Negative HIV Test Research Articles

Therapeutic drug monitoring of tenofovir disoproxil and emtricitabine in oral HIV pre-exposure prophylaxis (PrEP) users who have undergone gastrointestinal surgery.

Oral HIV pre-exposure prophylaxis (PrEP) is highly effective in preventing HIV, but its efficacy depends on adequate absorption of drug, which may decrease following gastrointestinal surgery. Clinicians across eight Genito-urinary Medicine clinics in the United Kingdom submitted data on PrEP users with history of gastrointestinal surgery who were referred to a national complex PrEP multi-disciplinary team between June 2021 and April 2023. Anonymised data were submitted on demographics, surgical history, PrEP regimen, and results of therapeutic drug monitoring (TDM) and HIV screening tests. Descriptive analyses were performed in SPSS version 29. Nine cases described cis-gender men-who-have-sex-with-men (MSM) with median age of 47.4 years (IQR = 43 - 56.5) taking tenofovir disoproxil (TDF)/emtricitabine (FTC) daily (n = 8) or event-based (n = 1) as PrEP. Median time between PrEP initiation and TDM was 53 days (IQR = 8.5-1705). The mean (±SD) trough concentration of tenofovir (TFV) and FTC were 90.2 ± 27.7ng/mL and 76.0 ± 45.9ng/mL, respectively. All patients had a negative HIV test at follow-up. Plasma trough concentrations of TFV observed in our cohort taking TDF/FTC were above the expected concentrations associated with PrEP efficacy as previously described in the literature, suggesting that PrEP can be safely given in this population, with TDM used for reassurance.

Very high HIV prevalence and incidence among men who have sex with men and transgender women in Indonesia: a retrospective observational cohort study in Bali and Jakarta, 2017-2020.

There are no longitudinal HIV incidence data among men who have sex with men (MSM) and transgender women (TGW) in Indonesia. We aimed to estimate HIV prevalence and incidence and identify associated factors among clinic attendees in Jakarta and Bali. We conducted a retrospective cohort study using medical records from five clinics. We reviewed HIV tests among MSM/TGW aged ≥18 years who attended the clinics between 1 January 2018 to 31 December 2020 in Jakarta and 1 January 2017 to 31 December 2019 in Bali. HIV prevalence was measured at the first test. Those with an HIV-negative test and ≥1 follow-up test/s were included in the person-years (PY) at risk to determine HIV incidence. The PY at risk calculation started at the first negative test until the last recorded negative test or seroconversion. Multivariate Poisson regression was used to determine factors associated with HIV acquisition. Among 5203 and 2815 individuals with an HIV test result in Jakarta and Bali, respectively, at the first HIV test, 1205 and 616 were HIV positive (HIV prevalence 23.2% and 21.9%). The longitudinal sample included 1418 and 873 individuals, respectively. The median number of tests among repeat testers was 3 in Jakarta (interquartile range [IQR] = 2-4) and 3 in Bali (IQR = 2-5). At baseline, about one-quarter were aged <25 years, >90% were MSM and >35% had been tested for HIV previously. In Jakarta, there were 127 HIV seroconversions in 1353 PY (incidence 9.39/100 PY, 95% CI = 7.89-11.17), and in Bali, 71 seroconversions in 982 PY (incidence 7.24/100 PY, 95% CI = 5.73-9.13). Compared to those aged 18-24 years, the incidence rate was lower in older patients (Jakarta-30-39 years: aRR = 0.56, 95% CI = 0.34-0.92; 40+ years: aRR = 0.34, 95% CI = 0.14-0.81; Bali-25-29 years: aRR = 0.44, 95% CI = 0.25-0.79; 30-39 years: aRR = 0.33, 95% CI = 0.18-0.61; 40+ years: aRR = 0.06, 95% CI = 0.01-0.48). In Jakarta, incidence was lower in those with university education than in those without (aRR = 0.66, 95% CI = 0.45-0.96). In Bali, those who had been referred by outreach workers had a higher incidence than those who self-presented for testing (aRR = 1.85, 95% CI = 1.12-3.07). We observed very high HIV prevalence and incidence rate estimates. Measures to encourage regular testing and effective use of HIV prevention, including pre-exposure prophylaxis scale-up and demand creation, are needed.

