Undiagnosed HIV Infection Research Articles

Relationships Among COVID-19-Related Service Uptake, HIV Status, Drug Use, and COVID-19 Antibody Status Among HIV Testing Intervention Participants in KwaZulu-Natal, South Africa

People living with HIV (PLWH) and people who use drugs are vulnerable populations who may face barriers to accessing health services and may have irregularities in immune function. People with undiagnosed HIV infection may be particularly likely to have compromised immune function. However, research about whether/how HIV status is related to COVID-19-related health outcomes has been equivocal, and research on the predictors of COVID-19-related health service access/uptake has been limited in Sub-Saharan African settings. Among 470 participants of a peer-recruitment-based HIV-testing intervention in KwaZulu-Natal, we examined whether HIV status and/or hard drug use were associated with uptake of COVID-19 testing and vaccination, and whether they moderated the relationship between COVID-19 vaccination status and COVID-19 IgG antibody status. Women were significantly more likely than men to report testing for COVID-19 (OR = 1.84; p = 0.002) and being vaccinated (OR = 1.79; p = 0.002). Neither HIV status nor drug use was associated with likelihood of getting tested or vaccinated. Vaccinated participants (90% of whom obtained vaccines more than 6 months before the study) were significantly more likely to test positive for COVID-19 IgG antibodies (OR = 6.86; p < 0.0005). This relationship held true for subgroups of PLWH and participants with previously undiagnosed/uncontrolled HIV infection, and was not moderated by HIV status or hard drug use. These findings may suggest that both people who use drugs and PLWH were served as well as other people by KwaZulu-Natal’s COVID-19 response. However, gender-based disparities in COVID-19 service uptake suggest that special care should be taken during future COVID-19 outbreaks or other new epidemics to improve access to related healthcare services among men in this region.

School-Based Protective Factors for HIV Prevention in the United States: Secondary Analysis of the Youth Risk Behavior Survey 2015-2019.

This secondary analysis of the National Youth Risk Behavior Survey (years 2015-2019) examines associations between school-based protective factors (i.e., safe school environments and academic achievement) and HIV risk behaviors among sexually experienced adolescent gay and bisexual men ( n = 644), a population with the highest prevalence of undiagnosed HIV infections. Demographics included Hispanics/Latinos (25%, n = 158), Other race/ethnicity (14%, n = 88), and non-Hispanic Blacks/African Americans (13%, n = 81). Adjusted models showed that protective factors reduced odds for early sexual debut, multiple sexual partners, sex under the influence of drugs/alcohol, and condomless sex, with an additive effect demonstrated when two protective factors were present. Hispanics/Latinos had greater odds of reporting multiple sexual partners and HIV testing, indicating opportunities for school-based HIV prevention and further research. Our findings provide support for school-based programs that aim to improve social and structural determinants of health and ultimately reduce adolescent HIV burdens.

Use of routinely collected blood donation data for expanded HIV and Syphilis surveillance in Blantyre district, Malawi.

The World Health Organization recommends that all blood donations be screened for transfusion transmissible infections; these data are currently not incorporated into national disease surveillance efforts. We set out to use routinely collected data from blood donors in Blantyre district, Malawi to explore HIV and syphilis prevalence and identify sero-conversions among repeat donors. We conducted a retrospective cohort analysis of blood donation data collected by the Malawi Blood Transfusion Service from 2015 to 2021. All blood donations were routinely screened for HIV and syphilis. We characterized donor demographics as well as screening outcomes, including identifying sero-conversions among repeat donors who previously tested negative on their last donation. A total of 23,280 donations from 5,051 donors were recorded, with a median frequency of donations of 3 (IQR:2-6). Most donors were male (4,294; 85%) and students (3,262; 64.6%). Prevalence of HIV at first donation was 1.0% (52/5,051) and prevalence of syphilis was 1.6% (80/5,051); 52 HIV sero-conversions and 126 syphilis sero-conversions were identified, indicating an incidence rate per 1,000 person-years of 5.9 (95% CI: 4.7, 7.4) and 13.3 (95% CI:11.4, 15.4) respectively. Students had a lower prevalence of HIV and syphilis but higher risk of syphilis seroconversion. While blood donors are generally considered a low-risk population for HIV and syphilis, we were able to identify relatively high rates of undiagnosed HIV and syphilis infections among donors. Routinely collected data from national blood donation services may be used to better understand local HIV and syphilis epidemiology, with the potential to enhance disease surveillance systems. These findings may be used to identify priority prevention areas and populations in Blantyre district that can inform targeted interventions for improved disease prevention, testing and treatment.

