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Although HIV antibody tests are the most appropriate for identifying infection, alternate technologies can contribute to an accurate diagnosis, assist in monitoring the response to therapy, and can be used to effectively predict disease outcome. Viral isolation through viral culture, nucleic acid tests to detect viral RNA, and tests to detect p24 antigen can be used to demonstrate virus or viral components in blood, thereby verifying infection. These methods are highly specific, and a positive result confirms infection. Each has limitations, however, and their use must be tailored to proper testing situations. Tests for viral nucleic acid have recently been introduced, but require sophisticated technology and dedicated, well-trained personnel.
The HIV antigen test is currently used for screening blood for transfusion and is appropriate for use
in several other testing situations. It offers the advantages of simplicity and cost effectiveness
for verifying infection, but is less than perfect.
The p24 antigen assay measures the viral capsid (core) p24 protein in blood that is detectable
earlier than HIV antibody during acute infection. It occurs early after infection due tothe initial
burst of virus replication and is associated with high levels of viremia during which the individual
is highly infectious.
(1) When antibodies to HIV become detectable, however, p24 antigen is often no longer demonstrable, most likely due to antigen-antibody complexing in the blood. When detected, p24 antigen is highly specific for infection. The specificity of the p24 antigen test in detecting HIV infection using PCR as the gold standard was calculated from data using test kits from 2 manufacturers to be 99.9%.
(2) In the same study, the sensitivity following a procedure of neutralization to confirm the presence of p24 antigen (see below) was 100%.
Testing for p24 can be of value in:
(1) detecting early HIV infection,
(2) screening blood,
(3) diagnosing infection in the newborn,
(4) monitoring antiviral therapy. A major limitation is that the test is insensitive when testing
blood, both because low levels of antigen are difficult to detect, and because antigenemia occurs
only transiently during different stages of infection.
(5) In fact, the HIV antigen test is incapable of detecting 75% of blood donors who are infected but
seronegative.
(6)p24 antigen is found in serum in either free form or bound by anti-p24 antibody. Free p24 can be
measured with enzyme immunoassays whereas detection of bound p24 requires pretreatment with an acid to dissociate the complex. Procedures to dissociate antigen-antibody complexes have improved the sensitivity of the p24 test, but antigen remains undetectable in most asymptomaticpatients.(7)
Antibody remains detectable throughout infection, whereas p24 antigen characteristically appears
early and late during infection.
p24 Antigen Test
There are several uses, and mis-uses, of the p24 antigen assay. It is important to realize that the
p24 antigen test detects soluble p24 antigen, presumably following viral replication, and does not
specifically identify live virus. Therefore, a positive antigen test does not confirm that a sample
is infectious, and should not be used for that purpose. The only means available to demonstrate that
a sample contains infectious virus is by virus isolation and culture. A negative result for antigen
does not rule out infection, because the test lacks exquisite sensitivity; i.e., the test should not
be used to verify noninfection. Antigen detection signals infection, however, and positive results in
seronegative individuals can be an effective, although not cost effective, means to identify early
infection.
The p24 antigen test is most useful in detecting antigen in supernatants from cultures that have been
inoculated with cells from a patient suspected of being infected (viral culture and isolation). The
antigen test is the method of choice for detecting the presence of free antigen in culture, and it is
two orders of magnitude more sensitive than the reverse transcriptase assay.(13) The test is most
useful for detecting viral antigen in culture fluids because large quantities of antigen are exuded
in the supernatant fluid during viral replication.
The antigen test can be performed on fluids other than those of culture and serum. Evidence
determined from the testing of cerebrospinal fluid (CSF) indicates that many patients with HIV
dementia and encephalopathy have detectable antigen in CSF, most likely due to active replication of
the virus in cerebral tissue.
The p24 antigen test can be of value in blood screening, for identification of acute infection, for
monitoring infection, andto assist in the diagnosis of infection in the newborn (each is discussed
subsequently). It has been used for detecting early infection in rape cases, identification of
infection after occupational exposure, and for assisting in the resolution of indeterminate Western
blot results. The degree to which p24 antigen assays can detect p24 antigen from all clades of HIV-1,
HIV-2, and HIV-1 Group O, however, is unknown.
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