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Persons infected with HIV are more likely to transmit the virus during the early stages (acute and recent) of infection, when viral load is elevated and opportunities to implement risk reduction are limited because persons are typically unaware of their status (1,2). Identifying recent HIV infections (acquired within the preceding 12 months)* is critical to understanding the factors and geographic areas associated with transmission to strengthen program intervention, including treatment and prevention (2). During June 2019, a novel recent infection surveillance initiative was integrated into routine HIV testing services in Malawi, a landlocked country in southeastern Africa with one of the world's highest prevalences of HIV infection. † The objectives of this initiative were to collect data on new HIV diagnoses, characterize the epidemic, and guide public health response (2). New HIV diagnoses were classified as recent infections based on a testing algorithm that included results from the rapid test for recent infection (RTRI) § and HIV viral load testing (3,4). Among 9,168 persons aged ≥15 years with a new HIV diagnosis who received testing across 103 facilities during October 2019-March 2020, a total of 304 (3.3%) were classified as having a recent infection. Higher proportions of recent infections were detected among females, persons aged <30 years, and clients at maternal and child health and youth clinics. Using a software application that analyzes clustering in spatially referenced data, transmission hotspots were identified with rates of recent infection that were significantly higher than expected. These near real-time HIV surveillance data highlighted locations across Malawi, allowing HIV program stakeholders to assess program gaps and improve access to HIV testing, prevention, and treatment services. Hotspot investigation information could be used to tailor HIV testing, prevention, and treatment to ultimately interrupt transmission., Competing Interests: All authors have completed and submitted the International Committee of Medical Journal Editors form for disclosure of potential conflicts of interest. No potential conflicts of interest were disclosed.

Tests for recent HIV infection (TRI) distinguish recent from long-term HIV infections using markers of antibody maturation. The limiting antigen avidity enzyme immunoassay (LAg EIA) is widely used with HIV viral load (VL) in a recent infection testing algorithm (RITA) to improve classification of recent infection status, estimate population-level HIV incidence, and monitor trends in HIV transmission. A novel rapid test for recent HIV infection (RTRI), Asanté™, can determine HIV serostatus and HIV recency within minutes on a lateral flow device through visual assessment of test strip or reader device. We conducted a field-based laboratory evaluation of the RTRI among pregnant adolescent girls and young women (AGYW) attending antenatal clinics (ANC) in Malawi.We enrolled pregnant AGYW aged <25 years testing HIV-positive for the first time at their first ANC visit from 121 ANCs in four high-HIV burden districts. Consenting participants provided blood for recency testing using LAg EIA and RTRI, which were tested in central laboratories. Specimens with LAg EIA normalized optical density values ≤2.0 were classified as probable recent infections. RTRI results were based on: (1) visual assessment: presence of a long-term line (LT) indicating non-recent infection and absence of the line indicating recent infection; or (2) a reader; specimens with LT line intensity units <3.0 were classified as probable recent infections. VL was measured for specimens classified as a probable recent infections by either assay; those with HIV-1 RNA ≥1,000 copies/mL were classified as confirmed recent infections. We evaluated the performance of the RTRI by calculating correlation between RTRI and LAg EIA results, and percent agreement and kappa between RTRI and LAg EIA RITA results.Between November 2017 to June 2018, 380 specimens were available for RTRI evaluation; 376 (98.9%) were confirmed HIV-positive on RTRI. Spearman's rho between RTRI and LAg EIA was 0.72 indicating strong correlation. Percent agreement and kappa between RTRI- and LAg EIA-based RITAs were >90% and >0.65 respectively indicating substantial agreement between the RITAs.This was the first field evaluation of an RTRI in sub-Saharan Africa, which demonstrated good performance of the assay and feasibility of integrating RTRI into routine HIV testing services for real-time surveillance of recent HIV infection., Competing Interests: The authors have read the journal’s policy and have the following competing interests to declare: As an inventor of LAg EIA and rapid test for recent infection, BSP receives a portion of royalties from the sale of these tests as per policy of the United States government. There are no patents, products in development or marketed products associated with this research to declare. However, the product (Asante Rapid Recency Assay kit) was developed and commercialized under a licensing agreement with the CDC. This does not alter our adherence to PLOS ONE policies on sharing data and materials.