Regional variations in HIV diagnosis in Japan before and during the COVID-19 pandemic

BackgroundThe number of people undergoing voluntary HIV testing has abruptly decreased since 2020. The geographical heterogeneity of HIV infection and the impact of COVID-19 on the diagnosis of HIV at regional level are important to understand. This study aimed to estimate the HIV incidence by geographical region and understand how the COVID-19 pandemic influenced diagnosis of HIV. MethodsWe used an extended back-calculation method to reconstruct the epidemiological dynamics of HIV/AIDS by geographical region. We used eight regions: Tokyo, the capital of Japan, Hokkaido plus Tohoku, Kanto plus Koshinetsu (excluding Tokyo), Hokuriku, Tokai, Kinki, Chugoku plus Shikoku, and Kyushu plus Okinawa. Four different epidemiological measurements were evaluated: (i) estimated HIV incidence, (ii) estimated rate of diagnosis, (iii) number of undiagnosed HIV infections, and (iv) proportion of HIV infections that had been diagnosed. ResultsThe incidence of HIV/AIDS during the COVID-19 pandemic from 2020 to 2022 increased in all regions except Kanto/Koshinetsu (51.3 cases/year), Tokyo (183.9 cases/year), Hokuriku (1.0 cases/year), and Tokai (43.1 cases/year). The proportion of HIV infections that had been diagnosed only exceeded 90% in Tokyo (91.7%, 95% confidence interval (CI): 90.6, 93.3), Kanto/Koshinetsu (91.0%, 95% CI: 87.3, 97.8), and Kinki (92.5%, 95% CI: 90.4, 95.9). The proportion of infections that had been diagnosed was estimated at 83.3% (95% CI: 75.1, 98.7) in Chugoku/Shikoku and 80.5% (95% CI: 73.9, 91.0) in Kyusyu/Okinawa. ConclusionsIn urban regions with major metropolitan cities, including Tokyo, Kinki, and Kanto/Koshinetsu, the number of undiagnosed HIV infections is substantial. However, the proportion of undiagnosed infections was estimated to be smaller than in other regions. The diagnosed proportion was the lowest in Kyusyu/Okinawa (80.5%), followed by Chugoku/Shikoku and Hokkaido/Tohoku. The level of diagnosis in those regional prefectures may have been more influenced and damaged by the COVID-19 pandemic than in urban settings.

Mobile Phone-Based Confidential Social Network Referrals for HIV Testing (CONSORT): Protocol for a Randomized Controlled Trial.

Critical to efforts to end the HIV epidemic is the identification of persons living with HIV who have yet to be diagnosed and engaged in care. Expanded HIV testing outreach efforts need to be both efficient and ambitious, targeting the social networks of persons living with HIV and those at above-average risk of undiagnosed HIV infection. The ubiquity of mobile phones across many high HIV prevalence settings has created opportunities to leverage mobile health (mHealth) technologies to engage social networks for HIV testing outreach, prevention, and treatment. The purpose of this study is to evaluate the acceptability and efficacy of a novel mHealth intervention, "Confidential Social Network Referrals for HIV Testing (CONSORT)," to nudge at-risk individuals to test for HIV using SMS text messages. We will conduct the CONSORT study in Moshi, Tanzania, the commercial center and administrative capital of the Kilimanjaro Region in northern Tanzania. After qualitative formative work and pilot testing, we will enroll 400 clients presenting for HIV counseling and testing and 200 persons living with HIV and receiving care at HIV care and treatment centers as "inviters" into a randomized controlled trial. Eligible participants will be aged 18 years or older and live, work, or regularly receive care in Moshi. We will randomize inviters into 1 of 2 study arms. All inviters will be asked to complete a survey of their HIV testing and risk behaviors and to think of social network contacts who would benefit from HIV testing. They will then be asked to whom they would prefer to extend an HIV testing invitation in the form of a physical invitation card. Arm 1 participants will also be given the opportunity to extend CONSORT invitations in the form of automated confidential SMS text messages to any of their social network contacts or "invitees." Arm 2 participants will be offered physical invitation cards alone. The primary outcome will be counselor-documented uptake of HIV testing by invitees within 30 days of inviter enrollment. Secondary outcomes will include the acceptability of CONSORT among inviters, the number of new HIV diagnoses, and the HIV risk of invitees who present for testing. Enrollment in the randomized controlled trial is expected to start in September 2024. The findings will be disseminated to stakeholders and published in peer-reviewed journals. If CONSORT is acceptable and effective for increasing the uptake of HIV testing, given the minimal costs of SMS text reminders and the potential for exponential but targeted growth using chain referrals, it may shift current practices for HIV testing programs in the area. ClincalTrials.gov NCT05967208; https://clinicaltrials.gov/study/NCT05967208. PRR1-10.2196/55068.