7504 A Case of Methicillin Sensitive Staphylococcus Aureus Thyroiditis

Abstract Disclosure: K. Patel: None. P. Kachhadia: None. S. Khan: None. F. Akanbi: None. A. Abu Limon: None. S.A. Aldasouqi: None. Introduction: Acute suppurative thyroiditis refers to bacterial infection of the thyroid gland. It is rare as the thyroid gland is typically protected from infection due to isolation of the gland from neighboring structures as well as its rich blood supply and adequate lymphatic drainage. It shares characteristics with subacute and autoimmune thyroiditis which make for difficult diagnosis. Here we present a case of acute suppurative thyroiditis in the setting of methicillin sensitive staphylococcus aureus (MSSA) bacteremia. Case Presentation: We have a 45 year old gentleman with a history of polysubstance abuse who was admitted after a drug overdose. He was being treated for rhabdomyolysis and approximately ten days after admission he became febrile with Tmax 103.3 Farenheit with a sore throat and dysphagia. Workup showed leukocytosis, ESR 86 mm/h [0-15], CRP 45.5 mg/dL [0-1], blood cultures with MSSA, negative viral upper respiratory panel, throat culture, Syphilis and HIV testing. He had a positive Hepatitis C antibody without a detectable viral load. Echocardiogram ruled out vegetations. He was treated with cefazolin. CT neck was obtained and showed thyroid enlargement. Subsequent ultrasound showed heterogeneous echotexture and increased color flow and a left inferior pole nodule 2.3 x 2.1 x 2.0 cm. Thyroid labs showed TSH 0.16 [0.35 - 4.01 u[IU]/mL,] Free T4 3.91 ng/dL [0.61 - 1.37], TPO &amp;lt;0.3. The nodule was biopsied and endocrinology was consulted. On exam thyroid was nontender. He was started on beta blockers and thyroid labs were monitored. TSI and TRAB were negative. TSH, Free T4 and Free T3 improved to normal range. Nodule biopsy results showed benign follicular cells with abundant acute inflammation suggestive of an abscess. Metronidazole was added after biopsy results. Post antibiotic therapy, CRP improved to 1.7 mg/dL. Discussion/Conclusion: Incidence of acute suppurative thyroiditis has been published as occurring &amp;lt;1% of all thyroid diseases. One systematic review found 200 cases reported from January 2000 to January 2020. Prior case reports have described acute suppurative thyroiditis in adult patients with prior thyroid gland pathology or an immunocompromised state and some demonstrated a correlation with intravenous drug users. The most common culprits include Staphylococcus spp, Streptococcus spp, Salmonella spp, Escherichia spp. Management includes antimicrobial therapy and/or needle aspiration. Non-responders can undergo incision and drainage of abscess or thyroidectomy. Mortality was reported in about 8% of the reported 200 cases. In our patient, his history of drug use and Hepatitis C likely made him prone to infection. Although there was no description of pus during biopsy, pathology suggested acute inflammation. This along with elevated inflammatory markers led to the diagnosis. This case highlights an uncommon but potential cause of thyroiditis. Presentation: 6/3/2024

A Statistical Model for Inference of Recent and Incident HIV Infection Using Surveillance Data on Individuals Newly Diagnosed With HIV Infection in Scotland

Background: To inform global ambitions to end AIDS, evaluation of progress toward HIV incidence reduction requires robust methods to measure incidence. Although HIV diagnosis date in routine HIV/AIDS surveillance systems are often used as a surrogate marker for incidence, it can be misleading if acquisition of transmission occurred years before testing. Other information present in data such as antibody testing dates, avidity testing result, and CD4 counts can assist, but the degree of missing data is often prohibitive. Methods: We constructed a Bayesian statistical model to estimate the annual proportion of first ever HIV diagnoses in Scotland (period 2015–2019) that represent recent HIV infection (ie, occurring within the previous 3–4 months) and incident HIV infection (ie, infection within the previous 12 months), by synthesizing avidity testing results and surveillance data on the interval since last negative HIV test. Results: Over the 5-year analysis period, the model-estimated proportion of incident infection was 43.9% (95% CI: 40.9 to 47.0), and the proportion of recent HIV infection was 21.6% (95% CI: 19.1 to 24.1). Among the mode of HIV acquisition categories, the highest proportion of recent infection was estimated for people who inject drugs: 27.4% (95% CI: 20.4 to 34.4). Conclusions: The Bayesian approach is appropriate for the high prevalence of missing data that can occur in routine surveillance data sets. The proposed model will aid countries in improving their understanding of the number of people who have recently acquired their infection, which is needed to progress toward the goal of HIV transmission elimination.

The risk of non-AIDS defining events is lower in ART-naive HIV controllers than in normal progressors on suppressive ART.

