHRC.
c) Training of Laboratory Technicians ofSHRC, HTL and HSLfor HIV testing.
j
Training workshops fortraining of laboratory technicians from SHRC, HTL and HSL lor IJ1V
antibody testing by ERS tests and their interpretation may be planned. Each workshop will be
of 5 days duration. The number of participants will be restricted to 20. The faculty will be
drawn from the expertise available at the SHRC, NHRC and other national centres. 1 hese
I
workshops will be held at SHRC.
■
,<«££» 1
;■
■-
,r^l
<•-
: ■
*
'
^E2*z
28
HIV TESTING WORKSHOPS FOR SHRC7HTL/HSL
Daily Schedule
Day /
0800 - 0900
0900-1030
1030-1130
1130-1230
1230- 1330
1330- 1430
1430-1530
1530- 1630
1
jsai
Day 2
0900-1000
1000-1100
1100-1130
1130-1300
1300- 1400
1400-1630
p*
'
0900- 1000
1000- 1100
1100-1130
1130-1300 ’
1400- 1430
Lecture # 5: Western Blot Assay-Theory', untility and interpretation.
Lecture # 6: Bio-safety and universal precautions
Tea
Demonstration-ELISA, Rapid and Simple tests
Practical # 2: ELISA, Rapid and Simple tests
Day 4
I
’^5
■ 1
*
Lecture U 3: Laboratory diagnosis of HIV infection including diagnosis in
new born
Lecture U 4: ELISA, Rapid and simple tests for detection of HI V antibodies
Tea
Demonstration-ELISA, Rapid ;nd Simple test
Lunch
Practical # 1: ELISA, Rapid and simple test
■
K
Day 3
Stf ■
0
Registration
Inauguration and Inaugural tea
Introduction and pre-test
Lecture # 1: HIV infection and AIDS-an overview
Lecture # 2: HIV virology and immunology
Lunch
Practical demonstration-collection, labelling, handling, transportation,
initial processing and storage of specimen .
Practical demonstration-methods of sterilization, disinfection and
discarding and disposal
0900- 1000
fc
I
i
■
■
Lecture U 7: National policy on Hl V testing; Evaluation and comparison of
screening and diagnostic tests (sensitivity, specificity and predictive
values)
29
e-
!
1000-1100
-
1100-1130
1130- 1300
1400-1630
Lecture # 8: Laboratory quality assurance, quality control and proficiency
testing
lea
Demonstration-ELISA, Rapid and Simple tests
Practical # 3: ELISA, Rapid and Simple Tests
Day 5
0900- 1000
1100-1300
1400- 1630
Lecture # 9: Counselling: skills, pre & post test counselling, role play.
Practical # 4: QA/QC/Proficiency testing for ELISA, Rapid and simple
tests
General questions and answers session
Closing ceremony
There will be two plenary sessions of one hour duraction each day except the last (fifth) day.
- There will be 1 h 30 min demonstration on the practical exercise to be carried out by the
participants each day except first and last day;
- There will be 2 h and 30 min practical exercise each day by the trainees except first and last
day.
■■
- -5
■
30
T
<1
receive the requisition and compile them for the entire state in the proforma given on pages 36 and
37. The number of tests required will be calculated on the following basis:
a) For Blood Transfusion
The calculation is based on the number ofblood units collected during the previous year. One test
for each unit ofblood collected in the last year plus 20% to meet emergency needs and wastage.
(Ten percent of the total demand may be for rapid tests to meet the requirement of transfusion in
emergency situations). For HSL-I total requirement should consist of Rapid/Simple tests.
b) For surveillance purposes
Two types of ERS kits should be procured. The number of tests for screening should be obtained
from surveillance protocol of each sentinel site. For the second test (supplemental test), twice the
number of positives expected in the population should be requested. In addition, 10% more kits
will be given to meet emergency and wastage.
■ 1
'i;
c) For Identification ofHIV Positive Individuals
Three types of ERS should be procured. The number of first test should be equal to the total
number of persons to be screened. The number of first and second supplemental tests required
should be equal to twice the number ofexpected positives. In addition, 10% more kits will given to
meet emergency and wastage
dj For A IDS Case Diagnosis
During the first year, ten tests will be allocated per each district PRAM (Physician Responsible for
AIDS Management), 100 tests per each State PRAM, plus ten to fifty tests for each million ofthe
urban population in the State depending on the number of AIDS cases reported during the
previous year. The number of supplemental testswill be counted as for the identification of HIV
positive individuals. Allocation for the following years will be based on the number of suspected
AIDS patients submitted during the first year ofoperation multiplied by two.
e) Por Research, Monitoring Intervention Projects, and (Quality Assurance
The number oftests will be calculated according to the protocols approved by S APO/N ACO.
I
r
5.3 Procurement
(
The HIV kits will be procured by the NACO through the WHO. These kits are selected from the
32
I
i
•
■"
‘
'
'
'
'
" '
'
..........................
? '
'.................................................. ...........
'
? ? '
list of the kits which have been evaluated by the WHO as well as by NHRC and are suitable for
Indian conditions. These are ordered by NACO for delivery to the four Regional Store Depots at
Bombay, Madras, Calcutta and Delhi. From these store depots, subject to an agreement between
SHRC, S APO and NACO, the kits will be collected by S APO or his representative for his state
and stored at SHRC. Once the kits are in the SHRC stores, distribution in the state will be the
responsibility of S APO and SHRC.
1
<2“ i
CL*
5.4 Storage
The kits must be stored at 4°C. The kits with earlier expiry dates should be quickly dispensed and
used. SAPO will be provided with walk-in cooler for storage of kits.
5.5 Distribution
Jr5
The distribution ofthe kits from SHRC depot to the peripheral laboratories should be planned
jointly by the SCOHT and SAPO considering the geographic location, transport, communication
network and convenience ofthe peripheral laboratories.
