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International Journal of Medical Science and Current Research (IJMSCR)
Available online at: www.ijmscr.com
Volume2, Issue 4, Page No: 466-473
July-August 2019
International Journal of Medical Science and Current Research | July-August 2019 | Vol 2 | Issue 4
466
ISSN (Print): 2209-2870
ISSN (Online): 2209-2862
(International Print/Online Journal)
SJIF IMPACT FACTOR: 4.617
PUBMED-National Library of
Medicine ID-101739732
IJMSCR
Outcome of Indeterminate HIV Test Results in the Wouri Division, Littoral Region of
Cameroon
Elvis T. Amin1, Alain Tegomo Awungia1, Charles Njumkeng1, Regina N. Mugri1, Mispa Zuh1, Robert Foncha1,
Achu C. Awah1, Agnes Keko1, Mado Efuetngwa1, Patrick A.Njukeng1.
1Global Health Systems Solutions, Limbe, Cameroon
*Corresponding Author:
Prof. Patrick A. Njukeng
The Principle Investigator/Executive Director, Global
Health Systems Solutions, Denveur layout, Bonamousadi, P.O, Box. 3918 Douala,
Littoral Region, Republic of Cameroon
Type of Publication: Original Research Paper
Conflicts of Interest: Nil
ABSTRACT
An indeterminate test result is reached when the first line test is reactive and the second line test is non-reactive. Individuals with HIV
infection who are not aware of their HIV status are responsible for a disproportionate number of new HIV infections. The aim of this
study was to determine the outcome of indeterminate HIV test results in some health facilities in the Wouri Division, Littoral region of
Cameroon. The study was a hospital-based retrospective analysis of HIV testing records at all testing sites in health facilities from
October 2017 to October 2018. All persons with indeterminate test results reported in the HIV National testing registers were included
in the study. Data were extracted from the registers using a checklist that captured personal information as well as the follow-up
measure taken by the health facility to reach a final result. Data analysis was done with SPSS version 20. Proportions were calculated
for categorical variables while the difference in proportions was compared with the chi-square tests. A total of 433 cases of
indeterminate HIV test results were reviewed in this study. Majority of the cases 380 (87.8%) were tested in the laboratory, while the
rest were tested by non-laboratory testing sites. The overall monthly average indeterminate test results were 36 (SD, 10). Out of 433
individuals who had indeterminate HIV test results, 117 were sent to do an Enzyme-Linked Immunosorbent Assay (ELISA) while
316 were requested to return after 3 weeks to re-do a Rapid Diagnostic Test (RDT). Furthermore, 96 (82.1%) of those sent for ELISA
actually did the test and 15(15.6%) of those who did the test had a positive HIV result. The majority 291(92%) of persons requested to
repeat RDT after 3 weeks did not turn up for the RDT to be done, while 14(56.0%) of those who repeated RDT after weeks still had
indeterminate HIV test results. The study highlights that several individuals with indeterminate HIV test results were still unable to
confirm their HIV status with RDT even when the test was repeated after 3 weeks, as stipulated by the National HIV Rapid Testing
Algorithm for Cameroon. Referring patients for ELISA to confirm their HIV status after an indeterminate HIV test result proves to be
more effective than requesting them to come back in 3 weeks to repeat RDT. Therefore ensuring the accessibility and affordability of
ELISA as well as emphasizing on proper counselling of individuals with indeterminate test results in health institutions, will go a long
way to reduce medical, psychological, and social impacts associated with HIV.
Keywords: ELISA, Cameroon, Indeterminate HIV test results, Outcome, RDT
INTRODUCTION
Rapid testing for human immunodeficiency virus
(HIV) is the most efficient and sometimes the only
feasible way to quickly provide information about
HIV status among adults and children ≥18 months of
age in sub-Saharan Africa [1,2]. Contrary to enzyme
immunoassays (EIAs) and Western blot assays
(WBs), HIV rapid tests are relatively cheap, easy to
use and fast to perform. Most of them do not require
refrigeration, sophisticated laboratory equipment,
skilled technicians, and electricity supply. Results
from serum, plasma, whole blood, and saliva samples
are obtained by visual reading after a few minutes
[3]. They are also accurate and reliable as a result of
applying a quality system approach recommended by
the World Health Organization [4].
