S IMPLE AM PLIFICATION B ASED - A SSAY

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1 S IMPLE AM PLIFICATION B ASED - A SSAY a point of care platform for resource-limited settngs Helen Lee & team Diagnostics for the Real World University of Cambridge

2 Complexity of automated NAT - Abbott Real time PCR Room 1 - Sample processing and extraction

3 Abbott HIV RealTime PCR system Room 2 Detection

4 Disposables & reagents for 1,000 Roche PCRtests Dry Ice

5 Reducing complexity of NAT 1. Converting complicated detection system into a visual signal Reference Wicking Pad Target sequence Capture Zone Capture probe Detection Complex Dineva et al, JCM 2007

6 3. Simplifying front end sample preparation SAMBA Roche Qiagen Storage at 4 o C No Yes Yes Alcohol No Yes Yes Chaotropic salts No Yes Yes Preparation of reagents by users No Unit dose Yes Carrier RNA & ethanol Yes Carrier RNA & ethanol

7 5. Develop stable reagents to avoid cold chain transport freeze balls reagents Sample Preparation Amplification Enzyme 1 Internal Control Reagent 1 Enzyme 2 Reagent 2

8 % Signal Strength Real time stability data of amplification enzymes C 4 C 25 C 37 C Now 12 months Time Shipping stability - stable at 55 C for 1 month

9 4. Closed amplification cartridge containing all liquid & dry reagents Prevent contamination of amplified products

10 Roche added target located in LTR but only in some assays principally used in developed world 5 LTR Gag Vif LTR 3 Pol Env Nef SAMBA BioMerieux Roche v. 1 Abbott Sequence variation: Env > Gag > Pol > LTR

11 Signal strength SAMBA detection of HIV-1 WHO subtype panel A B C D AE F G AGGH 712 (CRF02) NIBSC standard (B) Group N Group O Negative plasma Group M (400 copies/ml) SAMBA primers detect all subtypes, including groups N and O

12 Blinded evaluation of SAMBA performance with NIH external quality assurance subtype panels (Rush University Medical Center, J Bremer) Subtype N pos / N tested A 12/12 A/E 42/42 A/G 9/9 C 36/36 D 18/18 F 30/30 G 12/12 TOTAL 168/168 (100%)

13 SAMBA system for HIV diagnosis Visual detection of nucleic acids on a dipstick Unit dose device containing pre-loaded reagents Simplified sample preparation Integrated internal control Results < 90 minutes Qualitative test (Plasma or whole blood) Acute infection during window period Early infant diagnosis Semi-quantitative copies/ml (plasma) Viral level for therapy monitoring

14 SAMBA 1 semi-automated instruments

15 SAMBA test visual readout NEGATIVE LOW POSITIVE

16 Blinded comparison of SAMBA qualitative assay (plasma) vs. Roche Taqman v1 in HIV patients at Royal London Hospital Subtype No. samples Virus level No. SAMBA + A B C D F G H J K x x x10 5 7x x x x x10 3-2x10 5 1x10 3-2x /31 24/25 30/30 9/9 7/7 5/5 1/1 4/4 5/5 Overall Detection rate: 116/117 (99.1%)

17 SAMBA detection of HIV recombinant subtypes vs. Roche Taqman v.1.0 (Royal London Hospital) Subtype No. samples Viral level No. SAMBA + CRF01_AE CRF02_AG CRF06_CPX CRF13_CPX CRF14_BG AD A/CRF02_AE Other CRF Untyped x x10 6 8x10 3-2x x10 3-3x10 4 1x10 3-2x x10 5 3x10 4-4x10 7 2x10 4-5x10 5 6/6 19/20 2/2 1/1 5/5 11/11 9/9 15/15 5/5 Overall detection rate: 73/74 (98.6%)

18 Roche v1 negative HIV samples detected by SAMBA (Barts hospital, London) Subtype SAMBA signal Roche result Abbott HIV copies/ml C 5 0 1,118 A/D 1 0 1,780 K 5 0 1,028 CRF02_AG ,276 CRF02_AG ,508 CRF13_CPX

19 Performance of SAMBA detection of HIV-1 clinical samples (Barts hospital, London) Sample Number No. SAMBA + HIV positives /191 HIV patients With undetectable viral load (<40 copies/ml) 9 0/9 HIV negative 216 0/216 SAMBA sensitivity (Roche + Abbott combined) = 98 % (189/191) 0 false positive in 225 clinical samples

20 Roche added target located in LTR but only in some assays principally used in developed world 5 LTR Gag Vif LTR 3 Pol Env Nef BioMerieux Roche v. 1 Abbott SAMBA Roche Taqman v. 2 Sequence variation: Env > Gag > Pol > LTR