Introduction: Testing for recent HIV infection can distinguish recently acquired infection from long-standing infections. Given current interest in the implementation of recent infection testing algorithms (RITA), we report our experiences in implementing a RITA in three pilot studies and highlight important issues to consider when conducting recency testing in routine settings., Methods: We applied a RITA, incorporating a limited antigen (LAg) avidity assay, in different routine HIV service-delivery settings in 2018: antenatal care clinics in Siaya County, Kenya, HIV testing and counselling facilities in Nairobi, Kenya, and female sex workers clinics in Zimbabwe. Discussions were conducted with study coordinators, laboratory leads, and facility-based stakeholders to evaluate experiences and lessons learned in relation to implementing recency testing., Results: In Siaya County 10/426 (2.3%) of women testing HIV positive were classified as recent, compared to 46/530 (8.7%) of women and men in Nairobi and 33/313 (10.5%) of female sex workers in Zimbabwe. Across the study setting, we observed differences in acceptance, transport and storage of dried blood spot (DBS) or venous blood samples. For example, the acceptance rate when testing venous blood was 11% lower than when using DBS. Integrating our study into existing services ensured a quick start of the study and kept the amount of additional resources required low. From a laboratory perspective, the LAg avidity assay was initially difficult to operationalise, but developing a network of laboratories and experts to work together helped to improve this. A challenge that was not overcome was the returning of RITA test results to clients. This was due to delays in laboratory testing, the need for multiple test results to satisfy the RITA, difficulties in aligning clinic visits, and participants opting not to return for test results., Conclusion: We completed three pilot studies using HIV recency testing based on a RITA in Kenya and Zimbabwe. The main lessons we learned were related to sample collection and handling, LAg avidity assay performance, integration into existing services and returning of test results to participants. Our real-world experience could provide helpful guidance to people currently working on the implementation of HIV recency testing in sub-Saharan Africa.

Introduction: Surveillance of recent HIV infections in national testing services has the potential to inform primary prevention programming activities. Focusing on procedures required to accurately determine recent infection, and the potential for recent infection surveillance to inform prevention efforts, we present the results of three independent but linked pilots of recency testing., Methods: To distinguish recently acquired HIV infection from long-standing infection, in 2018 we applied a Recent Infection Testing Algorithm that combined a laboratory-based Limiting Antigen Avidity Enzyme Immunoassay with clinical information (viral-load; history of prior HIV diagnosis; antiretroviral therapy-exposure). We explored potential misclassification of test results and analysed the characteristics of participants with recent infection. We applied the algorithm in antenatal clinics providing prevention of mother-to-child transmission services in Siaya County, Kenya, outreach sites serving female sex workers in Zimbabwe, and routine HIV testing and counselling facilities in Nairobi, Kenya. In Nairobi, we also conducted recency testing among partners of HIV-positive participants., Results: In Siaya County, 2.3% (10/426) of HIV-positive pregnant women were classified as recent. A risk factor analysis comparing women testing recent with those testing HIV-negative found women in their first trimester were significantly more likely to test recent than those in their second or third trimester. In Zimbabwe, 10.5% (33/313) of female sex workers testing HIV-positive through the outreach programme were classified recent. A risk factor analysis of women testing recent versus those testing HIV-negative, found no strong evidence of an association with recent infection. In Nairobi, among 532 HIV-positive women and men, 8.6% (46) were classified recent. Among partners of participants, almost a quarter of those who tested HIV-positive were classified as recent (23.8%; 5/21). In all three settings, the inclusion of clinical information helped improve the positive predictive value of recent infection testing by removing cases that were likely misclassified., Conclusions: We successfully identified recently acquired infections among persons testing HIV-positive in routine testing settings and highlight the importance of incorporating additional information to accurately classify recent infection. We identified a number of groups with a significantly higher proportion of recent infection, suggesting recent infection surveillance, when rolled-out nationally, may help in further targeting primary prevention efforts., (© 2020 The Authors. Journal of the International AIDS Society published by John Wiley & Sons Ltd on behalf of the International AIDS Society.)

Background: Serological tests can distinguish recent (in the prior 12 months) from long-term HIV infection. Integrating recency testing into routine HIV testing services (HTS) can provide important information on transmission clusters and prioritize clients for partner testing. This study assessed the feasibility and use of integrating HIV recency into routine testing., Methods: We conducted a multi-method study at 14 facilities in Kenya, and key informant interviews with health care providers. We abstracted clinical record data, collected specimens, tested specimens for recent infection, returned results to participants, and conducted a follow-up survey for those recently infected., Results: From March to October 2018, we enrolled 532 clients who were diagnosed HIV-positive for the first time. Of these, 46 (8.6%) were recently infected. Women aged 15-24 years had 2.9 (95% confidence interval: 1.46 to 5.78) times higher adjusted odds of recent infection compared with 15-24-year-old men and those tested within the past 12 months having 2.55 (95% confidence interval: 0.38 to 4.70) times higher adjusted odds compared with those tested ≥12 months previously. Fourteen of 17 providers interviewed found the integration of recency testing into routine HTS services acceptable and feasible. Among clients who completed the follow-up interview, most (92%) felt that the recency results were useful., Conclusions: Integrating recent infection testing into routine HTS services in Kenya is feasible and largely acceptable to clients and providers. More studies should be done on possible physical and social harms related to returning results, and the best uses of the recent infection data at an individual and population level.

