Objectives

1- Describe the epidemiological pattern of HIV infection.

2- Determine the main HIV screening tests.
3- Define sensitivity, specificity, predictive-value positive
and predictive-value negative.
4- Illustrate the relationship between prevalence and
predictive value.
5- Identify the important trade-offs between sensitivity
and specificity.
6- List the principles of a good screening programs
 Epidemiological pattern of HIV
infection
HIV, the virus that causes AIDS, acquired immunodeficiency
syndrome has become one of the worlds most serious health
and development challenges. The first cases were reported in
1981.
There were 35.3 million people living with HIV in 2012, up
from 29.4 million in 2001, the result of continuing new
infections, people living longer with HIV, and general
population growth.
The global prevalence rate (the percent of people ages 15-49
who are infected) has leveled since 2001 and was 0.8% in 2012.
 Main HIV screening tests
ELISA (enzyme-linked immunosorbent assay)
these tests detect HIV antibodies, which the
body starts producing between 2 and 12 weeks
after becoming infected with HIV. Current HIV
antibody tests can detect antibodies as early as 3
weeks after exposure
Some HIV antibody tests will not detect HIV-2
(a strain of HIV that is found in western Africa)
The Western blot test :
is the most common test used to confirm
positive results from an ELISA or rapid HIV
test. It generally is used only as a confirmatory
test because it is difficult to perform and
requires highly technical skills
 Main HIV screening tests
IgG antibody to p 24 (anti-p24)
Viral p 24 antigen : disappeared after 8-10
weeks after exposure which comes directly from
the HIV virus
Note : window period 3 12 weeks
 The sensitivity of a test is the
percentage of results that will be
(correctly) positive when HIV is actually
present. Lower rates of sensitivity will
produce more false negative results.
The specificity of a test is the
percentage of results that will be
(correctly) negative when HIV is not
 The calculations for sensitivity and
specificity can be expressed as
equations in the following way:
Sensitivity = (true positive results) /
(true positive results + false negatives)
Specificity = (true negative results) /
(true negative results + false positives)
*The positive and negative predictive values of a
test depend, not only upon the sensitivity and
specificity of the test, but also upon the
prevalence of HIV in the population being
studied.
*The positive predictive value is the
proportion of persons with positive test results
who are correctly diagnosed.
Illustrate the relationship between
prevalence and predictive value.
 relationship between prevalence and
predictive value
The prevalence of a disease in the population
has an important influence on the positive
predictive value of a diagnostic test. With
increasing disease prevalence, the more likely it
becomes that a person with a positive test result
has the disease, and the less likely it becomes
that a positive result is a false positive
 the important trade-offs between
sensitivity and specificity.
The higher the acceptance threshold, the higher
the specificity and the lower sensitivity.
Conversely , the lower the acceptance threshold,
the lower the specificity and the higher the
sensitivity
So the accuracy always lies in between
sensitivity and the specificity . For HIV example,
the classification accuracy 55% is between the
sensitivity (48%) and the specificity (66%)
Since the accuracy is a weighted average of the sensitivity
and specificity , if the sensitivity is much higher than the
accuracy, then the specificity has to fall much below the
accuracy. On the other hand , the specificity can be
improve at the expense of a reduce sensitivity .The trade
off between specificity and sensitivity can best be describe
by means of a receiver operating characteristic. which is
defined as a curve comprising sensitivity and specificity
for the entire the range of the acceptance threshold
Principles of screening
Screening refers to the application of a test to
a population which has no overt signs or
symptoms of the disease in question, to detect
disease at a stage when treatment is more
effective. The screening test is used to identify
people who require further investigation to
determine the presence or absence of disease
and is not primarily a diagnostic test.
World Health Organization guidelines, often referred to as
Wilson's Criteria were published in 1968, but are still applicable
today.

The condition should be an important health problem..

There should be a treatment for the condition.
.Facilities for diagnosis and treatment should be available.
There should be a latent stage of the disease.
.There should be a test or examination for the condition.
.The test should be acceptable to the population.
The natural history of the disease should be adequately understood.
.There should be an agreed policy on whom to treat.
.The total cost of finding a case should be economically balanced in relation
to medical expenditure as a whole.
.Case-finding should be a continuous process, not just a "once and for all"
project