We aimed to compare the non-AIDS events (nADE) risk between normal progressors using ART (NP-ART) and people with HIV (PWH) that naturally control HIV infection (HIV controllers), as well as the outcomes after ART in HIV controllers on nADE. The primary endpoint was major nADE defined as the composite of cardiovascular disease, non-AIDS malignancy or all-cause mortality, whichever came first.. The role of ART in HIV controllers was assessed as a time-varying covariate. We included 1007 ART-naive HIV controllers (of which 60 elite controllers), 1510 Early-ART (<6 months after negative HIV test) and 15437 NP-ART (reference group), contributing 3813, 11,060 and 160,050 years of follow-up, respectively. HIV controllers had lower risk of the primary endpoint (HR 0.55, 95%CI 0.38-0.81, P = 0.0023), all-cause mortality (Adjusted Hazard ratio [aHR]: 0.45, 95% confidence interval [CI] 0.25-0.79, P = 0.0054), cardiovascular disease (aHR 0.47, 95%CI 0.22-0.99, P = 0.046) , but not non-AIDS malignancy (aHR 0.74, 95%CI 0.41-1.35, P = 0.33) than NP-ART. Among HIV controllers, each log10 lower baseline viral load further decreased the risk of nADE (aHR 0.54, 95% CI 0.29-0.99, P = 0.045). ART in HIV controllers did not reduce the risk of any nADE (aHR 1.22, 95% CI 0.66-2.29, P = 0.53). We found a lower risk of nADE in HIV controllers than NP-ART, especially in those with low plasma viral loads. Initiation of ART did not alter the nADE risk in HIV controllers. Our findings help clinicians to decide on prescribing ART in HIV controllers.

Understanding Opportunities for Prescribing Pre-exposure Prophylaxis (PrEP) at Two Academic Medical Centers in a High Priority Jurisdiction for Ending the HIV Epidemic.

Pre-exposure prophylaxis (PrEP) is an effective, yet underutilized tool for HIV prevention. We sought to understand practice patterns and opportunities for prescribing PrEP across two large, urban, academic healthcare institutions in Chicago, Illinois. We analyzed electronic medical record data from two institutions including encounters for persons ≥18 years of age with ≥1 negative HIV test between 1/1/2015-12/31/2021 who had indications for PrEP. Eligible encounters were those within a six-month window after STI diagnosis, or as long as injection drug use (IDU) was documented. We categorized encounters as inpatient, emergency department (ED), primary care, infectious disease (ID), obstetrics and gynecology/women's health (OBGYN) and other outpatient settings. We performed bivariable and multivariable mixed effects regression models to examine associations, reporting odds ratios (or adjusted odds ratios) and 95% confidence intervals (OR, aOR, 95% CI). In total, 9644 persons contributed 53031 encounters that resulted in 4653 PrEP prescriptions. The two healthcare institutions had differing patient demographics; institution A had more 18-24 year-olds (58.3% vs 31.3%), more African Americans (83.8% vs 27.9%), and more women (65.7% vs 46.3%). Institution B had more White (40.6% vs 7.1%) and Hispanic persons (14.0% vs 4.2%), and more men who have sex with men (MSM) (15.2% vs 3.3%). Institution A had more eligible encounters in the ED (30.8% vs 7.3%) as well as in infectious disease, inpatient, OBYGN, and primary care settings. Institution B accounted for the majority of PrEP prescriptions (97.0%).Adjusted models found lower odds of PrEP prescriptions in non-Hispanic Black (aOR 0.23 [0.16, 0.32]) and Latino (aOR 0.62 [0.44, 0.89]) patients, those with injection drug use (aOR 0.01 [0.00, 0.09]), men who have sex with women (aOR 0.36 [0.23, 0.56]), women who have sex with men (aOR 0.11 [0.06, 0.19]), and in the ED (ref) or OBGYN (0.11 [0.04, 0.27]) settings; while increased odds of PrEP prescription were associated with non-Hispanic White (ref) and MSM (aOR 24.87 [15.79, 39.15]) patients, and encounters at Institution B (aOR 1.78 [1.25, 2.53]) and in infectious disease (aOR [11.92 [7.65, 18.58]), primary care (aOR 2.76 [1.90, 4.01]), and other outpatient subspecialty settings (aOR 2.67 [1.84, 3.87]). Institution A contained persons historically underrepresented in PrEP prescriptions, while institution B accounted for most PrEP prescriptions. Opportunities exist to improve equity in PrEP prescribing and across ED and OBGYN settings.