When two rapid test kits are used in serial to confirm
a positive test result, an indeterminate test result is
reached when the first test kit is reactive and the
second test kit is non-reactive [5]. In other words
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indeterminate test results mean that the test didn't
provide a clear negative or positive result. An
indeterminate HIV test result could be due to early
stages of HIV infection, a time that the antibodies
level in the body might not be detectable by some
rapid tests. A person with indeterminate results may
truly be HIV uninfected and can be caused by a
different viral infection or just nonspecific antibodies
in the blood [5].
It is usually challenging for HIV counselors and
health care providers to disclose indeterminate results
[6]. Timely treatment of HIV-positive individuals
improves their outcomes and has the potential to limit
further transmission of the HIV infection. Persons
with HIV infection who are not aware of their HIV
status are responsible for a disproportionate number
of new HIV infections, with a transmission rate
approximately two-fold higher than persons with
HIV infection who are aware of their HIV status [7].
Persons who become aware of their HIV infection
can lower their risk of transmitting HIV to others by
practicing risk reduction strategies [8]. There is need
to create awareness as well as properly manage
indeterminate as well as false positive HIV results, so
as to avoid situations such as marital disharmony,
rejection by family members, stigma, depression,
suicidal ideation and other psychosocial problems
[9]. Given the potential for the severe medical,
psychological, and social impacts of HIV
misdiagnosis and the evidence of elevated false-
positive results from some settings, it is imperative
that HIV diagnosis is confirmed to by both a sensitive
and specific test. More research strategies are needed
to identify and accurately conclude on the HIV status
of individuals who are unaware of their infection [8].
Cameroon is currently implementing the USAIDS
95-95-95 goals to end the AIDS epidemic by 2030
and there has been Scale-up of HIV testing
throughout the country by creation of several testing
sites at the various entry points in most health
facilities. Because of this, HIV testing is increasingly
done by a variety of lay providers. Accurate
laboratory diagnosis of HIV infection depends on
testing algorithms that maximize overall sensitivity
and specificity by employing a sequence of tests in
combination and applying decision rules for
resolving indeterminate test results [10]. The
National HIV Rapid Testing Algorithm recommends
a series and combination of tests for HIV RDTs and
ELISA as a means of determining the HIV status of
indeterminate test results. However, there is still
limited information available on the outcome of
indeterminate test results following diagnosis as the
follow up of the cases remains a challenge.
Materials and methods
Study Area
Douala is the economic capital of Cameroon as well
as the head quarter of Littoral Region. It is the most
populated urban center in Cameroon [11], with about
2, 768 436 inhabitants. The prevalence of HIV/AIDS
reached 4.6% for people aged 15 to 49 years in the
city of Douala. Women were particularly affected,
with a prevalence of 6.4% as opposed to 2.6% for
men [12].
Study design and Population
It was a retrospective analysis of data from files from
October 2017 to October 2018. HIV testing registers
were reviewed in 21 health facilities, which have
been listed for high HIV testing and high positive
yield within the Wouri division. The study consisted
of retrieving records of persons with indeterminate
HIV test results, evaluate the actions taken with
regards to the final outcome of the indeterminate HIV
test following an ELISA test or repeating RDT after
3-4 weeks. Given that we did not have enough
information to calculate the sample size, all patients
with indeterminate HIV test results reported in the
HIV national testing registers were included in the
study.
HIV testing algorithm in Cameroon
Cameroon uses the serial (for diagnosis) and parallel
(for blood screening in blood banks) HIV testing
strategy with two RDTs. The first line test kits are
Determine HIV1/2 (Alere test, USA) or Uni-Gold
HIV Rapid Test and the second line test kits are
OraQuick HIV-1/2 and Shanghai HIV (1+2).
