Improving HIV Diagnosis at Birth to Increase Early ART Initiation

Salim S. Abdool Karim, MD, PhD reviewing Mitchell C et al. Clin Infect Dis 2014 Feb 5.


A study in Mozambique suggests that more-sensitive assays using larger volumes of DNA from dried blood spots can improve HIV detection among infants with low-copy HIV infection at birth.


Diagnosing HIV infection at birth and immediately initiating antiretroviral therapy could reduce the infectious HIV reservoir in CD4 cells, potentially contributing to functional cure. Early diagnosis is therefore important, but the sensitivity of standard diagnostic testing for HIV DNA in newborns is highly variable, and false negatives are common when HIV DNA concentrations are low. Might increasing DNA input from dried blood spots (DBS) into polymerase chain reaction (PCR) improve detection of HIV infection at birth among infants with low concentrations of viral DNA?

To answer this question, researchers conducted HIV DNA testing on DBS specimens collected at birth, 2, 4, and 8 weeks of life from 849 HIV-exposed infants in Mozambique. HIV infection at birth was identified in 47 (6%) of the infants with standard testing and in an additional 15 (24% of all HIV-infected infants) when samples were retested using the more-sensitive nested PCR technique, which involved 20 dried blood-spot punches instead of a single one.


The nested polymerase chain reaction approach used in this study improved detection of HIV infection at birth by 24%. Infants with low concentrations of HIV at birth may be the best target population for evaluating whether immediate antiretroviral therapy can contribute to functional cure. The implementation of more-sensitive HIV DNA–detection assays is therefore important to improve early infant diagnosis.

Note to Readers: At the time that NEJM Journal Watch reviewed this paper, its publisher noted that it was not in final form and that subsequent corrections might be made.


  1. Mitchell C et al. Low concentrations of HIV-1 DNA at birth delays diagnosis, complicating identification of infants for antiretroviral therapy to potentially prevent the establishment of viral reservoirs. Clin Infect Dis2014 Feb 5; [e-pub ahead of print]. (