Unawareness of partner risk factors thwarts implementation of USPSTF recommendations for HIV pre-exposure prophylaxis in primary care

ABSTRACT The United States Preventive Services Task Force recommends pre-exposure chemoprophylaxis for persons at high risk of HIV exposure. The optimal screening strategy for at-risk individuals in primary care is not known. We evaluated the strategy of universal screening and discussed challenges to the implementation of this recommendation in primary care. Around 430 of 500 (86%) screening surveys were completed. Mutual monogamy was common but monogamous partners with recent negative HIV testing were uncommon. Likewise, among heterosexually active men and women, inconsistent condom use was common. Such individuals would be on guideline for HIV pre-exposure prophylaxis (PrEP) if their partner was at risk for HIV exposure. None of these potentially at-risk individuals met the criteria for PrEP, but 13% lacked knowledge of their partners' sexual and behavioral risk factors, preventing a clear decision on whether PrEP should be used. Our screen identified no individuals who clearly met the guideline criteria for HIV PrEP. We conclude that universal screening for HIV PrEP in primary care is unlikely to be an efficient strategy; targeted screening is likely more appropriate. Moreover, the 2019 guidelines for heterosexually active men and women rely on information that is often unknown to the patient, which makes these guidelines difficult to implement. Future guidelines should address these problems.

Elevated serum lactate dehydrogenase aids prediction of mortality in Pneumocystis jirovecii pneumonia without underlying human immunodeficiency virus infection – Derivation of a clinical risk score

Pneumocystis jirovecii pneumonia (PCP) is associated with significant mortality amongst patients without underlying human immunodeficiency virus infection (HIV). We sought to develop a risk score to predict mortality in this population. We reviewed patients with a presumed or confirmed PCP and a negative HIV test from 2006–2023. We constructed a multivariable model to identify parameters independently associated with mortality and the adjusted odds ratios were converted to weights to derive a risk score. Subsequently, we compared the performance of our score to the CURB-65 score by means of area under receiver operating characteristic curve (AUC). In total, we examined 93 patients with PCP without HIV. Mortality was 31.2%. Risk factors for mortality included older age, male sex and high serum lactate dehydrogenase levels (LDH) and C-reactive protein levels. A risk score was derived comprising age> 65 years (2 points), male sex (2 points) and LDH> 770 U/L (3 points). Our risk score (AUC 0.71, 95%CI 0.60–0.82) performed better than the CURB-65 score (AUC 0.53, 95%CI 0.41–0.66). A low-risk score of 0–1 had excellent negative predictive value for mortality (97.5%). In conclusion, a risk score comprising age, sex and LDH can predict mortality in PCP without underlying HIV and help with prognostication.

Zinc supplementation on cellular immune response in splenectomized thalassemia major

Background: The immune response of thalassemia patients is different from usual; therefore, thalassemia patients are susceptible to infection. A study at Thalassemia Center in Cipto Mangunkusumo Hospital showed that all thalassemia patients experience zinc deficiency. The decreased cellular immune response is associated with zinc deficiency, whereas splenectomy exacerbates the condition. This study aims to evaluate the improvement of cellular immune response in splenectomized thalassemia major patients after zinc supplementation. Method: Randomized double-blinded controlled trial was conducted on splenectomized thalassemia major patients in 12 weeks period. The inclusion criteria were aged &gt; 12 years and had negative HIV test results. The subject receiving corticosteroids were excluded. Fifty-six subjects were randomly divided into two groups, the zinc group and the placebo group. Between 2 groups, data on zinc serum, T lymphocyte count, CD4+ T lymphocyte count, CD8+ T lymphocyte count, and CD4+/CD8+ ratio were evaluated at the beginning and the end of the study and were analyzed with unpaired t-test, Mann Whitney test, and Wilcoxon Signed Rank test. Result: After zinc supplementation, only 18 of 28 subjects in the zinc group recovered normal zinc serum levels. There were no significant changes after zinc supplementation in all parameters of cellular immune response (p &gt; 0.05) between the two groups. This might be due to the subjects' adherence, which was lower in the zinc group (75.82%) than in the placebo group (83.19%). Conclusion: The effect of zinc supplementation on cellular immune response in splenectomized thalassemia major patients had not been proven yet.

Brief Report: Self-Reported HIV-Positive Status but Subsequent HIV-Negative Test Results in Population-Based HIV Impact Assessment Survey Participants-11 Sub-Saharan African Countries, 2015-2018.

