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ORIGINAL ARTICLE
Year : 2013  |  Volume : 12  |  Issue : 4  |  Page : 232-235  

The role of polymerase chain reaction in early diagnosis of human immunodeficiency virus infection in infants


1 Department of Surgery, Paediatric Surgery Unit, Usmanu Danfodiyo University, Sokoto, Nigeria
2 Department of Outpatient, Baptist Hospital Mutengene, South west Province, Cameroon, Nigeria
3 Department of Nursing Sciences, Ahmadu Bello University, Zaria, Nigeria

Date of Web Publication4-Dec-2013

Correspondence Address:
Christopher S Lukong
Department of Surgery, Usmanu Danfodiyo University Teaching Hospital, Sokoto
Nigeria
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/1596-3519.122692

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   Abstract 

Background: The prevalence of human immunodeficiency virus (HIV) infection is rising in Sub- Saharan Africa. The various indirect tests readily available have not been helpful in neonatal and early infant diagnosis of the disease. Polymerase chain reaction (PCR) is a direct test that can be used in these groups of children. Early infant diagnosis is important in achieving good outcome in the management of HIV infection. The aim of this article was to examine the role of PCR in the evaluation HIV-infected infants, with a view to achieve early diagnosis, early treatment, and good outcome.
Materials and Methods: This was a prospective review of 174 infants delivered by HIV-infected mothers in a rural hospital from January 2007 to September 2008. The blood samples of the patients were collected and subjected to PCR analysis for detection of viral antigen. Two samples were collected, the first at 6 weeks and the second 6 weeks after that. The results were recorded, collated, and analyzed using SPSS version 17.
Results: There were 174 infants, 100 boys, and 74 girls. The age range was 6-8 weeks (median 6 weeks). PCR was positive for both the samples in 12 (6.9%) infants. PCR was negative in both samples in 162 (93.1%) infants. All infants who were negative in the first sampling were found to be negative in the second sampling as well. None of the infant was positive for only one sample. Analysis of 12 positive infants revealed that 5 (2.9%) infants were placed on anti-retroviral drugs, 3 (1.7%) infants were not placed on anti-retroviral drugs because of low CD+ count, and 1 (1.0%) infant was lost to follow-up, while 3 (1.7%) infants died from sepsis.
Conclusion: PCR has a role as a direct test in early diagnosis of HIV infection in infancy, particularly where the other direct test are not readily available.

   Abstract in Spenish 

Résumé
Fond:
La prévalence d'infections au virus de l'immunodéficience humaine (VIH) augmente en Afrique subsaharienne. Les différents tests indirects facilement disponibles n'ont pas été utiles dans le diagnostic des nourrissons néonatal et au début de la maladie. Réaction en chaξne par polymérase (PCR) est un test direct qui peut être utilisé dans ces groupes d'enfants. Diagnostic précoce des nourrissons est important dans la réalisation de bons résultats dans le traitement de l'infection par le VIH. Le but de cet article était d'examiner le rôle de la PCR chez les nourrissons infectés par le VIH évaluation, en vue de parvenir à un diagnostic précoce, un traitement précoce et bon résultat.
Matériel et Méthode: Il s'agissait d'une étude prospective de 174 enfants envoyées par des mères infectées par le VIH dans un hôpital rural de janvier 2007 à septembre 2008. Les échantillons de sang des patients ont été recueillis et soumis à l'analyse PCR pour la détection de l'antigène viral. Deux échantillons ont été prélevés, le premier à 6 semaines et les deuxième 6 semaines après cela. Les résultats ont été enregistrés, rassemblées et analysées à l'aide de SPSS version 17.
Résultats: Il y a 174 nourrissons 100 garçons et 74 filles. La tranche d'âge était de 6-8 semaines (médiane 6 semaines). PCR était positif pour les deux échantillons dans 12 nourrissons (6,9 %). PCR a été négatif dans les deux échantillons dans 162 nourrissons (93,1 %). Tous les enfants qui ont été négatifs dans le premier prélèvement se sont révélés négatifs dans la deuxième échantillonnage aussi bien. Aucun du nourrisson a été positive pour un échantillon seulement. Analyse de 12 bébés positives a révélé que 5 (2,9 %) nouveau-nés ont été placés sur les médicaments anti-rétroviraux, 3 bébés (1,7 %) ont été imposées pas de médicaments anti-rétroviraux en raison de la faible numération CD+ et 1 bébé (1,0 %) a été perdu de vue, tandis que 3 bébés (1,7 %) sont morts de septicémie.
Conclusion: PCR joue un rôle en tant que directe d'essai dans le diagnostic précoce de l'infection à VIH chez le nourrisson, particulièrement oω l'autre test direct ne sont pas facilement disponibles.
Mots-clés: Diagnostic, virus de l'immunodéficience humaine, Réaction en chaξne par polymérase, Afrique subsaharienne