■cSS^
1
I
I
.^a^\
I
i
33
• 'i
I
'' ’
•'
1 7"
**
r
NATIONAL AIDS CONTROL PROGRAMME
II
Record for requisition of IIIV lest kits by a 1UV Laboratory' (NHRC SIIRC, HTL, HSL)
Type
of
kits
Manufacturer
or Trade mark
Received Used
last year last
year
5
Requisition for the year
Name of the HIV Laboratory:
Kits
in
stock
Blood
Transfusion*
Surveillance
Suspected
AIDS****
Voluntary
Testing
Research Monitoring of
Intervention
projects* • • • •
|
Quality
Assurance
Total
I
1.
ELISA
2.
;■
I.
RAPID
—
i-
5
I
SIMPLE
2
I
* Based on the number of blood transfusion performed during the last year, plus 10 o
** Based on the calculations made for each surveillance site, plus 10%
***Ten tests for each district PRAM. 100 kits for each State PRAM, plus ten to filly kits for each million of urban population in the Stale
**** Based ont the past and planned performance of every recognized by SAPO Voluntary Testing Centre.
***** According Io the protocols.
I
A
1
I
NATIONAL AIDS CONTROL PROGRAMME
RECORD OF ANNUAL REQUIREMENT OF HIV TEST KITS BY QUARTER OF THE YEAR
Quarters of the* year
1
Type of kit
II
l
ELISA
2
1
:ffl
RAPID
1
■
1 I
simple:
iJ
___ J
2.
• 1
* This figure should match the same one on the record (a).
Date of requisition
Officer in charge of HIV Laboratory: Name
5 i
.T- ®
■<
%
Designation
Signature
III
IV
Total per year*
NATIONAL AIDS CONTROL PROGRAMME, INDIA
Statc HIV test kits requirement, by activity
Year
State
■
No. of tests kits required
'■-1
2
1
2
1
Total
SIMPLE
RAPID
ELISA
Activity
2
1
Blood Safety
HIV Surveillance
AIDS Case Diagnosis
HIV Voluntary Testing
Others:
<
L
4
. .Li
Total
HIV test kits requirement, by quarter of the year
Year
State
HIVtests kits required
Quarter of
the year
1
SIMPLE
RAPID
ELISA
2
1
2
2
1
. I
II
I
III
IV
Total
____
Date
SAPO Name
Chief, SHRC Name
Designation
Signature
Signature
T
Total
NATIONAL AIDS CONTROL PROGRAMME, INDIA
State report on annual requisition of HIV test kits
Year
State
No. of tests required ‘
No.
HIV
Laboratory'
1
2
1
t|
wagfi^
Total
37
■
SIMPLE
RAPID
ELISA
2
1
2
Total
CHAPTER 6
■■
5
Procurement, Distribution and Maintenance of Equipment
E $
6.1 List of Equipments
-
?
The following equipments will be required for HIV Testing network
(1) HIV Screening Laboratory-1 (HSL-1)
Micropipettes, dilution tubes
Centrifuge machine
Domestic Refrigerator (one)
Incinerator (1/2-1 kgm capacity)
(2) HIV Screening Laboratory-II (HSL-II)
$
ELISA Reader with filters & washer
Micropipettes, dilution tubes
Centrifuge machine
Incubator
Domestic Refrigerator
Incinerator (1/2-1 kgm capacity)
Voltage stabilizer (5 kva) (one)
(3) HIV Testing Laboratory (HTL)
1
ELISA Reader with filters & washer
Micropipettes, dilution tubes
Centrifuge machine
Incubator
Air Conditioner (Hot & Cold) (one)
Domestic Refrigerator (one)
Incinerator (1/2-1 kgm capacity)
Voltage stabilizer (Two) - 5 kva - (one); 3 kva (one)
38
■
I
(4) State HIV Reference Centre
i
I
I
ELISA Reader with filters & washer (I wo)
Micropipettes, dilution tubes
Centrifuge machine
Incubator
Air Conditioner (Hot & Cold) (onc/two)
Domestic Refrigerator (two)
Incinerator (1-2 kgm capacity)
Computer PC/AT (one)
Deep Freezers of-40°C (one/two)
Generator (one)
Voltage stabilizer (Two) 10 kva each
(5) State AIDS Programme Officer
u
eI
a) Walk in cooler (one/two)
b) Generator (onc/two)
c) Polyurethane boxes with ice-packs
(two per laboratory)
d) Domestic refrigerator (one)
c) Voltage stabilizer (one) 10 kva
& I
Ct
(6) National HIX’ Reference Laboratory
ELISA Reader with filters washer (Two)
Micropipettes, dilution tubes
Centrifuge machine
Incubator
Air conditioner (I lot & Cold) (two)
Domestic Refrigerator (two)
Incinerator (1 -2 kgm capacity)
Deep Freezers of -40°C (two)
Walk-in cooler (one)
Flow Cytometer (one)
Computer PC-AT (one)
Generator (one)
Voltage stabilizer (Two) 10 kva each
39
'■
■rJCL......
6.2 Procurement and Distribution
Procurement of the equipment costing more than Rs. 100,000/- may be done at central level
through DGS & D rate contract by NACO.
Equipment costing less than Rs 1 Lakh may be procured by the State AIDS Control Cell
through central/state/DGS & D rate contract
Equipment will be installed by the suppliers who will also help in standardising the
equipment.
6.3 Maintenance
/tE®^
A panel of minimum three firms for the maintenance of the equipments alongwith their rates
and the price list of spare parts will be finalised by NACO on all India basis. SAPO will have
the freedom to choose and cancel any one of them depending upon their performance. The
payment of maintenance charges and the spare parts will be made by SAPO after satisfying
himself with the maintenance of equipments in the state.
■ ’‘ ar-
.^ssf.^
.
■
1
40
^
' /
•' ”
''
*
•■” "■’
,,T“
CHAPTER 7
Quality Assurance Programme
7.1 Necessity and Importance
The diagnostic tests to detect antibodies to HI V have sensitivity and specificity which arc not
absolute. In all these tests we have false negative results as well as false positive results which
are inherent and cannot be avoided. The percentage of false positive results will increase as
the prevalence rate of persons with HIV antibodies in a population decreases. These two
problems are compounded with the fact that during screening programmes, laboratories
will rarely be able to perform to the level ofaccuracy that the tests are technically capable
ofachieving. Thus, the validity of diagnostic test results is dependent to a very large extent oh
the quality of the technical conditions under which the tests are performed. Meaning thereby,
consistent production of reliable results requires a stringent overall assurance programme
which would control technical conditions before, during and after each assay.