Specifically for testing sites using the serial
algorithm, a non-reactive test result for the first line
test is considered negative for HIV. A reactive result
on the first test warrants another test to be done (a
second line test) for confirmation. If the second line
test is non-reactive, the result is declared
indeterminate and the patient is retested in 3 weeks or
referred to do an ELISA test. A positive result on the
second test means the patient is HIV-positive; but a
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Volume 2, Issue 4; July-August 2019; Page No.466-473
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verification testing is done by a second tester before
the results are given to the client. .
Data collection and archiving
Data for this study was extracted from registers using
a checklist which was designed to capture testing
point, date of test done, and the follow-up measure
put in place within the health facility and outcome of
the follow-up test. To ensure the ongoing security of
the data after data entry and upon completion of the
study, all primary data extracted were stored in
special cabinets at the headquarters of the hosting
institutions for the study. These files will be retained
for a 10-year period and discarded thereafter.
Data analysis
Data collected with the checklists were entered into
Excel spread sheet and the analysis was done with
SPSS version 20 (IBM, Chicago, IL). Proportions
were calculated for categorical variables while means
were computed for continuous variable. The
difference in proportions was compared with the chi-
square tests. A p-value was considered statistically
significant if it is less than 0.05.
Ethical Considerations
Administrative authorizations for this study was
obtained from the Littoral Regional Delegation of
Public Health and the directors of all the health
facilities involved. Ethical clearance for the study
(IRB2018-50) was obtained from the Cameroon
Baptist Convention Institutional Review Board
Considering that the study does not directly involve
human subjects and as it was not possible to trace all
these individuals, a consent waiver was applied.
Results
Overview of HIV testing in the study population
With respect to HIV testing within the study area, an
average of 12,640 (SD, 989) HIV tests are done per
month. The highest number of tests were done in
public health facilities (mean testing 6227.4; SD 886)
while the least number of tests were done in private
health facilities (Mean testing 1968; SD 338). An
average of about 567 HIV positive cases are tested
each month and 36 (SD 10) indeterminate cases are
recorded each month as shown in table 1.
Follow up of indeterminate HIV test results in the
study population
A total of 433 records of patients with HIV
indeterminate test results were reviewed. Of the 433
participants, 241(55.7%) were females and the age
group 20 to 29 years was the most represented
(36.5%). Public health facilities had the highest
number of participants 205(47.3%) enrolled in the
study followed by Faith-based health facilities
148(34.2%) as shown in table 2.
Among the 433 participants with indeterminate test
results, 312(72.1%) did a follow-up test (either
repeated RDT after 3 weeks or did ELISA) to
determine the HIV status and the remaining 121
(27.9%) were lost. Out of the 121 participates who
did not go for a follow-up test, majority 91(44.4%)
were tested in Faith-based facility compared to
17(11.5%) and 13(16.2%) for public and private
health facilities, respectively (p, 0.0001). Also,
majority of them 69(57%) were females and most of
them, 46(38%) were within the age range of 20 to 29.
The number of participants who did not do a follow-
up test was significantly higher for those who were
initially tested in the laboratory 113(29.7%)
compared to those who were tested in non-laboratory
HIV testing sites 8(15.1%), (p, 0.026). The number
of participants who came back for a follow-up test
was not associated with sex and age group (Table 2).
Follow up measures of Indeterminate HIV test
Result
Out of the 433 indeterminate test results, 117(27.0%)
were immediately sent to do ELISA test, while the
rest 316 (73%) were requested to return after 3 weeks
to repeat the RDT. Furthermore, 96 (82.1%) of those
sent for ELISA actually did the test, while the
remaining 21(17.9%) did not. Out of the 316 persons
requested to come for RDT after 3 weeks, 291(92%)
did not return. See Figure 1.
Elvis T. AMIN et al International Journal of Medical Science and Current Research (IJMSCR)
Volume 2, Issue 4; July-August 2019; Page No.466-473
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Figure 1: Measures taken to follow-up Indeterminate HIV test Result and its outcome.