Keywords: Diagnosis, human immunodeficiency virus, polymerase chain reaction, Sub-Saharan Africa


How to cite this article:
Lukong CS, Tshimwanga ED, Mfuh AY. The role of polymerase chain reaction in early diagnosis of human immunodeficiency virus infection in infants. Ann Afr Med 2013;12:232-5

How to cite this URL:
Lukong CS, Tshimwanga ED, Mfuh AY. The role of polymerase chain reaction in early diagnosis of human immunodeficiency virus infection in infants. Ann Afr Med [serial online] 2013 [cited 2020 Nov 29];12:232-5. Available from: https://www.annalsafrmed.org/text.asp?2013/12/4/232/122692


   Introduction Top


HIV infection has assumed a serious health hazard in Sub-Saharan Africa as well as the world at large. There are about 34 million people worldwide living with HIV infection, with 68% in Sub-Saharan Africa. [1] The infection has been on the increase, with 2.7 million new infections recorded in 2011. [2] About 2 million children less than 15 years are living with HIV infection, 90% of them in Sub-Saharan Africa. It is estimated that 3,90,000 new infections were recorded in this group in 2010. [3] The mortality from this infection is high, with an average of 270,000 child deaths recorded in the 2010 WHO statistics. [4]

The diagnosis of HIV infection in children less than 15 years is not reliable using indirect test such as ELISA. This is because of the circulating maternal antibodies as a result of vertical transmission from mother to child. The diagnosis is better made with direct test that detect the agent or the antigenic substance of the HIV virus. These direct tests are often not readily available in facility limited environments. The consequence is diagnosis conundrum, leading to late presentation, poor evaluation, and poor treatment outcome.

Among the direct tests, PCR technology is an immunological test that identifies the viral antigenor antigenic body. It was found to be useful in early infant diagnosis of HIV infection. [5],[6],[7]] This is because, in this technology, any small amount of antigen present is picked and proliferated so that it can be assayed.

The aim of this article was to highlight the role of PCR in the evaluation HIV-infected infants, with a view to achieving early diagnosis, early treatment, and good outcome.


   Materials and Methods Top


Setting

This study was conducted in Baptist Hospital Mutengene, a rural hospital in southwest Cameroon.

Mutengene is a cosmopolitan junction town in the southwest province of Cameroon. Its inhabitants are mainly plantation workers, most of them from the northwest province of Cameroon.

Design

This study was a prospective analysis of infants born to HIV-infected mothers in our hospital from January 2007 to September 2008.

Selection criteria

Infants delivered by HIV-positive mothers, who tested positive to HIV by ELISA test.

Infants with clinical features of HIV infection, who tested positive to the rapid ELISA HIV screening.

Methodology

A cohort of mothers attending antenatal clinic in our centre were all counseled and tested for HIV infection by ELISA. Those who tested positive and delivered in our centre were randomly selected, and their infants were tested for HIV infection by rapid ELISA. The infants who tested positive with ELISA were recruited for the study. The other group of infants recruited included those who presented to our clinic with clinical features of HIV infection and tested positive to rapid ELISA. All infants who satisfied the above inclusion criteria were recruited for the study. Their mothers were precounseled and verbal consent was obtained before the blood samples were collected from the infants.

The first sample from the infant age 6-8 weeks (median 6 weeks) was collected, tested for HIV by subjecting it to the PCR, and results recorded on a structured proforma. The second sample was collected 6 weeks later, analyzed similarly, and results recorded on the proforma. The blood samples were also analyzed for full blood count, CD+ count, urea, and electrolytes. The results of the other investigations together with the demographic data of the infants were recorded on the proforma. Data was extracted from the proforma and analyzed SPSS version 17.0.


   Results Top


There were 174 infants within the study period: 100 boys and 74 girls.

The median age was 6 weeks (range 6-8 weeks). Twelve infants (6.9%) were positive at the first and second sampling that was tested by PCR and 162 (93.1%) tested negative for both samples tested by PCR. None of the infants tested positive for only one sample. The analysis of the 12 infants who tested positive with the PCR revealed that 5 (2.9%) infants were placed on anti-retroviral drugs, 3 (1.7%) infants were not placed on anti-retrovrial drugs due to low CD+ count, 1 (1.0%) infant was lost to follow-up, and 3 (2.9%) infants died from sepsis. Of the 162 infants who were PCR-negative and ELISA-positive, 30 (17.2%) infants seroconverted by rapid ELISA test 6 weeks after cessation of breast milk. None of the 12 infants who were positive with PCR, seroconverted. The CD+ count range was 36-452 cells/nl (median 181 cells/nl).