The Quality Assurance Programme ensures that the final results reported by the
laboratory are correct, reliable and accurate as far as possible. This programme oversees
reporting results in a timely manner and to the appropriate individual. It also ensures use of
the most reliable tests for the diagnosis of HIV infection. It is dependent on a good Quality
Control Programme and its efficacy may be verified by a good Quality Assessment
Program me.
a) Quality Control Programme: This programme includes measures which are introduced
during each assay to verify the validity and reliability of the test. However, this does not
indicate that the results generated are accurate (which,indeed,is the characteristic of the
test). It also does not indicate that the results have been reported timely, properly and
correctly.
b) Quality Assessment Programme: This is a means to determine the quality of results. It is
an external evaluation of a laboratory performance by incorporating proficiency panels as
the means to evaluation. For a laboratory to be considered a respected testing facility,
it must be a laboratory that can always produce accurate, reliable and reproducible
results.
4!
’
.a
. ja J5.. _ _
OK.
®1
jn A
c
7.2 Guidelines to Improve Quality' of Testing
i) Condition of the Specimens
All specimens must be inspected at the time of receiving and also before testing to ensure that
they arc suitable. Use of lipaemic, hacmolysed and contaminated sera should be avoided. Il
they have to be used, the reporting officer should mention on the report that the result o! the
test may not be valid because of the condition of the serum samples. A new specimen should
be requested for repeat testing.
i
All specimens should be properly labelled before acceptance. 1 he label should include
following information: a) name of the patient, b) collection date, c) patient’s identification
number if applicable. Each specimen must be accompanied with a test request form,which
should include age and sex of the patient, name of the physician requesting the investigation,
risk group of the patient, reason for the investigation in addition to the information given on
the label. In case of unlinked anonymous testing, only code number and collection date may
be mentioned on the label as well as on the request form.
If the serum or plasma sample is frozen before testing, it is essential that after thawing at
room temperature/37°C, the sample should be inspected for any clot or floating particles. The
sample should be clarified before testing. The sample should be well-mixed before testing.
Presently, all the test kits distributed by the NACO, are meant for testing serum or plasma
onl v. Therefore, these kits may not reliably detect presence of antibodies in other body fluids.
ii) Quality of kits and equipments
I hc test kits must be used within the expiration date stated on the kit to ensure valid results.
Every batch of the kit should be tested and certified for its efficacy (sensitivity and
specificity) before distribution (see page 50 for details).
ELISA reader, washers, incubators, pipettes should be checked regularly lor their optimal
performance. They need to be calibrated at least annually.
iii) Controls used in the tests
.«£#!
Each test run requires a set of controls to validate the results. These controls must be treated
in the same manner as unknown samples. They are run simultaneously and under the same
conditions as the unknown samples. Upon completion of the test, the results of the controls
and the samples are examined using the same criteria for interpretation. The assay is valid and
the results are reliable when the controls produce acceptable results.
42
MS
Kt
^£1
, ______
i ...__>. ■'■ ■: ■■J-- ■■'
rtl
h«
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if.
There arc two types of controls which must be included in each run .
a) Internal Controls: These controls (positive and negative) are included in each HIV-test
kit by the manufacturer and are to be included in each test run. I hese are essential for
quality control measures for each run. They arc intended for use with the same lot number
of the kit in which they have been packed. Internal kit controls arc generally adjusted y
the manufacturer so that an expected range of values are obtained with each lot of kits, o
avoid considerable fluctuations in the OD values due to variable coating of the antigen on
' the solid surface during manufacturing, the maoufacturer artificially stabilizes kit controls
£
to give the same values as the previous lot.
b) External Controls: These should be included with each test-run to monitor consistent
performance and lot to lot variation which cannot be detected using internal controls r
the reasons mentioned above. These controls are made from pooled test kit controls o
made from pooled sera from HIV-positive or negative individuals in each laboratory (in
house controls). However, for monitoring the performance of other lab°rat0"eS’ he
samples for external controls are drawn in sufficient quantities to last for at
12
rA'
-523;
months.
The most important external control to include is a borderline reactor. This control
would indicate any minor change specially around cut off value because such changes
would effect the results of unknown samples with OD values near the cut oil. It may take
several months to establish ranges for external controls. Nonetheless, this type ol contro
system can be very effective in helping to identify potential problems and inaccuracies in
the laboratory setting.
c) Standardcatton of the Quality of External Controls: Reproducibility and quality of
internal and external controls must be standardized by mtra-run rcproduc.bility and
inter-run reproducibility. The control samples (cither internal or external) arc teste
atleast three times on the same test-run. This will indicate intra-run reproducibility, ns
exercise is then carried out on test-runs on three consecutive days to determine inter-run
reproducibility. By either of these methods variations should not exceed 10%. 1 hese serum
samples ma? also be evaluated at NHRC/SHRC.
i
..j:
casr
iv) Interpretation of data
The test kit inserts carry instructions to establish range of internal controls and to dciine the
outliners Since the external controls are included in each test run to monitor consistent
performance of the test kit, it is necessary to determine the hrmt of acc^abdity statis io y
bv calculating arithmetic mean, standard deviation and error, coefficient of variation etc.
However, the values for the internal controls, external controls and the cut oft can be
monitored easily by quality control graphs. This is because the graphic presentation of the
control values overtime will make subtle changes in controls more easily discernible.
