MSc (Med), Dept of Haematology, School of Pathology, Faculty of Health Sciences, University of the Witwatersrand / BACKGROUND: Human Immunodeficiency Virus (HIV) is a global epidemic with growing numbers of people on highly active anti‐retroviral therapy (HAART) programmes. Effectiveness of treatment needs to be monitored to ensure the uncompromised well being of patients. This is currently done using both Viral Load (VL) and CD4 cell counts for HAART initiation and follow‐up. Although VL is the best predictor of disease progression it is often too expensive for monitoring patients in resource‐limited settings. There is thus a need for a cheaper, more accessible alternative to monitor long term patient response to therapy. METHODS: This study evaluated the use of a recently described flow cytometric assay of CD38 expression (previously developed at the Johannesburg Flow Cytometry Reference Laboratory) in a cohort of HIV+ patients failing 1st line therapy, who were subsequently enrolled onto 2nd line HAART. CD38 and CD8 were “piggy ‐backed” onto the PLG/CD4 protocol and mean fluorescence intensity (MFI) of the CD8/38 expression was monitored longitudinally. Patterns of CD38 expression were compared to 1st line treatment observations to establish equivalence in the predictive power of CD38 expression of fluctuation in viral load on 2nd line treatment patients. In addition, the effect of sample age on assay accuracy was tested before implementation of the CD38 assay at a secondary testing site. RESULTS: The patterns observed in the cohort of 2nd line therapy patients mirrored patterns previously seen in 1st line therapy with 55% of patients showing a continuous decline in CD38 MFI that mimicked changes in VL. The remaining 33% of patients had non‐specific increases in CD38 MFI without concurrent increases in VL and one patient showed irregular VL and CD38 MFI (non‐responder). The CD38 assay showed acceptable accuracy and reproducibility up to 48 hours after venesection (%CV<5%). Implementation at the secondary testing site was successful with 98% similarity (%CV<5%) compared to the reference laboratory. CONCLUSION: CD38 monitoring of 2nd line therapy patients showed comparable patterns to observations in 1st line therapy patients. The assay proved stable over time and easy to implement at another PLG/CD4 testing facility. As such, the CD38 assay offers a cost‐effective, reliable real time supplementary test to long‐term VL monitoring of HIV infected patients on the national ART programme.

<p dir="ltr">Since the beginning of the HIV/AIDS epidemic, 85.6 million people worldwide have become infected with HIV; more than half of whom have died from AIDS-related complications.[1] Sustained viral suppression below the clinically relevant threshold (1000 copies per mL) with highly active antiretroviral therapy (HAART) has proven effective at managing and prolonging the life expectancy of people living with HIV (PLHIV). However, in 2022, 11.3 million PLHIV had still not achieved viral suppression and may become susceptible to both HIV transmission and a variety of opportunistic infections. Of particular importance is the complex issue of patient non-compliance in global HIV management due to social, economic, behavioral, and healthcare access barriers, potentially disconnecting many PLHIV from the HIV care continuum. Therefore, to boost patient engagement in clinical care and to improve overall patient outcomes, new approaches to viral load monitoring practices need to be developed to increase access, particularly in regions of high HIV prevalence.</p><p dir="ltr">Nucleic acid amplification tests (NAATs) have emerged as potent tools for monitoring viral load, with reverse transcription quantitative polymerase chain reaction (RT-qPCR) being recognized as the benchmark due to its sensitivity and ability for real-time quantification enabled by fluorescence signal emission. Nevertheless, RT-qPCR is burdened by drawbacks including extended processing times, high operational costs, and the requirement for specialized laboratory facilities. In this study, we propose a novel method for HIV-1 viral load monitoring by integrating reverse-transcriptase loop-mediated isothermal amplification (RT-LAMP) with real-time particle diffusometry (PD). This approach allows for the continuous monitoring of changes in the diffusion of 400 nm fluorescent particles during RT-LAMP amplification, targeting the <i>p24</i> gene region of HIV-1 RNA. This enables the real-time detection of amplification curves, achieving a detection sensitivity in water samples as low as 25 virus particles per μL within a short duration of 30 minutes. Additionally, to address challenges related to amplification inhibition in complex human specimens, we developed a power-free sample processing system specifically designed for extracting HIV-1 RNA from both whole blood and plasma.Top of FormBottom of FormThis system modifies a commercially available spin-column protocol by integrating a syringe device and handheld bulb dryer, thus eliminating the requirement for a centrifuge. The adaptation allows for the completion of the entire extraction procedure, encompassing viral lysis, RNA capture, washing, and elution of purified HIV-1 RNA, within a timeframe of less than 16 minutes. Subsequent analyses, including RT-LAMP and RT-qPCR, demonstrate a limit of detection of 100 copies per μL and an average RNA recovery of 32% (for blood) and 70% (for plasma) in the elution fraction. Further investigations emphasize the significant presence of purified RNA in the spin column volume (termed as dead volume), and the cumulative recovered RNA copies align with those obtained using the gold standard centrifugation extraction method. Ultimately, we incorporated the real-time quantitative PD-RT-LAMP assay onto a field-compatible handheld portable platform suitable for field use, featuring built-in quality control measures. This platform enables sample-to-answer viral load testing near the point of care (POC). Subsequently, we undertook essential preparatory steps, such as reagent drying to obviate the need for cold storage, initial device calibration, and hands-on training of laboratory personnel regarding device operation, to validate device performance within a cohort of individuals living with HIV (PLHIV). These innovations facilitate quick and comprehensive viral load determination, offering promise for enhanced HIV management and patient care</p>