HIV testing is a critical step to accessing antiretroviral therapy (ART) because early diagnosis can facilitate earlier initiation of ART. This study presents aggregated data of individuals who self-reported being HIV-positive but subsequently tested HIV-negative during nationally representative Population-Based HIV Impact Assessment surveys conducted in 11 countries from 2015 to 2018. Survey participants aged 15 years or older were interviewed by trained personnel using a standard questionnaire to determine HIV testing history and self-reported HIV status. Home-based HIV testing and counseling using rapid diagnostic tests with return of results were performed by survey staff according to the respective national HIV testing services algorithms on venous blood samples. Laboratory-based confirmatory HIV testing for all participants identified as HIV-positives and self-reported positives, irrespective of HIV testing results, was conducted and included Geenius HIV-1/2 and DNA polymerase chain reaction if Geenius was negative or indeterminate. Of the 16,630 participants who self-reported as HIV-positive, 16,432 (98.6%) were confirmed as HIV-positive and 198 (1.4%) were HIV-negative by subsequent laboratory-based testing. Participants who self-reported as HIV-positive but tested HIV-negative were significantly younger than 30 years, less likely to have received ART, and less likely to have received a CD4 test compared with participants who self-reported as HIV-positive with laboratory-confirmed infection. A small proportion of self-reported HIV-positive individuals could not be confirmed as positive, which could be due to initial misdiagnosis, deliberate wrong self-report, or misunderstanding of the questionnaire. As universal ART access is expanding, it is increasingly important to ensure quality of HIV testing and confirmation of HIV diagnosis before ART initiation.

Ocular Syphilis in an Immunocompetent Young Man

Introduction : Syphilis is called the great imitator because its clinical presentations vary widely and overlap with many other etiologies. We present a case of ocular syphilis in an immunocompetent young man with negative HIV test and history of unprotected sexual activities.&#x0D; Case Illustration : A 27 year-old male initially presented to an outpatient Solo Eye Hospital with complain of blurred vision and sudden visual impairment in the right eye and acute onset left eye redness, pain, clear discharge. His right eye VA was counting finger and 0,2 in his left eye. The patient diagnosed with acute posterior uveitis in the RE and acute iridocyclitis in the LE. A detailed sexual history, he endorsed having unprotected sex with numerous men in the past. Patient was subsequently started on P-Pred ED/2 hourly, atropine ED and testing to evaluate cause of iridocyclitis was sent. Fundus RE : clouded fundus view, vascular occlusion, vitreous opacification. Fundus LE : within normal limit. Rheumatoid factor negative, HIV antigen antibody screen non-reactive, syphilis IgG reactive, RPR screen reactive, RPR quantitative titer 1:128. ANA screen negative. The patient was started on intravenous penicillin G, and both his genital lesion and bilateral visual acuity improved. He was discharged to complete 14 fays of iv penicillin G.&#x0D; Discussion : HIV-positive patients may often present with ocular syphilis before the HIV status is known. Ocular syphilis is considered to be neurosyphilis for treatment purposes.&#x0D; Conclusion : Ocular syphilis should be kept in the differential diagnosis in immunocompetent/HIV negative patient, and the importance of obtaining a detailed sexual history should not be forgotten.

Ocular Syphilis in an Immunocompetent Young Man

Introduction : Syphilis is called the great imitator because its clinical presentations vary widely and overlap with many other etiologies. We present a case of ocular syphilis in an immunocompetent young man with negative HIV test and history of unprotected sexual activities.&#x0D; Case Illustration : A 27 year-old male initially presented to an outpatient Solo Eye Hospital with complain of blurred vision and sudden visual impairment in the right eye and acute onset left eye redness, pain, clear discharge. His right eye VA was counting finger and 0,2 in his left eye. The patient diagnosed with acute posterior uveitis in the RE and acute iridocyclitis in the LE. A detailed sexual history, he endorsed having unprotected sex with numerous men in the past. Patient was subsequently started on P-Pred ED/2 hourly, atropine ED and testing to evaluate cause of iridocyclitis was sent. Fundus RE : clouded fundus view, vascular occlusion, vitreous opacification. Fundus LE : within normal limit. Rheumatoid factor negative, HIV antigen antibody screen non-reactive, syphilis IgG reactive, RPR screen reactive, RPR quantitative titer 1:128. ANA screen negative. The patient was started on intravenous penicillin G, and both his genital lesion and bilateral visual acuity improved. He was discharged to complete 14 fays of iv penicillin G.&#x0D; Discussion : HIV-positive patients may often present with ocular syphilis before the HIV status is known. Ocular syphilis is considered to be neurosyphilis for treatment purposes.&#x0D; Conclusion : Ocular syphilis should be kept in the differential diagnosis in immunocompetent/HIV negative patient, and the importance of obtaining a detailed sexual history should not be forgotten.

Racial inequities in HIV incidence among men who have sex with men prior to and amidst an Ending the HIV Epidemic initiative.