43
p'«.oK™.r"co>^
>0 the CnM,Tv«lue. This is imponani as the OD as in™“o raS"
Two ty^ of changes can be observed in the quality control graphs. These are
b) Trends: When control values of six consecutive test are distributed in on.
v) Calculation of gray-zone reactors
all the samples which give an OD value of 10% below the cut off Althnf t n • .teStOn
arbitrary, this approach increases the chance of finding some early HIV seroconv^iony6*7
vi) Accuracy of Enzyme Immunoassay (EIA)
Any ElA may be false negative under following conditions:
u) Biological Conditions
■• The test may be false negative during early stages of HIV infection. This period generally
44
- M
I
j
varies from 2-24 weeks but may be as long as 42 months. The false negative rate varies
from 16% to 50% during this period. (Farzadegan et al, J. Clin. Microbiol 27\ 1882,
1989)
ii. In some patients there is an early production of antibodies followed by a cessation of
antibody production and disappearance of antibodies from blood. This may be due to
sequestration of the virus.
b) Technical Conditions
i. The test kit generally has a sensitivity ranging from 99.4% to nearly 100%. However, if
performed under less optimal conditions the sensitivity may drop considerably.
The EIA may be false positive under following conditions:
a) Biological Conditions
i. Certain conditions increase false positivity rates of ELISA. These are chrouce alcoholism,
parenteral drug abuse, haemodialysis, multiple pregnancies and multiple blood
transfusions.
ii. False positivity rises if the prevalence of HIV antibodies in the population decreases.
b) Technical Conditions
False positive rates vary from one ELISA kit to another. Even the same type of kit may
show a significant variation in specificity from batch to batch.
ii) Human error, e.g., specimen mixing may account for false positivity.
iii) Laboratories with less than optimum performance also account for higher false positivity
rates.
i)
vii) Reporting of Results
Unlike any other test report, the HIV-test reports must be handled with care. Since HIV
infected individuals may face social stigma, improper reporting may sometimes lead to
emotional breakdown ofan individual or even suicides. Therefore, before reporting the result
of HIV-antibody test it must be borne in mind that:
a) The results of any screening test (ERS) are only presumptive and should not be reported.
These must be validated by a supplemental test.
b) In blood-banking only donated blood is screened by a single ERS as per recommendations
of Govt, of India. Therefore, these results should not be used to identify the individuals.
c) In serosurveillance studies since the positive results of first ERS are validated by a second
ERS and not by a supplemental test, these results may not be used to identify the
individuals.
45
d) for making a diagnosis of HIV-infection, the recommendations of the Govt, of India
(chapter 2, page 11) must be followed.
c) HIV test results should be reported to the physician who has requested the test. All HIV
testing, in which an individual is identified, must be prccecdcd and followed by pre-test
and post-test counselling respectively.
0 All test results must be kept confidential and should never be discussed in public. The test
results should never be communicated on telephone.
7.3 Proficiency Testing ofLaboratory
Proficiency testing is synonymous with Quality Assessment. Recently, National AIDS
Control Organisation has formulated a Quality Assessment Programme. Under this
programme coded panels of known HIV antibody positive and negative sera are provided to
the participating laboratories for HIV proficiency testing on a regular basis. These panels are
processed and tested within a specified period so that results from all the participating
laboratories may be analysed together. The participating laboratories are requested to handle
these coded panels in exactly the same manner as 1 lie other routine samples for HIV testing in
ELISA. This is because the purpose of such a programme is to identify the problems in HIV
testing.
While analyzing the results and preparing a comprehensive report, care is taken not to
identify any of the participating laboratory either by name or by location. These reports are
then transmitted to the participating laboratories where the laboratory in-charge may assess
the adequacy of quality assurance and quality control measures in his own laboratory and
compare the performance of his laboratory with other laboratories. In case there is a problem
he may investigate, identify and take appropriate timely action to rectify the problem.
Since every laboratory aspires to be a respected testing facility it must initiate a good and
effective quality assurance/quality control (QA/QC) programme. Effectiveness of such a
programme may be assessed by an external quality assessment. However, a good QA/QC
programme cannot be substituted by quality assessment programme, but a good QA/QC
programme may substitute for quality assessment.
Many a time false negative and false positive results may be due to technical errors
especially if the tests are performed under less optimal conditions. Therefore, it is necessary
to monitor the performance of the laboratory workers periodically by incorporating the
samples with known results with the routine samples without the knowledge of the laboratory
workers. This is done to ensure the accuracy, reliability and reproducibility of the test results
reported by the laboratory.
46
UL ..
7.4 Structure of the National HIV Quality Assessment Programme
PTSed StrUCtUre °fthe HIV ant,b0dy testin8 network in the “untD' (Chapter 3
negative serum samples to each SHRC on a regular basis for HIV proficiency testing by ERS
b Ot/aSSay' a^h Par11clPat'ng laboratory will be asked to process and test the panel
to them within a specified period and submit their results to NHRC in a specified form (see
page 55). The results from all the laboratories will be analyzed together
H
Similarly,.each SHRC will send coded panels ofknown HIV antibody positive borderline
postfive and negative serum samples to all HTL, HSL-I and HSL-II in its respective state on a
regular basis for HIV proficiency testing by ERS. Each participating laborato^ will be asked to
process and test the panel sent to them within a specified period and submit the results to SHRC
the specified form (see page 55). The results from all the laboratories will be analyzed together.
i f
7
The regional reference centres other than those recoginized as either NHRC or SHRC will be
involved in the quality assessment programme as National Participating Centres. The details of
their involvement will be determined by NACO with the help ofNHRC.
All the participating laboratories may be asked to enrol in the quality assessment programme
(see Laboratory Enrollment form, page 54).
7.5 Record Keeping
-1
»■!
a) A laboratory must maintain a log book for recording ofthe laboratory specimens. The information
contained m the log book should be kept confidential
b) A work sheet (see page 56) containing the identification numbers of sera to be tested must
be prepared each time before the test run is performed.
c) Daily records of temperature of water baths, incubators, refrigerators and freezers should
be maintained.
d) Micropipettes should be calibrated atleast annually.
e) ELISA readers should be calibrated to ensure accuracy of their readings.
readyreferenw Sh°Uld h13'"13'" 3 f‘le >vhere 311 Procedures/package inserts are kept for
g) Number of ELISA positive samples being reported by each laboratory from various risk
groups, highi risk group, moderate risk group and low risk group should be maintained
(see pages 57 to 64).
h) Number ofELISA positive samples which ha, e been found negative by Western blot assay
should be mamtained (see pages 57 to 64).