21 SAMBA performance vs. Roche Taqman No. samples Clade Sensitivity Specificity 485 (plasma) A, B, C, D, F, G, H, J, K, recombinants 99.2 % (252/254) 100 % (231/231) 144 (whole blood) ND 98 % (48/49) 100 % (95/95) % (300/303) 100% (326/326) *Roche Taqman v1.0 (Royal London Hospital) for 416 samples; Roche Taqman v2 for subsequent 213 samples

22 Major Challenges of EID LTFU between testing and treatment Country LTFU Kenya 83% Mozambique 69% - 87% Uganda 79% Malawi 77% Swaziland 82% Zambia 37% Clinton Foundation

23 Blind evaluation of SAMBA EID with NIH HIV-1 DNA sensitivity EQA Panel (Rush University Medical Center, J Bremer) HIV DNA copies/test SAMBA Roche Amplicor v /6 0/6 8 7/7 1/7 (5/7 indeterminate) 20 6/7 6/7 40 5/5 5/5 80 5/5 5/5 TOTAL 29/30 23/30

24 Evaluation of SAMBA EID test in whole blood from adult patients attending HIV clinic (London Barts Hospital) Whole blood SAMBA tested blinded DBS prepared on-site Frozen aliquot Zambia (Amplicor) Uganda (TaqMan) Royal London Hospital Proviral DNA PCR using multiple genes

25 Roche Roche SAMBA EID test vs. Roche DNA Amplicor v1.5 by DBS (Lusaka, Zambia) INITIAL SAMBA + - RETEST SAMBA * 50-9* 50 *14/22 DBS false-negative became positive, 1 positive became negative SAMBA (whole blood) Roche (DBS) Initial Retest Sensitivity 100 % (114/114) 81 % (92/114) 92 % (105/114)

26 Roche Roche SAMBA EID test vs. Roche Ampliprep/TaqMan by DBS (Kampala, Uganda) INITIAL RETEST SAMBA + - SAMBA * 50 *11/16 DBS false-negatives became positive, 3 positives became negative Sensitivity SAMBA (whole blood) 100 % (114/114) Initial 86 % (98/114) Roche (DBS) Retest 93 % (106/114)

27 Field evaluation of SAMBA semi-quantitative assay at Chiradzulu, Malawi 200 patients recruited by MSF staff from HIV clinic during routine visit 200 µl fresh plasma SAMBA by MSF staff on-site Data sent blinded Frozen plasma shipped directly Roche TaqMan v2 Royal London Hospital Discordant Samples Abbott RealTime PCR Addenbrooke s Hospital All data sent to MSF for analysis

28 Roche Roche Blinded validation of SAMBA semi-quant in 134 clinical samples St Thomas & Royal London Hospitals In absolute counts SAMBA <1000 >1000 < * Within 0.3 Log accuracy of Roche SAMBA <1000 >1000 < >1000 3** 34 > *2/4 within 0.3 Log accuracy of Roche ** 2/3 within 0.3 Log accuracy of Roche Concordance between SAMBA & Roche Taqman v % (131/134)

29 Malawi results SAMBA vs Roche TaqMan v2 Viral Load (cp/ml) < 500 (<1.7 Log) Roche TaqMan VL ( Log)* >2,000 >(3.3 Log) Total SAMBA >1, SAMBA < 1, Total (%) 146 (73%) 8 (4%) 46 (323%) 200 * Roche TaqMan is 0.3 Log accuracy (package insert) Overall concordance with Roche v2 = 98% (196/200)

30 Uganda results SAMBA vs Roche TaqMan v2 Viral Load (cp/ml) < 500 (<1.7 Log) Roche TaqMan VL * ( Log) >2,000 >(3.3 Log) Total SAMBA >1, SAMBA < 1, Total (%) 92 (60%) 2 (1%) 60 (39%) 154 * Roche TaqMan is 0.3 Log accuracy (package insert) Overall concordance with Roche v2 = 96.1% (148/154)

31 Conclusion SAMBA platform is much simpler than currently available molecular technologies which require highly-trained personnel and sophisticated infrastructure only available in centralised laboratories SAMBA device is much easier to handle and being a closed system, prevents contamination by amplicons Staff training requirement for SAMBA is minimal SAMBA can be implemented in lower healthcare levels such as district hospitals or health centres with a basic laboratory but supplied with electricity Reagents do not need cold chain transport or cold storage, a considerable advantage in resource-poor settings

32 Dilution series of whole blood clinical samples for blinded evaluation of SAMBA & DBS in Zambia & Uganda Plasma VL (cp/ml) ARV start Last CD4 Subtype 2 samples with high VL ,021 No 412 A , B 2 samples with low VL * G C 2 samples with undetectable VL B C