   Discussion Top


The HIV infection and its end-stage disease AIDS has become a major pandemic in recent times. The morbidity and mortality rates from HIV type 1 infection has remained high in African continent. [8],[9] Despite the fact that children are vulnerable in Sub-Saharan Africa, the pediatric HIV diagnostic facilities are limited. Therefore, most children are diagnosed late or not at all. Late diagnosis accounts for poor outlook of HIV in children in these settings. Also, 95% of infants get the infection through vertical transmission from mother to child and 5% get it by other means. [10]

The various indirect tests such as ELISA, which assess antibodies, are not reliable in children. This is because the maternal antibodies continue to circulate in the child for up to age 1 year and sometimes beyond. [11]

The direct tests that assay the antigen or the antigenic component of the virus are more reliable and preferred in infants and children. Such direct tests include PCR, western blot, and viral culture. [12] Viral culture are often time consuming, require a biosecurity secluded laboratory, and sometimes results in low sensitivity. [13]

The PCR was used in the study and found to be useful in our setting. This assertion corroborated with reports that found PCR useful in similar settings. [14],[15],[16],[17],[18],[19] Twelve (6.9%) infants tested positive with the PCR and were therefore diagnosed as having HIV infection. This figure is higher than the global prevalence of 5.0% for Sub-Saharan Africa. [1] The test was conducted at a median age of 6 weeks. This was appropriate as some studies have demonstrated that the antigen load peaks after 28 days of life. [20],[21],[22],[23]

Thirty (17.2%) infants out of 162 were found to have seroconverted 6 weeks after cessation of breast milk. Most of the children were aged 6-12 months, with a few aged 18-24 months. This fact further explains the weakness of indirect serological test in diagnosis of HIV infection in infants and children. Following the diagnosis, 5 were placed on ART, 3 had good CD4 levels and were not on drugs, 3 died before commencement of the drugs, and 1 was lost to follow-up. The mortality in the study was 3 (1.7%), mainly due to sepsis. Low immunity is common in this age group, and may contribute to mortality.

Generally mortality from this disease has improved with introduction of anti-retroviral therapy (ART). These drugs have been noted to suppress viral replication, delay disease progression, and thereby reduce mortality. [24]

Five (2.9%) infants on ART drugs were found to be growing and developing well at 6 months of follow-up.

In conclusion, PCR is a useful tool for early diagnosis of HIV infection in infants and children, especially in a facility limited setting. Early diagnosis and early treatment may confer a good outcome.

We recommend the use of PCR in the sub region to enable early detection and prompt treatment of HIV infection in infants. This will help to curb the menace from this dreaded pandemic.


   Acknowledgment Top


We are grateful to Dr. Palmer for providing the PCR facility.

 
   References Top

1.UNAIDS 2012 Report on global AIDS Epidemic [Last accessed on 2013 Apr 09].  Back to cited text no. 1
    
2.UNAIDS (2011) 'UNAIDS World AIDS Day Report 2011 [Last accessed on 2012 Mar 13].  Back to cited text no. 2
    
3.UNAIDS (2010) Unite for universal access: Overview brochure on 2011 high level meeting on AIDS.  Back to cited text no. 3
    
4.WHO/UNAIDS/UNICEF (2011) 'Global HIV/AIDS Response: Epidemic update and health sector progress towards universal access; 2011. p. 16-31.  Back to cited text no. 4
    
5.Zhang Q, Wang L, Jiang Y, Fang L, Pan P, Gong S, et al. Early infant human immunodeficiency virus type 1 detection suitable for resource-limited settings with multiple circulating subtypes by use of nested three-monoplex DNA PCR and dried blood spots. J Clin Microbiol 2008;46:721-6.  Back to cited text no. 5
    
6.Sison AV, Campos JM. Laboratory methods for detection of human immunodeficiency virus type 1 in newborns and infants. Clin Microbiol Rev 1992;5:238-47.  Back to cited text no. 6
    
7.Newell ML, Loveday C, Dunn D, Kaye S, Tedder R, Peckham C, et al. Use of polymerase chain reaction and quantitative antibody tests in children born to Human immunodefficiency virus-1-infected mothers. J Med Virol 1995;47:330-5.  Back to cited text no. 7
    
8.Newell ML, Coovadia H, Cortina-Borja M, Rollins N, Gaillard P, Dabis F. Ghent International AIDS Society (IAS) Working Group on HIV Infection in Women and Children. Mortality of infected and uninfected infants born to HIV-infected mothers in Africa: A pooled analysis. Lancet 2004;364:1236-43.  Back to cited text no. 8
    
