1. Toward a More Perfect World
… or at Least Better HIV Testing Algorithms

2. 1987: State of the Art
Western blot
ELISA

3. 1987: State of the Art

4. 2005: State of the Art

5. 2005: Still the Gold Standard?
Western blot
ELISA

6. Objectives Differ Across Settings
Blood banks
Donor screening: ↑ Sensitivity
Confirmatory testing: ↑ Predictive value
Reference laboratory
↑ Efficiency
↓ Cost
↓ Ambiguity
HIV-2: ↑ Sensitivity, ↑ Surveillance
Point-of care: rapid test combinations
↑ Positive predictive value
↑ Receipt of confirmed results
Just about everybody, everywhere:
↓ Indeterminates

7. Assessment of Alternative Options
How do we measure improvements?
Gold standard: 14K or 24K?
Indeterminate results don’t fit into 2 X 2 tables
We have “truth” on our side
Longitudinal follow-up
“Realized sensitivity”
The importance of testing is not the test result
but in getting individuals test results
… into care
… on treatment

8. Moving Forward From Here
Ready,
Fire,
…………… AIM!