4)
47
i
■
....................
a. . a
.
.
.
1
.
.
.
■
.
.
.
J
i) Number of times an ELISA positive serum sample was rerun before subjecting it to
supplemental test should be maintained (see pages 57 to 64).
These data will reflect upon the technical problems any existing in a laboratory.
■1
7.6 Laboratory Aspects
a) Specimen collection and processing
I
Five ml blood is collected by venipuncture using either a disposable plastic syringe or an
autoclaved glass syringe. After collection of the sample the disposable syringe is properly
discarded, whereas the glass syringe is kept in a beaker containing liquid bleach disinfectant for 10
to 15 min before resterilization. Since lipaemic, haemolysed and contaminated serum samples
donot yield reliable results, care should be taken to collect blood fasting or after a light breakfast in
a dry sterile container. Haemolysis can l?e avoided by a) not leaving the tourniquet on the arm for
more than 1 min; b) not forcefully transferring the blood through a needle to a tube. Universal
precautions including wearing gloves must be followed while drawing the blood. It is very
important to prevent infection being passed from an individual to the laboratory worker and viceversa. Labelling of the sample for proper identification ofthe individual is extremely important to
avoid incorrect reporting ofHI V status. Therefore, the tube must be labelled properly immediately
upon collection ofblood sample. The sample is allowed to sit at 3 7°C for 30 min and then at 4°C
for clot retraction.
Thereafter, the sample is spun at 1500 rpm at 4°C and the serum is collected aseptically in a
sterile container. No preservative is added. In case it is not tested for HIV antibodies, it may be
stored at 4°C for 1 -10 days or at -3 0°C for long term storage. Repeated freezing and thawing
should be avoided.
■I
b) Preparation of the external controls
Positive & NegativMe Controls
One unit of blood from each donorjested negative for hepatitis B surface antigen, but tested
(i) positive for HIV antibody by ELISA and Western blot, or (ii) negative for HIV antibody
(out dated blood sample), or (iii) positive for HIV antibody by ELISA but negative by Western
blot assay (False positive result) is collected from the blood bank. The plasma is separated,
heat inactivated at 56°C for 30 min and then recalcified. It is then incubated at 3 7°C for clotting to
occur. The clot is spun down and the serum is separated aseptically. It is filtered through a
millipore filter (0.2 um or 200nm pore size) to remove any bacterial contamination. No
preservative is added. It is aliquoted, labelled properly and stored at —40°C. Once thawed, the
aliquot is stored at 2°C to 8°C. It is discarded after using it once.
48
HIV positive serum samples should not be discarded. These should be sent to SHRC/NHRC
for long term storage in serum bank at -40°C.
c) Borderline or low positive control
Ten fold serial dilutions (10_| to 10’6) ofa known positive serum are prepared in the serum from
HIV negative donor which is used as a diluent in place of normal saline or buffered salt solution to
keep the proteins in a natural environment. Each dilution is assayed in sextuplicates for HIV
antibodies. The mean OD of each dilution and SD are calculated. A graph with OD of each 10
fold dilution is then plotted. The highest dilution of the serum giving positive result in ELISA is
. taken as an end point. Three dilutions, viz., end point dilution-*-1 SD, end point dilution and end
point dilution-1 SD are tested by ELISA in sextuplicates and also by WB assay. If these dilutions
give reproducible results (intra-run variability), they are tested on six consecutive days for inter-run
variability.
Care must be taken not to select a sample with so low antibody titer that the OD fluctuates
above and below the cut offdue to normal variations. Also the sample with a very high antibody
titer should not be selected. It will be oflimited use for borderline monitoring.
d) Recalcification ofplasma
11
3
i
^3
3
Ideal material for quality control and quality assessment is serum. This is because plasma
tends to be unstable on long storage and may clot spontaneously during transport. Since under
many circumstances blood collected from a blood bank may be the only source for HIV
positive and HIV negative sample, plasma must be recalcified to produce serum. However,
recalcification should be done with care because excessive recalcification may affect some
assays like gelatin particle agglutination adversely. Only citrated blood should be recalcified.
a) Make a 10X Recalcification solution (CaCI2.6H2O 55g, MgCln.6H2O 16g, in 100 ml
distilled water; autoclave at 121°C for 20 min).
b) Add 1.5 ml of recalcification solution to 1 unit of blood or 250 mi of plasma which has
been brought to room temperature.
c) Incubate at 37°C for 30-60 min (until clot formation).
d) Keep at 4°C overnight.
e) Spin at 1500 rpm for 20 min.
f) Separate the serum aseptically.
g) Label and store in small aliquots at -40°C.
h) Test small aliquot from each sample for HIV antibodies by ERS tests and Western blot assay.
=35^
e) Preservatives for serum samples
^3
Although Seitz filters may be used to remove bacteria and fungi from the serum samples, filtration
ofrecalcified serum is often difficult as filters tend to clog due to fibrin clots. Centrifugation would
49
remove clots by and large before filtration. Use of prefilters will also help in clarifying the serum
samples.
Even though one may start with sterile serum sample, subsequent use and manipulation
in the laboratory may easily contaminate it. Therefore, addition of Bronidox L (5-bromo-5nitro-l,3-dioxane in propylene glycol, Henkel Chemicals) to the serum sample to a final
concentration of 0.05% may help in preventing growth of contaminants. Thiomersal
(mercuric chloride) is generally used in a final concentration of 0.01% but it is effective only
for a few weeks. This is because it loses its activity especially when exposed to light. Sodium
azide should not be used as it inactivates peroxidase conjugate.
dil
*^5
f) Storage of serum
Serum stocks are best stored at —40°C or below in small aliquots of 5-10 ml. Repeated
freezing and thawing should be avoided. Once thawed, it should be further aliquoted in
smaller size and kept at 4°C until used.
g) Use of Freeze-dried Controls
Freeze drying of a serum sample is an effective method for storage of serum sample at 2-8°C
for a very long time. In addition, the shipment of freeze dried sample is very simple and
straight forward. However, during the process of freeze drying, antibody activity especially of
the borderline samples may be lost.