33 Limit of detection: SAMBA, TaqMan Qual Test and Amplicor v1.5 (dilutions of 2 samples with high viral load) DNA (cp/ml) RNA (cp/ml) SAMBA TaqMan Amplicor Sample 1547, VL 269,021, subtype A 3, , / , /+ 34 2, /+ -/ /+ +/ /+ -/ / Sample 1346 VL 230,788 subtype B 3, , / , /+ 33 2, /+ -/ /+ +/ /- -/ /

34 Sensitivity of SAMBA, TaqMan Qual Test and Amplicor v1.5 using dilutions of 2 samples with low viral load DNA (cp/ml) RNA (cp/ml) SAMBA TaqMan Amplicor /+ +/ /- -/- Sample 1524 VL208/ml subtype G /- -/- -/ / / DNA (cp/ml) RNA (cp/ml) SAMBA TaqMan Amplicor Sample 1554, VL 83, subtype C /+ +/ /+ -/+ +/ /- -/- -/ /- - -

35 Sensitivity of SAMBA, TaqMan Qual Test and Amplicor v1.5 using dilutions of 2 samples with undetectable viral load DNA (cp/ml) RNA (cp/ml) SAMBA TaqMan Amplicor Sample 1348, VL 0, subtype B /+ +/ /+ -/+ +/ /- -/- -/ /- - - DNA (cp/ml) RNA (cp/ml) SAMBA TaqMan Amplicor Sample 1352, VL 0, subtype C /- +/ /+ +/- +/ /- -/+ -/ /- - -

36 Sensitivity of SAMBA, TaqMan Qual Test and Amplicor v1.5 using WHO 2 nd International RNA standard diluted in whole blood DNA (cp/ml) RNA (cp/ml) SAMBA Qual Test TaqMan Qual Test Amplicor DNA PCR v , , /+ -/ /- +/ /

37 Summary of SAMBA, TaqMan Qual Test and Amplicor v1.5 sensitivity in dilutions of clinical samples SAMBA Qual Test TaqMan Qual Test Amplicor DNA PCR v1.5 Sample type Whole blood DBS DBS Nucleic acid detection RNA/DNA RNA/DNA DNA Limit of detection in clinical samples (RNA cp/ml) Limit of detection In NIBSC RNA standard (IU/ml) Limit of detection In clinical samples (DNA cp/ml) NA NA

38 Sensitivity of SAMBA, TaqMan Qual Test and Amplicor v1.5 using 8E5 LAV cell line diluted in whole blood DNA (cp/ml) RNA (cp/ml) SAMBA Qual Test TaqMan Qual Test Amplicor DNA PCR v , ,000,000 +/ ,000 16,500,000 +/ ,000 1,650,000 +/+ + +/ ,000 +/+ + +/ ,500 +/+ + -/ / ,650 +/ /+ +/ /+ +/ /+ -/ Amplicor only detects DNA; SAMBA & TaqMan detect both RNA & DNA

39 Comparison of SAMBA with Roche TaqMan v.2 in dilution series (100 ul whole blood) Roche TaqMan v.2 RNA cp/ml plasma Number SAMBA Qualitative Test In whole blood HIV negative blood donors (Ab neg, Roche Amplicor neg) 95 0 HIV positive RNA negative patients 23 22* 40 cp/ml * Pos on repeat testing 49 48

40 Next steps: EID clinical trials Cameroon Protocol in development Judith Shang CDC - Cameroon Kenya Protocol submitted, awaiting approval Clement Zeh CDC - Kenya & KEMRI Malawi Protocol approved T. Banda-Kuthyola MOH South Africa Protocol in final stage of preparation Gayle Sherman - NHLS Ashraf Coovadia - MRC & RMMC Hospital Uganda Protocol approved by local IRB; awaiting approval by US IRB Mary Glenn Fowler - Makarere & Johns Hopkins Adeodata Kikitiinwa - Baylor-Uganda Clinic Zambia Protocol submitted Charles Nyambe - MOH Jeff Stringer - CIDRZ Zimbabwe Protocol approved Sekesai Zinyowere - MOH

41 SAMBA 2 instrument prototype

42 ISO 13485:2003 and CAN/CSA ISO certified CA-FDA Licensed medical device manufacturing facility

43 Dry room <5% humidity

44 Vanuatu prevalence: 23 % - Validated bottled drinking water - Sustainable implementation a bigger challenge!

45 Analysis of 8 repeat DBS false negatives at Zambia by Roche Amplicor v1.5 ID Roche TaqMan VL Clade SAMBA (blood) Zambia (manual Amplicor v1.5) Uganda (automated Ampliprep/ TaqMan) Initial Repeat Initial Repeat Proviral DNA (blood) 97 2,979 C ND ND ,450 ND CRF02_AG <40 ND D C

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