Outcome of Indeterminate HIV test result
It is important to note that, of the 117 individuals sent
for ELISA test 96(82.1%) did the follow-up test,
while out of the 316 individual who were asked to
return to the facility for another RDT in 3 weeks,
only 25(7.9%) came back for a follow-up test.
Among the 121 individuals who did a follow-up test,
17(14.0%) were confirmed positive for HIV, giving
an overall prevalence of 14.0 among individuals with
indeterminate test results. Out of the 25 persons who
returned for RDT, 14(56%) of them still had an
unknown HIV status as their serologic status was still
The findings of this study revealed that 4(50.0%) of
those who repeated RDT in a non-laboratory testing
site still had indeterminate test results compared with
11(9.7%) for those who were retested in the
laboratory. This difference was statistical significant
(p = 0.003). The outcome of indeterminate test
results was not associated with participants’ sex and
age group (Table 4).
Discussion
Timely treatment of HIV-positive individuals
improves their treatment outcomes and has the
potential to prevent further transmission of the virus
[6]. Given the potential for the severe medical,
psychological, and social impacts of HIV
misdiagnosis and the evidence of false-positive
results from some settings, it is imperative that HIV
diagnosis is confirmed by both sensitive and specific
test [9]. The aim of this study was to determine the
outcome of HIV indeterminate test results.
In this study, the overall monthly average
indeterminate test results were 36 and the highest
number of indeterminate test results were found
among faith-based facilities with a monthly average
of 18 indeterminate results. This can be partially
accounted for by the fact that more public health
facilities have been actively involved in laboratory
quality assurance activities in Cameroon. Since
indeterminate test results cannot be completely
dissociated from tester’s knowledge and mastery of
testing quality assurance, it is likely that public health
facilities being more involved in implementing
quality assurance activities could lead to fewer
indeterminate HIV test results. It was also noted that
non-laboratory HIV testing sites had a slightly higher
indeterminate HIV test results than the laboratory.
This could be explained by the fact that, following
the scale-up of HIV testing in Cameroon, HIV testing
is increasingly being done by a variety of lay
providers who are often located at other newly
created non-laboratory testing sites [13]. Majority of
27
73
82.1
17.9
7.9
92
0
10
20
30
40
50
60
70
80
90
100
Sent for
ELISA
Do RDT in
3weeks
Was Done
Wasn't done
Wan done
Wasn't done
Action taken
ELISA
RDT in 3weeks
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those doing HIV testing in non-laboratory testing
sites are lay providers or non-laboratory personnel
such as nurses, counselors and many other
individuals who need more training to carry out HIV
testing [14].
It was also noted that 17.9% of those requested to do
ELISA test in order to determine their HIV status did
not go for the test. This can be explained by the fact
that the test is costly and the ELISA test centers are
very few. Most often, patients are required to move
out of their health area to do an ELISA test.
Furthermore, ELISA is not a routine test in most
health facilities or laboratories as most sites which
carry out the test do so just once or twice a week.
Moreover, there is no referral system in place for
such patients to be referred to the facilities doing the
test within the shortest possible time. Longer
turnaround time has been reported as a major
challenge on the application of ELISA in voluntary
counselling and testing (VCT) programs, despite its
high sensitivity [15-16]. On the other hand, 92% with
indeterminate test results who were requested to
return in 3 weeks to re-do RDT, did not turn up for
the follow-up test. This can be accounted for by the
fact that there is no effective follow-up mechanism in
place to ensure that the patient return for the re-
testing. Furthermore, the psychological effect of such
results might lead to patients seeking alternative
means or going to other health facilities to know their
HIV status, which can’t be traced directly by the
hospitals. These findings underscore the need for the
state and national HIV programs to put in place a
means of breaking any tie between the first and
second line test within the shortest time possible.