The aim of this study was to examine trends in HIV incidence among men who have sex with men (MSM) relative to the scale up of Ending the HIV Epidemic (EHE) initiatives, including biomedical prevention strategies, and to describe racial inequities over time. A cross-sectional study, matching annual cohorts of New York City (NYC) Sexual Health Clinic (SHC) patients from 2010 to 2018 to the citywide HIV registry to identify seroconversions during 1 year of follow-up, through 2019. We examined HIV incidence for each annual cohort of MSM using diagnoses within 1 year after last negative HIV test. We calculated incidence rates and rate ratios (IRR) pooled across 3-year intervals (2010-2012, 2013-2015, 2016-2018) by race/ethnicity, age, neighborhood poverty level, recent STI diagnosis, and condom use during anal sex. There were 36 156 study visits among MSM attending NYC SHCs, including 37% among White MSM and 63% among MSM of color. From 2010 to 2018, HIV incidence decreased overall from 2.82 to 0.82/100 person-years, and among all race/ethnicity, age, poverty, STI, and condom use subgroups. For 2010-2012 vs. 2016-2018, adjusted IRRs (95% CI) increased for Black MSM [1.8 (1.3-2.6) vs. 6.0 (3.5-10.2)], Latino MSM [1.4 (1.0-2.0) vs. 4.0 (2.3-6.8)], and MSM of other races [1.0 (0.6-1.7) vs. 2.5 (1.3-4.9)] compared with White MSM. Black and Latino MSM seroconverted at significantly higher rates than White MSM in the same age groups and neighborhood poverty level. Despite decreases in HIV incidence among MSM, racial inequities were exacerbated over time. Addressing structural factors that impact racial inequities in risk of HIV should undergird EHE initiatives.

Acceptability and performance of dual HIV/syphilis testing in male circumcision clients, 2021.

Dual HIV/syphilis testing may be an acceptable intervention to identify men with sexually transmitted infections (STIs) and at risk of HIV acquisition. We sought to determine the acceptability, and performance of dual HIV/syphilis testing among men attending voluntary medical male circumcision (VMMC) services at six public sector facilities in Gauteng. This was a cross-sectional study at VMMC facilities. Men ≥ 18 years were enrolled. The men had (1) a questionnaire administered, (2) on-site dual HIV/syphilis testing with First Response HIV1+2/Syphilis Combo Card Test by routine lay counsellors, and (3) a blood specimen collected for centralised laboratory testing for HIV and syphilis serology. We evaluated pre-test and post-test acceptability and performance compared to serological testing. Of the 679 men analysed (median age 32.1 years), 96.7% of HIV-negative men preferred testing for HIV and syphilis simultaneously. Of the 675 men tested for syphilis, 28 (4.7%) tested positive (past or recent). In the laboratory, 43/609 (7.1%) had syphilis infection detected, with 9/609 (1.5%) having recent syphilis. There was sub-optimal sensitivity for HIV detection (90.9%; 95% confidence interval [CI]: 88.5% - 93.3%), and for past/recent syphilis (55.8%; 95% CI: 51.9% - 59.8%), improving to 88.9% (95% CI: 86.4% - 91.4%) for recent syphilis. Specificities were > 99% for HIV and syphilis (past or recent). Post-test acceptability was 96.6% and willingness to pay for future testing was 86.1%. Dual HIV/syphilis testing was acceptable but had sub-optimal sensitivity for HIV and syphilis. Syphilis detection was adequate for recent infection.

Diagnostic challenge of Pneumocystis jirovecii pneumonia infection mimicking interstitial lung disease in initially HIV negative patient

Background: Pneumocystis jirovecii pneumonia (PJP) infections are common in immunocompromised patients and are rarely found in immunocompetent patients. Lung radiology in PJP patients could mimic the appearance of interstitial lung disease (ILD) and could be used to diagnose HIV-negative patients. Clinicians should rule out false negatives in patients with patterns suggestive of opportunistic infections and risk factors for HIV infection. Case illustration: A 34-year-old man presented with a chief complaint of shortness of breath, had history of 15 years of smoking, and daily chlorine exposure. The radiology pattern and initial HIV-negative test results suggested an ILD diagnosis. Owing to persistent symptoms despite initial management and the presence of risk factors, repeat HIV testing was initiated and was positive. The patient was treated with cotrimoxazole and showed rapid clinical improvement. Discussion: The diagnosis of PJP in our patient was based on radiology and an HIV-positive status. In patients who are not immunocompromised, the diagnosis of PJP is unlikely, and other diagnoses, such as ILD, should be considered. However, in the HIV testing window period of infection, a poor advanced state of HIV could cause a false negative result. Therefore, clinical judgement is essential in suspecting such a result. The empirical treatment course of cotrimoxazole has been shown to provide better clinical outcomes in PJP. Conclusion: The possibility of PJP must be considered in patients with initially HIV-negative results, especially in patients with risk factors and clinical symptoms suggestive of immunocompromise. While some ILD showed similar PJP, the risk factors for ILD and PCP could be distinguishing factors. Retesting for HIV infection can confirm the diagnosis and rule out false-negative results.