We examined three waves of National HIV Behavioral Surveillance surveys of persons who inject drugs (PWID) in San Francisco to assess meeting UNAIDS 90-90-90 targets. Diagnosis of PWID living with HIV increased from 64.4% in 2009 to 80.5% in 2015. Antiretroviral treatment among those diagnosed did not improve (63.8% in 2009, 62.9% in 2015). Programs in San Francisco have not achieved the first two UNAIDS targets for PWID by 2015. In a context of a rising opioid epidemic, there is urgent need for increased case finding of PWID living with HIV who are undiagnosed with rapid linkage to treatment.

We mapped hot spots and estimated the numbers of people who use drugs (PWUD) and who inject drugs (PWID) in 12 regions of Tanzania. Primary (ie, current and past PWUD) and secondary (eg, police, service providers) key informants identified potential hot spots, which we visited to verify and count the number of PWUD and PWID present. Adjustments to counts and extrapolation to regional estimates were done by local experts through iterative rounds of discussion. Drug use, specifically cocaine and heroin, occurred in all regions. Tanga had the largest numbers of PWUD and PWID (5190 and 540, respectively), followed by Mwanza (3300 and 300, respectively). Findings highlight the need to strengthen awareness of drug use and develop prevention and harm reduction programs with broader reach in Tanzania. This exercise provides a foundation for understanding the extent and locations of drug use, a baseline for future size estimations, and a sampling frame for future research.

Guatemala has a concentrated HIV epidemic disproportionately affecting men who have sex with men (MSM) and transgender women. We recruited 205 self-identified MSM, bisexuals, transvestites, and transgender women in western Guatemala using long-chain peer referral, wherein "seed" participants were asked to invite as many as three acquaintances to participate in the study. Self-reported sexual or gender identity was MSM, 46%; bisexual, 28%; transvestite, 21%, and transgender woman, 5%. Median age of the participants was 23 years, and 36% self-identified as being indigenous. Indigenous persons were more likely to self-identity as transvestite (32.9% vs 13.8%, P = 0.04), strongly perceive themselves at risk for HIV (87.7% vs 51.5%, P = 0.001), have had an HIV test in the last 12 months and know the result (97.3% vs 85.4%, P = 0.008), and experience barriers to testing and treatment (86.3% vs 67.7%, P = 0.004). HIV prevention services for indigenous MSM should especially target transvestites and how to overcome stigmatization and barriers to care.

Background: An increase in heroin seizures in East Africa may signal wider local consumption of illicit drugs. Most information about drug use in Tanzania is from the economic capital, Dar es Salaam, and well-travelled Zanzibar. More data are needed on the extent, trends, and characteristics of illicit drug use in the vast coast and interior of the country., Methods: The study was a rapid assessment, triangulating data from in-depth interviews of primary key informants (people who use drugs [PWUD]), secondary informants (police, community members, service providers), and ethnographic mapping of hotspots in 12 regions of Tanzania., Results: We conducted 436 in-depth interviews from September 2013 to August 2014. Regions were categorized as (1) nascent: drug use is beginning to take root; (2) established: drug use has existed for some time; or (3) pervasive: drug use is spreading into new sub-groups/areas. Multiple sources corroborated that illicit drug use has been increasing in all regions. Most PWUD worked in the cash economy as bus touts, labourers, fishermen, miners, or sex workers, or stole to survive or support their habit. PWUD congregated around bus stops along transit corridors, in abandoned buildings, and in low-income residential areas. Informants described less visible PWUD among military, police, and working-class people. Cannabis was the most common, smoked alone or with tobacco and heroin ("cocktail"). Heroin was available in all regions. Cocaine was less common, likely due to high price and variable availability. Substances such as petrol, shoe polish, and glue were used as inhalants., Conclusions: Illicit drug use is widespread with variable features beyond cosmopolitan areas of Tanzania. Improving transportation infrastructure and economic opportunities combined with poverty and inequality appear key factors for increasing use. Findings call attention to increasing and widening drug use in Tanzania and the need to plan prevention, treatment, and harm-reduction measures nationally., (Copyright © 2017 Elsevier B.V. All rights reserved.)

