PEDIATRICS Vol. 108 No. 1 July 2001, p. e3

ELECTRONIC ARTICLE:
Rational Testing of the HIV-Exposed Infant

Received Dec 11, 2000; accepted Feb 28, 2001.

Daniel K. Benjamin Jr^*, , William C. Miller, Susan A. Fiscus^§, Daniel K. Benjamin, Michele Morse^¶, Megan Valentine^#, and Ross E. McKinney Jr^*

From the ^* Duke University Medical Center, Department of Pediatrics, Durham, North Carolina;  Schools of Medicine and Public Heath, Department of Epidemiology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina; ^§ Department of Microbiology and Immunology, University of North Carolina, Chapel Hill, North Carolina;  Clemson University, Department of Economics, Clemson, South Carolina; ^¶ University of Virginia, Charlottesville, Virginia; and ^# Family Health International, Durham, North Carolina.

Objectives.  The objectives of this study were 1) to evaluate testing regimens of human immunodeficiency virus (HIV)-exposed infants and 2) to determine optimal methods of follow-up by enzyme-linked immunosorbent assay (ELISA) testing.

Methods.  We reviewed the results from 742 HIV-exposed infants in the state of North Carolina; 2474 samples were tested for HIV by DNA polymerase chain reaction (PCR) at the University of North Carolina Retrovirology Core Laboratory. We then reviewed the utility and costs of ELISA testing of all HIV-exposed infants who were seen at the Duke University Pediatric Infectious Disease Clinic between January 1, 1993, and May 5, 1998. We used likelihood ratios to model probability of HIV infection given 3 negative DNA (PCR) tests and to provide recommendations on the use of ELISA follow-up.

Results.  The overall sensitivity of the DNA PCR was 87.1%, and its specificity was 99.9%. We evaluated 224 HIV-exposed infants who were seen at Duke University and who had at least 3 negative diagnostic tests using either DNA PCR tests or HIV blood cultures. All 178 infants who subsequently underwent ELISA testing ultimately demonstrated seroreversion. The Duke University Pediatric Infectious Disease Clinic transferred the care of 65 patients to primary care physicians before ELISA testing and retained the care of the remaining 159 patients. Children who remained in Duke's care were more likely to have documentation of seroreversion (158 of 159 vs 20 of 65). We reviewed costs of travel, physician appointment, and HIV antibody testing in a tertiary care setting. Given 3 negative PCR tests, the expected cost per case of HIV detected by a positive ELISA assay is $23.8 million.

Conclusions.  Documentation of seroreversion in this cohort was nearly complete in the multidisciplinary subspecialty clinic but not when such responsibility was left to the primary care physician. Given the low probability of disease in patients who have had 3 negative PCR tests, documentation of a negative ELISA may not be an appropriate use of medical resources.  Key words:  pretest probability, posttest, likelihood ratio, cost analysis, HIV.

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