I
h) Preparation of Proficiency Panels
,-^i
A proficiency panel consisting of two strong positive, two negative and two borderline
positive serum samples is prepared from the aliquots of external controls stored at -40° C and
coded. If possible, representative serum samples from different areas of the country may be
included in the panel.
i) Tracking the performance of the kit under field conditions:
i
Each laboratory performing ELISA should maintain the following information to ensure good
performance of the kit.
, -sSiS i
i
i) OD values of internal and external positive controls of each test run
ii) OD values of internal and external negative controls of each test run
iii) OD values of external borderline positive controls of each test run
iv) Cut off value of each test run
v) Name, batch and lot number of the kit used.
vi) Expiry date ofthe kit used.
vii) Date ofthe test run.
50
This information will help to keep a track of the performance of the kit under the field
conditions.
j) Quality control of HIV antibody test kits
-
*
i) Monitoring ofdifferent lots of HIV Kit
Sometimes a manufacturer produces a reagent-lot that passes quality control requirement in
his unit but fails to perform adequately in the field. I his could be due to several factors
including artificial stabilization of the controls by the manufacturer, substandard storage and
shipping conditions etc. Therefore, it is imperative that these lots of reagents must be
identified quickly before distribution to the surveillance centres. This is done by a technique
called “Parallel testing” in which performance of new lots of kit with the previous lots via a
common control material (external controls and the controls from previous lots) is compared.
If all controls produce expected results, the new lot has passed the parallel test and may be
used for routine testing.
ii) Monitoring ofdifferent ELISA Kits
There are four main objectives of HI V-antibody screening programme, namely :
a) safe blood banking
b) scro surveillance
c) sero diagnosis
d) research
For safe blood banking, it is imperative that the ELISA or any other test kit should
correctly identify all antibody positive sera. In other words the test kit should have 100%
sensitivity. The sensitivity is generally expressed in tenns of percentage which is a qualitative
measure. A quantitative expression of sensitivity in terms of positive delta value (delta +) is
better and more reliable than percentage value. This helps in selecting among ELISA kits
with equal sensitivity. The higher the delta + value, the higher is the probability that this test
will correctly identify antibody positive sera.
For sero-diagnosis and sero-surveillance, an ELISA kit with a high sensitivity and high
specificity is needed.
A negative delta value (delta-) is quantitative expression ofspecificity. The greater the negative
delta (delta-) value, the higher is the possibility that this assay will correctly identify the true
negative sera.
S
A f I
51
32/5 JX S
07370
j
. ... .
l
J
Hi) Calculation ofDelta Values
1. To calculate the delta values, 50 confirmed positive and 50 confirmed negative sera are tested.
2. Cut off value is calculated as suggested by the manufacturer.
3. Mean OD and standard deviation of positive and negative samples is calculated.
4. Mean OD/CO ratio of positive and negative samples is calculated by the following
formula
mean OD of the samples
OD/CO ratio = --------------------------------mean CO value
Delta value js calculated by the following formula :
Mean OD/CO ratio of positive samples (log 10)
Delta +
Standard deviation of positive samples
I.
Mean OD/CO ratio of negative samples (log 10)
4*^
Delta -
‘
Standard deviation of negative samples
k) Evaluation of Indirect Immunofluorescence Assay (IFA) as a supplemental test
,«S3 'I
Although the Western Blot (WB) Assay has the advantage of being able to indicate actual
antibodies that react with the specific HIV antigens, it is very expensive and time consuming.
Sometimes the results arc difficult to interpret. In addition, it is very much technique
dependent.
j
On the other hand, the IFA offers several advantages over the WB assay. It is easy to
perform , much less expensive than WB and can be completed in a short period of time. The
test is easy to read but requires an expertise to do that.
-
*
Therefore, IFA may be used as a supplemental test in parallel with WB assay. IFA kits
are commercially available.
•!
52
■■■■
^'7
□
5
■.
.
NATIONAL AIDS CONTROL PROGRAMME
.
?
I
NATIONAL HIV/A’DS REI-ERENCE
CENTRE.
: ?
STATE HIV/A1DS
REFERENCE CENTRE
HIV TESTING
LABORATORY
HIV SCREENING
LABORATORY I
HIV SCREENING
LABORATORY II
STRUCTURE OF THE QUALITY ASSESSMENT PROGRAMME
j,.*
Figure 7.1
J
*
2
53
■
.
>"
............. -........................... ................ .......... .........
NATIONAL AIDS CONTROL PROGRAMME
QUALITY ASSESSMENT PROGRAMME
Laboratory Enrollment Form
• 1. Name of the Laboratory
2. Mailing Address
3. Telephone Number
Extn.
4. Telex Number
5. Fax Number
6. Laboratory'Incharge (Name)
*
7.
Laboratory Incharge (Title)
8.
I wish to enrol in the Quality assessment programme of the NHRC/SHRC.
YES / NO
Signature of the Incharge
Please mail the completed form toNHRC/SHRC
■■■
I
National AIDS Control Organisation
QUALITY ASSESSMENT PROGRAMME
Name of the laboratory
Location
Name of the Laboratory Incharge
Results of Proficiency Panel
2. Lot#:
Name of the kit:
Date of expiry:
5. Technician:
Date of test run:
Cut-off Value =
Results:
Panel
Serum #
OD
Interpretation
Panel
Scrum #
Interpretation
OD
Controls
1
11
Negative
2
12
Negative
3
13
Negative
4
14
Positive
5
15
Positive
6
16
Positive
7
17
8
18
9
19
OD
Interpretation
______
20_____________ L—J_____ _____ __________ -J
10
The negative and positive controls are provided by the manufacturer with the kit. In case you are incorporating
your external controls, please enter their OD values in the blank spaces above.
