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Outpatient Clinics Efficient in Spotting
Recent HIV in 3 African Countries
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2022 CROI, February 12-16 and 22-24, 2022
Mark Mascolini
Testing people for HIV in outpatient departments proved more effective in detecting recent HIV infection than other approaches like index testing (testing family members of HIV-positive people) and voluntary counseling and testing in a many-thousand person analysis in 3 southern African countries-Democratic Republic of Congo (DRC), Eswatini (formerly Swaziland), and Lesotho [1]. The results challenge the focus on targeted testing approaches like index testing by PEPFAR, the US President's Emergency Plan for AIDS Relief.
With the population-level effectiveness of prompt combination antiretroviral therapy well established, determining what HIV testing strategies work best in discovering recent HIV infection assumes growing importance. Researchers at Columbia University's International Center for AIDS Care and Treatment Program (ICAP) conducted this study to compare the effectiveness of recent infection testing algorithms (RITA) in routine HIV testing services.
The ICAP team used rapid tests for recent infection (RTRI) as a rapid point-of-care HIV test to distinguish recent HIV infection (within 12 months) from long-term infection in newly diagnosed people at least 15 years old. Recent infection testing algorithms or RITA consider initial viral loads in RTRI-determined recent infections to reclassify people with a viral load below 1000 copies as not having a new diagnosis.*
The analysis used (1) RITA in people 18 or older for 11 months at 77 sites in DRC, (2) RITA in people 15 or older for 27 months at 162 sites in Eswatini, and (3) RTRI in people 18 or older for 9 months at 29 sites in Lesotho. DRC has an adult HIV prevalence of 0.70% in a population of 92 million, Eswatini prevalence stands at 27.1% in a population of 1.2 million, and Lesotho prevalence measures 23.1% in a population of 2.1 million.
The study aimed to determine two major outcomes: Share of Recent Cases (number of RITA or RTRI recent cases at a testing location divided by total number of RITA or RTRI recent cases in the country) and Yield of Recent Cases (number of RITA or RTRI recent cases at a testing location divided by total number of RITA or RTRI tested at the testing location). Testing locations included outpatient departments (OPD)/emergency departments; index testing; voluntary counseling and testing (VCT); mobile clinic/community outreach; antenatal care/labor and delivery/postnatal care/child welfare clinics; inpatient/TB services; voluntary medical male circumcision; family planning; sexually transmitted infection (STI) clinics; and antiretroviral therapy (ART) clinics.
RITA recent infections made up 4% of 2512 RTRI-tested people in DRC and 5% of 14,540 RTRI-tested people in Eswatini, while RTRI recent infections made up 18% of 1118 RTRI-tested people in Lesotho.
In all 3 countries the largest proportion of recent infections were detected in OPD/emergency-65% in the DRC, 25% in Eswatini (versus 24% in VCT and 22% by index testing), and 91% in Lesotho. Among all recent cases in the 3 countries, OPD/emergency accounted for 7% of RITA recents in DRC, 4% of RITA recents in Eswatini, and 20% of RTRI recents in Lesotho. In all 3 countries substantially more RTRI tests were administered in OPD/emergency than at any other testing location.
The ICAP Columbia team concluded that outpatient departments are "a critical testing location to identify recent infections in diverse country settings." Family planning centers, STI clinics, VCT venues, and ante-/postnatal care centers sometimes had higher yields of recent HIV infections in the 3 countries studied, but numbers of recent infections at these sites were modest. The ICAP group stressed that "recency testing can inform HIV testing efforts in OPDs to improve efficiency . . . at epidemic control."
Reference
1. Saito S, Nsibandze LD, Simelane S, et al. Detecting recent HIV infections in outpatient departments: a multi-country analysis. 2022 CROI, February 12-16 and 22-24, 2022. Abstract 90.
*Presenting author Suzue Saito explained this distinction further in an email to NATAP: "RTRIs are tests that are commercially available (such as the one from Sedia Biosciences: Asanté™ HIV-1 Rapid Recency® - Sedia Biosciences). Because RTRIs are not recommended for use in those with prior ART use, baseline viral load is recommended as retesters with prior ART experience are common in many national HIV testing programs. Those who are RTRI recent but have a baseline viral load of <1000 c/mL are reclassified as Recent infection testing algorithm or RITA long term. Only those with RTRI recent and VL >=1000 copies/mL are classified as RITA recent."
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