Among the individuals with indeterminate HIV test
results who were to repeat RDT after 3 weeks, 56%
of those who repeated the test could not still ascertain
their HIV status as they still had indeterminate test
results. This high number of indeterminate HIV test
results after repeating RDT can be due to high
sensitivity of the first line RDT test kit. This finding
is in agreement with previous reports that indicated
that ELISA is the preferred screening test for the
detection of anti-HIV antibodies [17-18]. Though the
wide use of RDTs can increase the proportion of
patients gaining access to HIV antibody test [3], their
use as the only screening test in voluntary
counselling and testing programs cannot be justified,
keeping in view the possibility of missing early
infections as well as concerns regarding reporting
indeterminate HIV test results, given that up to 14%
of persons who were retested finally had positive
HIV test results.
Conclusion
Our study highlights that, despite the efforts being
put in place to ensure early diagnosis and timely
treatment of HIV-positive individuals, several
individuals turn out with indeterminate results. Out of
the 12640 average monthly HIV tests done, 36
(0.3%) have indeterminate HIV test results and are
still unable to confirm their HIV status even after
doing a follow-up test as stipulated by the National
HIV Rapid Testing Algorithm. 82% of those referred
for ELISA actually did the test compared to only 29
% who did a repeat RDT. Furthermore, 56 %
individuals with indeterminate HIV results referred to
repeat RDT still had an indeterminate result
compared to 0 % for those referred to do ELISA.
Therefore, if made accessible and more affordable,
ELISA would be a better test to ascertain the
outcome of indeterminate test results. There is also a
need to emphasize on proper counseling of
individuals with indeterminate HIV test results on the
need to know their HIV status by
repeating/conducting another test, this will help
improve on the low turnout of indeterminate
Consent for publication
Not applicable.
Competing interests
The authors declare that they have no competing
interests
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Volume 2, Issue 4; July-August 2019; Page No.466-473
© 2019 IJMSCR. All Rights Reserved
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Table 1: Average monthly indeterminate test results in 21 health facilities in the Littoral region from
October 2017 to September 2018
Category
Variable
Average tests
done per
Month (SD)
Average
positives per
Month (SD)
Average monthly
indeterminate test
results(SD)
Type of
facility
Public
6227.4 (886)
276.83 (60)
13.00 (4)
Private
1968.3(338)
128.08 (66)
5.08 (1,67)
Faith base
4444.3 (470)
162.25 (38)
18.33 (6)
Type of
Site
Laboratory
7622.7 (159)
281.83 (88)
15.00 (5)
Others
5017.3 (172)
285.33 (84)
21.42 (4)
Overall
12640 (989)
567.17(98)
36.42 (10)
Table 2: Factors affecting the follow up of indeterminate HIV test results in Wouri Division, October
2017 to September 2018
Category
Variable
Number N=433
(%)
Did a follow
up test (%)
Did not do
follow up test
(%)
P-value
Sex
Male
192(44.3)
140(72.9)
52(27.1)
0.721
Female
241(55.7)
172(71.4)
69(28.6)
Type of
facility
Public
148(34.2)
131(88.5)
17(11.5)
0.000
Private
80(18.5)
67(83.8)
13(16.2)
Faith base
205(47.3)
114(55.6)
91(44.4)
Type of Site
Laboratory
380(87.8)
267(70.3)
113(29.7)
0.026
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Others
53(12.2)
45(84.9)
8(15.1)
Age Group
(Years)
≤10
21(4.8)
18(85.7)
3(14.3)
0.786
10-19
31(7.2)
23(74.2)
8(25.8)
20-29
158(36.5)
112(70.9)
46(29.1)
30-39
102(23.6)
73(71.6)
29(28.4)
40-49
58(13.4)
40(69.0)
18(31.0)
≥50
63(14.5)
46(72.1)
17(27.0)
Total
433(100)
312
121
Table 3: Outcome of the indeterminate test results
Test
used
Number of test
done
Final Result
Negative (%)
Positive (%)
Indeterminate
(%)
ELISA
96
81(84.4)
15(15.6)
00
RDT
25
9(36.0)
2(8.0)
14(56.0)
Total
121
90(74.4)
17(14.0)
14(11.6)
ELISA = Enzyme-linked immunosorbent assay, RDT = Rapid diagnostic test