55
■■
.... , , ,
;__ . ,
NATIONAL AIDS CONTROL PROGRAMME
HIV-SCREENING TEST WORKSHEET
1. Name of the kit:
2. Lot#:
3. Date of expiry:
4. Date of test run:
5. Technician:
6. Results:
CUT-OFF VALUE =
INSTRUCTIONS : Fill in Sample Number and Results into Appropriate Space
1
2
3
4
5
7
6
A
B
C
D
!
E
.^1
F
2
G
H
Comments :
56
8
9
10
11
12
imii h ii
NA TIONAL AIDS CONTROL PROGRAMME:, INDIA
Monthly Laboratory Report on Serological Testing
Name of the Testing Centre/Laboratory
‘ly------------- -----------------------
r
State
Date of report: / /199 Report for the month of/199
.
NUMBER QI- PERSONS TESTED
POPULATION/
AREA
BY ONE TEST
TESTED
POSITIVE
X
X
PERCENT
BY SUPPLEMENTAL TESTS
TESTED
POSITIVE
PERCENT
STDCLINIC ATTENDANTS
MALES ________________
FEMALES________________
COMMERCIAL SEX
WORKERS' .___________
MALES__________________
FEMALES _______________
HOMOSEXUALS__________
INJECTING DRUG USERS
MALES
~ FEMALES
~
MOBILE MEN, SPECIFY
ANTENATAL CLINIC
ATTENDANTS____________
BLOOD DONORS. ALL
VOLUNTARY_____________
REPLACEMENT
PROFESSIONAL
~~
SUSPECT A1DS/ARC CASES
OTHER GROUPS, SPECIFY:
40$'^
NOT SPECIFIED______________
TOTAL, DURING Tl IIS MON I t I
TOTAL, SINCE INCEPTION 19«
TOTAL, DURING 1992
FOR REFERENCE LAB. ONLY
X
NO. OF CONFIRMATORY/
SUPPLEMENTARY TESTS
NO. OF TESTS FOR
QUALITYCONTROL
57
X
X
X
NATIONAL AIDS CONTROL PROGRAMME, INDIA
Monthly Laboratory Report on Serological Testing
Name of the Testing Centre/Laboratory
I
City
State
Date of report: / /199
Report for the month of
/199
AGE/SEX DISTRIBUTION OF HIV TESTED PERSONS
TESTED BY SUPPLEMENTAL TESTS
AGE GROUP
MALES
TESTED
FEMALES
POSITIVE TESTED
BOTH SEXES
POSITIVE
TESTED
POSITIVE
0-10
11-20
21-30
31-^0
41 and above
All ages
TEST KITS SUPPLY
TEST KIT
TYPE AND
NUMBER
OF TESTS
!
RECEIVED
THIS
YEAR
USED BY
IN STOCK
REPORT DATE
REPLACEMENT
REQUIRED
PER KIT
^^1
COMMENTS, PROBLEMS
Reporting Officer
(Name& Designation)
Date:
Signature:
fo be sent on the first day of each month for the previous month activities, to the State AIDS
Programme Officer.
^4
58
.............................................................................. ’........... ...... .................................. ....................................... .................................................................................................................................................... -........
NATIONALAIDS CONTROL PROGRAMME, INDIA
Monthly State Report on HIV Serological testing
State
Date of report: / / 199
Number of Testing Ccii'jes/Laboratorics
Report for the month of
I 199
NUMBER 01- PERSONS TESTED
TESTED
STD CLINIC APPENDANTS
BY SUPPLEMENTAL TESTS
BY ONE TEST
P0PUI.AT10N/AREA
PERCENT
POSITIVE
POSITIVE
MALES
FEMALES
COMMERCIAL SEX
WORKERS
MALES
FEMALES
HOMOSEXUALS
I
INJECTING DRUG USERS
MALES
FEMALES
MOBILE MEN, SPECIFY
ANTENATAL CLINIC
ATTENDANTS
BLOOD DONORS, ALL
VOLUNTARY
REPLACEMENT
PROFESSIONAL__________
St JSPECTA1DS/ARC CASES
net..i
OTHER GROUPS. SPECIFY:
NOT SPECIFIED
TOTAL, DURING THIS
MONTH
TOTAL, SINCE INCEPTION
198
d
TOTAL, DURING 1992
FOR REFERENCE LABS
NO OF CONFIRMATORY/
SUPPLEMENTARY TESTS
NO. OF TESTS FOR QUALITY
CONTROL
59
TESTED
POSITIVE
PERCENT
POSITIVE
.-r-;
NATIONAL AIDS CONTROL PROGRAMME, INDIA
Monthly State Report on HIV Serological testing
Number of Testing Centres/Laboratories
State
■
. g • |'
Report for the month of
Date of report: / /
/ 199
AGE/SEX DISTRIBUTION OF HIV TESTED PERSONS
TESTED BY SUPPLEMENTAL TESTS
AGE GROUP
(years)
FEMALES
MALES
TESTED POSITIVE
TESTED
POSITIVE
BOTH SEXES
TESTED
POSITIVE
0-10
11-20
21-30
31-40
41 and above
A11 ages
r
TEST KITS SUPPLY
TEST KIT
TYPE AND
RECEIVED
THIS
NUMBER
YEAR
OF TESTS
PER KIT
SENT TO
LABORATORIES
: BY REPORT
DATE
IN STOCK
IN
WITH
LABS
SAPO
REPLACEMENT
REQUIRED
COMMENTS, PROBLEMS
Reporting Officer
■ (Name & Designation)
Signature:
Date :
To be sent on the fifth day of each month for the previous month activities to the Additional Director
(Tech). NACO, IRCS Building, 1 Red Cross Road, New Delhi 110 001.
60
NATIONAL AIDS CONTROL PROGRAMME, INDIA
Monthly Donors Screening Report of Blood Bank/Transfusion Centre
Blood bank/transfusion centre
City
If
__________
Report for the month of
f
State
199
Date of report
NAME OF THE CENTRE/
No. OF TESTS PERFORMED/
/ / 199
No. OF SAMPLES FROM DONORS
Voluntary
Replacement
Professional
M
M
Total
No.OF POSITIVE
M
F
T
ZBTC
TESTED
POSITIVE
_____
BLOOD BANKS ATTACHED TO ZBTC
L
TESTED
POSITIVE
2.