Injection cessation and relapse to injection and the associated factors among people who inject drugs in Iran: The Rostam study

BackgroundDrug injection is a major health-related problem worldwide. Injection cessation and relapse to injection could significantly alter the risk of HIV and hepatitis C virus (HCV) among people who inject drugs (PWID). This study aimed to estimate the rate of injection cessation and relapse to injection among PWID in Iran.MethodsThis cohort study was conducted from 2018 to 2021 in the cities of Kerman and Tehran. Using a respondent-driven sampling (RDS) approach, 118 PWID with a history of injection in the last six months and negative HIV and HCV tests were recruited. Follow-up visits occurred every three months over a period of one year. Participants were interviewed and tested for HIV and HCV using rapid tests. Injection cessation was defined as the no injection of any type of drugs in the last three months. Relapse to injection was defined as re-initiating drug injection among those who had ceased injection. Two separate Cox regression models were applied, and an adjusted hazard ratio (aHR) with a 95% confidence interval (CI) were measured to assess the factors associated with each outcome.ResultsThe rate of injection cessation was 26.1 (95% CI: 21.3, 32.0) per 100 person-years, and the rate of relapse to injection was 32.7 (95% CI: 24.7, 43.2) per 100 person-years. At the baseline interview, 39.8% (n = 47) of participants reported injection cessation in the past three months before the interview. In the multivariable Cox regression analysis, the rate of relapse to injection was greater among women (aHR = 1.58; 95% CI: 1.01, 2.52), and those with higher monthly income (aHR = 1.63; 95% CI: 1.03, 2.59). However, there was no significant variable that predicted injection cessation.ConclusionInjection cessation was common among PWID in Iran, however, one-third relapsed to injection shortly after cessation. Harm reduction programs should include comprehensive strategies to reduce the probability of relapse among PWID who achieve injection cessation.

Clinical Features and Outcomes of Cytomegalovirus Retinitis in Immunosuppressed Non-HIV Patients

PURPOSE: To describe the nature and response of cytomegalovirus (CMV) retinitis in human immunodeficiency virus (HIV)-negative patients with hematological malignancies and other immunosuppressive causes. METHODS: This is retrospective case series of CMV retinitis patients with known immunocompromised status and negative HIV results. Patients’ data were reviewed for demographics, causes of the immunosuppressed status, concomitant systemic CMV infection, and its management. Ophthalmic findings included visual acuity (VA), anterior and posterior segments findings, CMV retinitis patterns and extensions, medications, number of intravitreal injections, fundus photographs, and CMV retinitis complications. RESULTS: During a study period of 2 years, 17 eyes of 9 patients were diagnosed with CMV retinitis with detected CMV in blood tests. Indolent granular retinitis pattern was found in 4 eyes (23.5%), and the fulminant necrotizing pattern in another 4 eyes (23.5%). In 1 eye (5.9%), frosted branch angiitis was observed. A mixed pattern between granular and necrotizing retinitis was seen in 4 eye (23.5%). The majority (n 11, 64.7%) of the affected eyes had an extensive retinal involvement (zone 1–3). Only two eyes had no macular involvement (11.8%). A large percentage of the included patients had controlled disease course with stable vision. Out of the studied 17 eyes, deterioration in terms of VA was seen in five eyes. In two patients, the disease course was complicated by vitreous hemorrhage. CONCLUSION: In the majority of the patients with HIV-negative tests who received intravitreal and/or systemic anti-CMV medications, the clinical course of CMV retinitis was controlled with final stable vision.

Temporal trends in, and risk factors for, HIV seroconversion among female sex workers accessing Zimbabwe's national sex worker programme, 2009–19: a retrospective cohort analysis of routinely collected HIV testing data