9.Taha TE, Graham SM, Kumwenda NI, Broadhead RL, Hoover DR, Markakis D, et al. Morbidity among human immunodeficiency virus-1-infected and -unfected African children. Pediatrics 2000;106:E77.  Back to cited text no. 9
    
10.AIDS Epidemic update, December 2001. Geneva: UNAIDS/World Health Organisation; 2001.  Back to cited text no. 10
    
11.Little K, Thorne C, Luo C, Bunders M, Ngongo N, McDermott P, et al. Disease progression in children with vertically-acquired HIV infection in sub-Saharan Africa: Reviewing the need for HIV treatment. Curr HIV Res 2007;5:139-53.  Back to cited text no. 11
    
12.Patton JC, Sherman GG, Coovadia AH, Stevens WS, Meyers TM. Ultrasensitive human immunodeficiency virus type 1 p24 antigen assay modified for use on dried whole-blood as a reliable, affordable test for infant diagnosis. Clin Vaccine Immunol 2006;13:152-5.  Back to cited text no. 12
    
13.Fischer A, Lejczak C, Lambert C, Servais J, Makombe N, Rusine J, et al. Simple DNA extraction method for dried blood spots and comparism of two PCR assays for diagnosis of vertical human immunodeficiency virus type 1 transmission in Rwanda. J Clin Microbiol 2004;42:16-20.  Back to cited text no. 13
    
14.Patton JC, Akkers E, Coovadia AH, Meyers TM, Stevens WS, Sherman GG. Evaluation of dried whole blood spots obtained by heel or finger stick as an alternative to venous blood for diagnosis of human immunodeficiency virus type 1 infection in vertically exposed infants in the routine diagnostic laboratory. Clin Vaccine Immunol 2007;14:201-3.  Back to cited text no. 14
    
15.Jain KK, Mahajan RK, Shevkain M, Kumar P. Early infant Diagnosis: A new tool of HIV diagonsis in children. Indian J Community Med 2011;36:139-42.  Back to cited text no. 15
[PUBMED]  Medknow Journal  
16.Ugochukwu EF, Kanu SO. Early infant diagnosis of HIV infection in Southwestern Nigeria: Prevalence of HIV infection among HIV-exposed babies. West Afr J Med 2010;29:3-7.  Back to cited text no. 16
    
17.Gbadegesin A, Adenibjuyan OA, Adegbesan MA, Salu OB, Omilabu SA. Efficacy of HIV PCR technique to diagnose HIV in infants born to HIV infected mothers at LASUTH. Nig Q J Hosp Med 2010;20:129-32.  Back to cited text no. 17
    
18.Shah I. Efficacy of HIV PCR techniques to diagnose HIV in infants born to HIV infected mothers--an Indian perspective. J Assoc Physicians India 2006;54:197-9.  Back to cited text no. 18
    
19.Read JS. Committee on pediatric AIDS, American Academy of Pediatrics. Diagnosis of HIV-1 infection in children younger than 18 months in the United States. Pediatrics 2007;120:e1547-62.  Back to cited text no. 19
    
20.Dunn DT, Brandt CD, Krivine A, Cassol SA, Roques P, Borkowsky W, et al. The sensitivity of HIV-1 DNA polymerase chain reaction in neonatal period and the relative contribution of intra-uterine and intra-partum transmission. AIDS 1995;9:F7-11.  Back to cited text no. 20
    
21.Brandt CD, Rakusan TA, Sison AV, Saxena ES, Ellaurie M, Sever JL. Human immunodeficiency virus infection in infants during the first 2months of life. Reliable detection and evidence of in utero transmission. Arch Pediatr Adolesc Med 1994;148:250-4.  Back to cited text no. 21
    
22.Nelson RP Jr, Price LJ, Halsey AB, Graven SN, Resnick L, Day NK, et al. Diagnosis of pediatric human immunodeficiency virus infection by means of commercially available polymerase chain reaction gene amplification. Arch Pediatr Adolesc Med 1996;150:40-5.  Back to cited text no. 22
    
23.Moodley D, Bobat RA, Contsoudis A, Coovadia HM. Predicting perinatal human immunodeficiency virus infection by antibody patterns. Pediatr Infect Dis J 1995;14:850-2.  Back to cited text no. 23
    
24.Coste J, Montes B, Reynes J, Peeters M, Segarra C, Vendrell JP, et al. Comparative evaluation of three assays for the quantitation of human immunodeficiency virus type 1 RNA in plasma. J Med Virol 1996;50:293-302.  Back to cited text no. 24
    



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