Background: People who inject drugs are at high risk of acquiring hepatitis B (HBV), hepatitis C (HCV), and human immunodeficiency virus (HIV) due to risky injection and sexual practices. The objective of this study is to investigate the epidemiology of HIV, hepatitis B, and hepatitis C, and co-infection of these viruses among people who inject drugs in Zanzibar, Tanzania., Methods: We used respondent-driven sampling to identify 408 participants, from whom we collected demographic data, information on sexual behaviours and injection drug practices, and blood samples for biological testing., Results: Prevalence of hepatitis B surface antigenaemia, HCV, and HIV infection were 5.9, 25.4, and 11.3%, respectively. Of the participants who were hepatitis B surface antigen (HBsAg) positive, 33.5% were infected with HCV and 18.8% were infected with HIV. Of the HCV-infected participants, 29.3% were infected with HIV. Of the participants who were infected with HIV, 9.0% were HBsAg positive, 66.6% had HCV and 8.5% had both. None of the potential risk factors we measured were associated with HBsAg positivity. In contrast, older age and longer duration of injection drug use were independently associated with HCV infection. HCV infection among people who inject drugs is lower in Zanzibar than in other countries, but could rise without proper interventions., Conclusions: These findings underscore the importance of screening people who inject drugs for HIV, HBsAg, and HCV; providing HBV vaccination to those who are eligible; initiating antiretroviral therapy for those who are co-infected with HIV/HBV and HIV/HCV; and introducing interventions that have high impact on reducing needle sharing.

To assess the reproducibility of respondent-driven sampling (RDS) in obtaining comparable samples across two survey rounds, we conducted integrated bio-behavioral surveillance surveys (IBBSS) using RDS in 2007 and 2011 among men who have sex with men (MSM) on Unguja island in Zanzibar. Differences in the two rounds were assessed by comparing RDS-adjusted population estimates, stratified estimates, and bottleneck plots. Participants in the 2011 survey round were younger (31.4 vs. 9.9% under 19 years old, p < 0.001), more likely to have tested for HIV in the last year (53.7 vs. 10.6%, p < 0.001), and less likely to have injected drugs in the last 3 months (1.0 vs. 23.2%, p < 0.001) compared to participants in the 2007 round. HIV prevalence was 12.3% in 2007 compared to 2.6% in 2011 (p < 0.001). The difference in HIV prevalence persisted after stratifying and adjusting for known differences in the two surveys rounds. Bottleneck plots suggest that recruitment chains were "trapped" in the social networks of MSM who injected drugs to a greater extent in 2007 than in 2011. We conclude that the two rounds of RDS sampled different subsets of the MSM population on Unguja, particularly with respect to inclusion of MSM within the social networks of people who inject drugs. Findings underscore the need to evaluate the reproducibility of RDS in repeated rounds of IBBSS and to develop new sampling methods for key populations at high risk for HIV in order to track the epidemic, develop evidence-based prevention and care programs, and assess their impact.

People who inject drugs (PWID) are at higher risk of acquiring HIV due to risky injection and sexual practices. We measured HIV prevalence and behaviors related to acquisition and transmission risk at two time points (2007 and 2012) in Zanzibar, Tanzania. We conducted two rounds of behavioral and biological surveillance among PWID using respondent-driven sampling, recruiting 499 and 408 PWID, respectively. Through faceto- face interviews, we collected information on demographics as well as sexual and injection practices. We obtained blood samples for biological testing. We analyzed data using RDSAT and exported weights into STATA for multivariate analysis. HIV prevalence among sampled PWID in Zanzibar was 16.0 % in 2007 and 11.3 % in 2012; 73.2 % had injected drugs for 7 years or more in 2007, while in the 2012 sample this proportion was 36.9 %. In 2007, 53.6 % reported having shared a needle in the past month, while in the 2012 sample, 29.1 % reported having done so. While 13.3 % of PWID in 2007 reported having been tested for HIV infection and received results in the past year, this proportion was 38.0 % in 2012. Duration of injection drug use for 5 years or more was associated with higher odds of HIV infection in both samples. HIV prevalence and indicators of risk and preventive behaviors among PWID in Zanzibar were generally more favorable in 2012 compared to 2007-a period marked by the scale-up of prevention programs focusing on PWID. While encouraging, causal interpretation needs to be cautious and consider possible sample differences in these two cross-sectional surveys. HIV prevalence and related risk behaviors persist at levels warranting sustained and enhanced efforts of primary prevention and harm reduction.