CDC-Funded HIV Testing and Undiagnosed HIV Infection in Ending the HIV Epidemic in the U.S. Jurisdictions.

Approximately 13% of persons with HIV (PWH) are unaware of their status. To help end HIV, it is important to understand the relationship between the rates of HIV testing and undiagnosed HIV infection. Ending the HIV in the U.S. (EHE) jurisdictions. Using 2021 data from the National HIV Surveillance System and the National HIV Prevention Program Monitoring and Evaluation system, we calculated estimated rates of undiagnosed HIV infections per 100,000 population and rates of CDC-funded HIV tests per 1,000 population. We assessed the association between the two rates using Spearman's rank correlation. We also calculated a rank difference between the two rates for each EHE jurisdiction to help identify jurisdictions with greater unfilled needs for HIV testing. Overall, CDC-funded HIV tests per 1,000 population were positively associated with estimated rate of undiagnosed HIV infection per 100,000 population (rho=0.55, p<0.001). EHE jurisdictions with the greatest magnitude of negative rank differences (i.e., higher undiagnosed HIV infection per 100,000 population and lower CDC-funded HIV tests per 1,000 population) were Prince George's County, MD; Mecklenburg County, NC; Hudson County, NJ; Bronx County, NY, and Hamilton County, OH. In general, CDC-funded HIV testing is being conducted in jurisdictions with the greatest needs. However, we also found large discrepancies between CDC-funded HIV testing and undiagnosed HIV infection rates for some jurisdictions. These jurisdictions may want to identify barriers to their HIV testing services and expand their programs to ensure that all PWH in their jurisdictions are diagnosed.

Social network strategy (SNS) for HIV testing: a new approach for identifying individuals with undiagnosed HIV infection in Tanzania

ABSTRACT Social network strategy (SNS) testing uses network connections to refer individuals at high risk to HIV testing services (HTS). In Tanzania, SNS testing is offered in communities and health facilities. In communities, SNS testing targets key and vulnerable populations (KVP), while in health facilities it complements index testing by reaching unelicited index contacts. Routine data were used to assess performance and trends over time in PEPFAR-supported sites between October 2021 and March 2023. Key indicators included SNS social contacts tested, and new HIV-positives individuals identified. Descriptive and statistical analysis were conducted. Univariable and multivariable analysis were applied, and variables with P-values <0.2 at univariable analysis were considered for multivariable analysis. Overall, 121,739 SNS contacts were tested, and 7731 (6.4%) previously undiagnosed individuals living with HIV were identified. Tested contacts and identified HIV-positives were mostly aged ≥15 years (>99.7%) and females (80.6% of tests, 79.4% of HIV-positives). Most SNS contacts were tested (78,363; 64.7%) and diagnosed (6376; 82.5%) in communities. SNS tests and HIV-positives grew 11.5 and 6.1-fold respectively, from October-December 2021 to January-March 2023, with majority of clients reached in communities vs. facilities (78,763 vs. 42,976). These results indicate that SNS testing is a promising HIV case-finding approach in Tanzania.

Systematic Review: Strategies for Improving HIV Testing and Detection Rates in European Hospitals.

Undiagnosed HIV infection is a prominent clinical issue throughout Europe that requires the continuous attention of all healthcare professionals and policymakers to prevent missed testing opportunities and late diagnosis. This systematic review aimed to evaluate interventions to increase HIV testing rates and case detection in European hospitals. Out of 4598 articles identified, 29 studies fulfilled the selection criteria. Most of the studies were conducted in single Western European capital cities, and only one study was from Eastern Europe. The main interventions investigated were test-all and indicator-condition-based testing strategies. Overall, the prevalence of undiagnosed HIV was well above 0.1%. The studied interventions increased the HIV testing rate and the case detection rate. The highest prevalence of undiagnosed HIV was found with the indicator-condition-driven testing strategy, whereas the test-all strategy had the most profound impact on the proportion of late diagnoses. Nevertheless, the HIV testing rates and case-finding varied considerably across studies. In conclusion, effective strategies to promote HIV testing in European hospitals are available, but relevant knowledge gaps regarding generalizability and sustainability remain. These gaps require the promotion of adherence to HIV testing guidelines, as well as additional larger studies representing all European regions.

Pilot Testing Two Versions of a Social Network Intervention to Increase HIV Testing and Case-finding among Men in South Africa's Generalized HIV Epidemic.