TESTED
I
POSITIVE
3.
TESTED
POSITIVE
4.
TESTED
POSITIVE
5.
TESTED
POSITIVE
6.
TESTED
c'
POSITIVE______________
"total FOR REPORTING
MONTH___________
TOTAL SINCE INCEPTION
(198)_____________
TO TAL DURING 199
61
F
T
F
T
M
F
T
NATIONAL AIDS CONTROL PROGRAMME. INDIA
Monthly Donors Screening Report of Blood Bank/Transfusion Centre
Blood bank/transfusion centre
/ I 199
Date of report
State
City
199
Report for the month of
11IV Testing protocol: One screening test
two or more screening tests
Screening and Western Blot tests-------
NUMBER OF SAMPLES FROM DONORS
TESTS AND RESULTS
VOLUNTARY
M
HBs Ag:
T
F
REPI ACEMENT
F
M
T
TOTAL
PROFESSIONAL
M
T
F
M
T
F
TESTED
POSITIVE
VDRL:
TESTED
POSITIVE
MALARIA: TESTED
POSITIVE
j
TESTS PERFORMED DURING THE CALENDAR YEAR
positive:
TESTED
TESTS
F
M
T
F
M
T
HBsAg
L VDRL
MALARIA
HIV TEST KITS SUPPLY
TEST KIT TYPE
AND NO. OF
TES TS PER KIT
RECEIVED
THIS YEAR
USED BY
REPORT
IN STOCK
REPLACEMENT
REQUIRED
PROBLEMS, COMMENTS
$
Reporting Officer
(Name & Designation)
Signature:
Date :
To be sent on the first day of each month for the previous month activities to the State AIDS Programme Officer.
40
<• ..
NATIONAL AIDS CONTROL PROGRAMME, INDIA
Monthly State Donors Screening Report
State
Report for the month of
199
No. OF SAMPLES FROM DONORS
NAME OF THE TRANSFUSION
CENTRE/// TESTS PERFORMED/
t
Replacement
Voluntary
No.OF POSITIVE
M
F
T
1.
TESTED
POSITIVE
2.
TESTED
POSITIVE
3.
TESTED
POSITIVE
^3
1
4.
TESTED
POSITIVE
5.
TESTED
POSITIVE
^-9
Total
Professional
6.
TESTED
POSITIVE______________
TOTAL FOR REPORTING
MONTH__________
TOTAL SINCE INCEPTION
(198)
TOTAL DURING 199
TOTAL DURING 199
^^1
63
M
F
T
M
F
T
M
F
T
S’
NATIONAL AIDS CONTROL PROGRAMME, INDIA
Monthly State Donors Screening Report
■!
State
Date of report / / 199
Report for the month of
199
NUMBER OF SAMPLES FROM DONORS
TESTS AND RESULTS
s
HBs Ag:
VOLUNTARY
REPLACEMENT
M
M
F
T
T
F
TOTAL
PROFESSIONAL
M
T
F
M
T
F
TESTED
POSITIVE
TESTED
VDRL:
POSITIVE
MALARIA: TESTED
POSITIVE
TESTS PERFORMED DURING Till- CALENDAR YEAR
POSITIVE
TESTED
M
TESTS
T
F
M
F
T
HBsAg
VDRL
MALARIA
HIV TEST KITS SUPPLY
^'3
■
TEST KI T TYPE
AND NO. OF
TESTS PER KIT
RECEIVED
THIS YEAR
SENT TO
ZBTCs BY
REPORT DA I F.
IN STOCK
AT
ZBTs
REPLACEMENT
REQUIRED
AT
STATE
^82
PROBLEMS. COMMENTS
Reporting Officer
(Name & Designation)
Signature:
Date:
To be sent on the first day of each month for the previous month activities to the State AIDS Programme Officer.
64
<1
Fit
SPECIFICATIONS OF HIV TEST KITS BULK-PURCHASED BY WHO
jM
Assay Name,
HIV
Test type.
Equipment
Cost/tcst
No. of
(Manufacturer)
Serotype
Antigen
Requirement
(USS)*
tests per kit
DETECT HIVl+U
(Biochcm)
HIV-1+2
ELISA (450nm)
synthetic peptides
A.H.C.D.E.F
0.50
96
192
GENLAVIA MIXT
(Sanofi Diagnostic Pasteur)
HIV-1+2
ELISA (492nm)
recombinant
A,B,C,l),E,b
0.50
96
480
960
INNOTEST HIV-1/HIV-2
(Innogcnetics)
HIV-1+2
ELISA (450nm)
recombinant
A,B,C,DJ-,F
0.50
96
480
UBI ELISA
HIV-1+2
ELISA (492nm)
viral lysate
synthetic peptide
A,B,C,DJE,F
0.50
192
960
Rccombigcn HTV-1//2 EIA
(Cambridge Biotech)
HIV-1+2
ELISA (492/603)
A,B,C,DJE,F
0.50
192
HIVSPOT (HIVCHEK)
(Gcnclabs Diagnostics)
inv-1+2
RAPID TEST
rccombincnt
antigen
synthetic peptide
G
1.50
20
100
Immunocomb Bispot
(PBS Orgcnics)
HIV-1 *2
RAPID TEST
recombinant
antigen
G
1.50
36
SERODIA-HIV
(Fujirebio)
inv-i
SIMPLE. TEST
viral lysate
D.F.G
0.65
100
220
United Biomedical)
■
•
I
•
A: ELISA reader, B: ELISA washer, C: Consumables, D: Ihppcttc. E: Power supply F: For large volume testing
more than 40 samples daily, G: For small volume testing 1 to 40 samples daily
•Please note that this price does not include freight and other taxes.
•• The cost of Serodia HIV1 ^2 is expressed in Japanese Yen
65
- Media
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