HIV Testing (cont.)
Mary D. Nettleman, MD, MS, MACP
Mary D. Nettleman, MD, MS, MACP
Mary D. Nettleman, MD, MS, MACP is the Chair of the Department of Medicine at Michigan State University. She is a graduate of Vanderbilt Medical School, and completed her residency in Internal Medicine and a fellowship in Infectious Diseases at Indiana University.
Daniel Havlichek, MD
Melissa Conrad Stöppler, MD
Melissa Conrad Stöppler, MD
Melissa Conrad Stöppler, MD, is a U.S. board-certified Anatomic Pathologist with subspecialty training in the fields of Experimental and Molecular Pathology. Dr. Stöppler's educational background includes a BA with Highest Distinction from the University of Virginia and an MD from the University of North Carolina. She completed residency training in Anatomic Pathology at Georgetown University followed by subspecialty fellowship training in molecular diagnostics and experimental pathology.
In this Article
What are the different types of HIV testing?
There are three main types of HIV tests: antibody tests, RNA tests, and a combination test that detects both antibodies and viral protein called p24. All tests are designed to detect HIV-1, which is overwhelmingly the most common type of HIV in the United States. Some antibody tests and a combination test can also detect HIV-2 infections, which are less common in the U.S. No test is perfect; tests may be falsely positive or falsely negative or impossible to interpret ("indeterminate," see below).
Positive test results are reportable to the health department in all 50 states and include the patient's name. This information is then reported to the CDC (without names) so that the epidemiology and rate of spread of the infection can be monitored. The names sent to the state remain confidential and will not be reported to employers, family members, or other such people. Some states allow anonymous testing in which the patient's name is not recorded.
HIV antibody tests: HIV possesses many unique proteins on its surface and inside the virus itself. When someone is infected with HIV, their body produces substances designed to neutralize the virus. These substances are called antibodies, and they are directed against the unique proteins of HIV. Unfortunately, these HIV antibodies do not eliminate the virus. However, their presence serves as a marker to show that someone is infected with HIV. HIV antibody tests are the most commonly used tests to determine if someone has HIV.
Antibody testing is usually done on a blood sample, often using an enzyme-linked assay called an ELISA or EIA. In this test, a person's serum is allowed to react with virus proteins that have been produced in the laboratory. If the person has been infected with HIV, the antibodies in the serum will bind to the HIV proteins, and the extent of this binding can be measured. Negative EIA results are usually available in a day or so.
There are some rapid HIV testing kits on the market that can be used in a doctor's office or other points of care. Most of these kits still require blood to be drawn, although it can be done using a simple finger stick in some cases. Home tests or self-tests are also available and may be more convenient for some individuals. Home testing is done by adding a drop of blood to a test strip and mailing the sample to a laboratory. The FDA has also approved kits that test for antibodies in saliva/oral fluid instead of blood. Saliva is obtained by swabbing the gums. Some of the newest tests are done on urine, although results may be less accurate than results from blood.
Because there is a small chance that a person's antibodies will falsely attach to the proteins during the test, a second test is done on all initially positive tests. This second test is called the Western blot test. In this test, the HIV proteins are separated by size and electric charge and the person's serum is layered on the test strip. If the test is positive, a series of bands are detected which indicate specific binding of the person's antibody to specific HIV virus proteins. This test is only done in combination with the initial screening test.
HIV RNA tests: The HIV RNA is different than all human RNA, and tests have been developed to detect HIV RNA in a person's blood. This uses a type of test called a polymerase chain reaction (PCR). These tests are important for newborn screening of HIV-positive mothers since maternal antibody may cross the placenta and be present in the newborn, leading to a positive antibody test even though the infant has not been infected with the virus. These tests may also be helpful in detecting HIV infection in the first four weeks following exposure, before antibodies have had time to develop. However, RNA tests are costly and are not routinely used to screen for infection.
HIV combination test: The HIV combination test detects antibodies directed against HIV-1 or HIV-2, as well as a protein called p24, which forms part of the core of the virus. This is important because it takes weeks for antibodies to form after the initial infection, even though the virus (and the p24 protein) is present in the blood. Thus, combination testing may allow for earlier detection of HIV infections. Preliminary studies suggest that diagnosis could be made an average of one week earlier using the combination test, compared to antibody testing alone. The test uses a reaction known as "chemiluminescence" to detect antibodies and p24 protein. In other words, if either the antibody or the p24 protein is present, the test reaction emits light which registers on a detector. There is only one currently approved combination test, the Architect HIV Ag/Ab Combo assay. If this test is positive, it is recommended it be repeated. Tests that remain positive are confirmed with Western blot as described above.