The frequency of new HIV infections among female sex workers in sub-Saharan Africa is poorly understood. We used routinely collected data that enable unique identification of repeat HIV testers to assess temporal trends in seroconversion and identify associated risk factors for female sex workers accessing Sisters with a Voice, Zimbabwe's national sex worker programme. We pooled HIV testing data gathered between Sept 15, 2009, and Dec 31, 2019, from 36 Sisters programme sites in Zimbabwe. We included female sex workers aged 16 years or older with an HIV-negative test and at least one subsequent programme test. We calculated HIV seroconversion rates (using the midpoint between the HIV-positive test and the last negative test as the seroconversion date) and estimated rate ratios to compare 2-year periods by using Poisson regression, with robust SEs to account for clustering by site and adjusting for age and testing frequency to assess temporal trends. We did sensitivity analyses to explore assumptions about seroconversion dates and the effects of variation in follow-up time on our conclusions. Our analysis included data for 6665 female sex workers, 441 (7%) of whom seroconverted. The overall seroconversion rate was 3·8 (95% CI 3·4-4·2) per 100 person-years at risk. Seroconversion rates fell with time since first negative HIV test. After adjustment, there was evidence of a decrease in seroconversion rates from 2009 to 2019 (p=0·0053). In adjusted analyses, being younger than 25 years, and having a sexually transmitted infection diagnosis at a previous visit, were significantly associated with increased seroconversion rates. Our findings were mostly robust to sensitivity analyses, but when 1 month before an HIV-positive test was used as the seroconversion date, seroconversion rates no longer fell with time. We identified high rates of seroconversion shortly after linkage to programme services, which emphasises the need to strengthen HIV prevention programmes from first contact with female sex workers in Zimbabwe. New infections among female sex workers remain challenging to measure, but longitudinal analysis of routine testing data can provide valuable insights into seroconversion rates and associated risk factors. UN Population Fund, Deutsche Gesellschaft für Internationale Zusammenarbeit, the Bill & Melinda Gates Foundation, The Global Fund to Fight AIDS, Tuberculosis and Malaria, US President's Emergency Plan for AIDS Relief, US Agency for International Development, and the Elton John AIDS Foundation.

Using testing history to estimate HIV incidence in mothers living in resource-limited settings: Maximizing efficiency of a community health survey in Mozambique.

Obtaining rapid and accurate HIV incidence estimates is challenging because of the need for long-term follow-up for a large cohort. We estimated HIV incidence among women who recently delivered in southern Mozambique by leveraging data available in routine health cards. A cross-sectional household HIV-testing survey was conducted from October 2017 to April 2018 among mothers of children born in the previous four years in the Manhiça Health Demographic Surveillance System area. Randomly-selected mother-child pairs were invited to participate and asked to present documentation of their last HIV test result. HIV-testing was offered to mothers with no prior HIV-testing history, or with negative HIV results obtained over three months ago. HIV incidence was estimated as the number of mothers newly diagnosed with HIV per total person-years, among mothers with a prior documented HIV-negative test. Among 5000 mother-child pairs randomly selected, 3069 were interviewed, and 2221 reported a previous HIV-negative test. From this group, we included 1714 mothers who had taken a new HIV test during the survey. Most of mothers included (83.3%,1428/1714) had a previous documented HIV test result and date. Median time from last test to survey was 15.5 months (IQR:8.0-25.9). A total of 57 new HIV infections were detected over 2530.27 person-years of follow-up. The estimated HIV incidence was 2.25 (95% CI: 1.74-2.92) per 100 person-years. Estimating HIV incidence among women who recently delivered using a community HIV-focused survey coupled with previous HIV-testing history based on patients' clinical documents is an achievable strategy.

Outcomes of a model for re-testing HIV-negative index contacts in Sedibeng, South Africa.

Index contact testing is an HIV case-finding approach that elicits sexual or needle-sharing partners, as well as biological children, of people living with HIV (PLHIV) and offers them HIV testing services. We aim to describe the results of an innovative project in Sedibeng District that expanded index testing by retesting previously negative contacts and incorporating status-neutral testing. We used registers to identify people who previously tested HIV-negative through index testing from March 2019 to September 2021. The individuals were telephonically traced and offered HIV retesting. Data were collected on a weekly basis using REDCap®. We monitored the number of individuals called, those who came back for retest, and their HIV results. Fifteen counsellors contacted 968 people over 12 months. Forty-eight percent (462 out of 968) of those called returned for testing. Of those, 121 (26%) tested positive. Overall, 66 out of 276 (24%) men with HIV and 55 out of 186 (30%) women with HIV were identified and linked to antiretroviral treatment (ART). Fifty-seven percent (194 out of 341) of clients who tested HIV-negative were offered, and 124 out of 194 (64%) initiated, pre-exposure prophylaxis (PrEP). All individuals who retested HIV-positive had a new diagnosis; none reported having had another positive test result between the original negative and the positive retest. Revisiting index clients with a previous negative HIV test result is worthwhile, creating an opportunity to identify undiagnosed PLHIV and high-risk people for PrEP. The high positivity rate highlights the importance of providing a sero-neutral approach to HIV testing, including integrating prevention messaging and linkage to PrEP services.