Locating undiagnosed HIV infections is important for limiting transmission. However, there is limited evidence about how best to do so. In South Africa, men have been particularly challenging to reach for HIV testing due, in part, to stigma. We pilot-tested two versions of a network-based case-finding and care-linkage intervention. The first, TRIP, asked "seeds" (original participants) to recruit their sexual and/or injection partners. The second, TRIPLE, aimed to circumvent some stigma-related issues by asking seeds to recruit anyone they know who might be at risk of being HIV-positive-unaware. We recruited 11 (18% male) newly diagnosed HIV-positive (NDP) seeds from two clinics in KwaZulu-Natal, South Africa and randomly assigned them to either TRIP or TRIPLE. Network members were recruited two steps from each seed. The TRIP arm recruited 12 network members; the TRIPLE arm recruited 62. Both arms recruited NDPs at higher rates than local clinic testing, with TRIP (50.0%) outperforming (p = 0.012) TRIPLE (14.5%). However, TRIPLE (53.2%) was far superior to clinics (27.8%) and to TRIP (25.0%) at recruiting men. Given challenges around testing and treating men for HIV in this context, these findings suggest that the TRIPLE expanded network-tracing approach should be tested formally among larger samples in multiple settings.

2675. Concurrent HIV and Sexually Transmitted Infections in People with Mpox in Guatemala City

Abstract Background High rates of HIV and sexually transmitted infections (STIs) among people with mpox have been reported. Guatemala has the highest number of mpox cases reported in Central America. Data on this topic in the region is lacking. We report the prevalence of STIs and HIV in people evaluated for mpox at Hospital Roosevelt in Guatemala City. Methods We conducted a cross-sectional analysis of confirmed mpox cases with outpatient care at our institution between July 2022 and January 2023. Sociodemographic and clinical data was retrospectively collected. This analysis includes new diagnoses of HIV, syphilis, chlamydia, gonorrhea, mycoplasma genitalium infection and herpes virus simplex (HSV) infection. Diagnoses were confirmed by serology or nucleic acid amplification tests. Rates of HIV/STIs were assessed and association with sociodemographic, behavioral and clinical characteristics was analyzed through non-parametric statistical tests. Results Sixty participants with mpox were included. All cis-gender male, 34 (56.6%) younger than 30 years old, 52 (86.6%) were residents of Guatemala City, 57 (95%) men who have sex with men (MSM), 51 (85%) had above secondary education, 36 (60%) with known HIV-positive status. Recent participation in group sex was reported in 9 (15%) participants and inconsistent or no condom use in 49 (81.6%). Among participants with known HIV-positive status 34 (94.4%) had CD4 count &amp;gt; 200/µL and 32 (88.9%) had a HIV viral load &amp;lt; 200 copies/ml. Two previously undiagnosed HIV infections were detected. Overall, 27 new STIs were found in 20 (33.3%) participants (5 had more than one STI). Comparisons between participants with concurrent STIs and those without are shown in Table 1. Nine cases of syphilis were detected. Eighteen STIs involved mucous membranes (oropharyngeal, genital or anorectal). Rates by site are shown in Table 2. Conclusion At least one STI was detected in a third of the mpox cases with syphilis being the most frequent. Almost half of STIs cases involved the anorectal site. People with previously known HIV-positive status had a significantly higher rate of STIs. HIV/STI care is key to an appropriate mpox management. Disclosures All Authors: No reported disclosures

HIV Syndemic Factor Associations Among Adolescent Gay and Bisexual Men in the Youth Risk Behavior Survey 2015-2019: A Secondary Data Analysis.

This analysis of the Youth Risk Behavior Survey examined HIV syndemic factor associations (substance use, violence, mental health, and HIV risk behaviors) among adolescent gay, bisexual, and other men who have sex with men-a population with the highest prevalence of undiagnosed HIV infections. The representative sample ( n = 644) exhibited low condom use (52%) and HIV testing (21%). Adjusted multivariate logistic regression models showed that Blacks were less likely to report HIV testing (adjusted odds ratio [aOR] = 0.06, 95% confidence interval [CI] [0.01-0.44], p < .01), whereas Hispanics were more likely to report four or more lifetime sexual partners (aOR = 3.75, 95% CI [1.49-9.44], p < .01), compared with Whites. A syndemic of substance use and intimate partner violence (sexual, sexual dating, and/or physical dating violence) was associated with early intercourse, multiple sexual partners, and drugs/alcohol before intercourse. Multiple syndemic factor exposures were associated with additive risk, suggesting multilevel approaches for HIV prevention.

Racial/ethnic disparities in estimated undiagnosed HIV infection among adolescents and adults in the United States, 2017-2021.

In 2021, there were an estimated 153 500 persons aged at least 13 years with undiagnosed HIV infection. Estimated rates among Black/African American, Hispanic/Latino, and White persons were used to assess disparity trends from 2017 to 2021. Rates decreased across two absolute and relative disparity measures. Despite these declines, Black and Hispanic persons had rates 8.3 and 4.2 times the rate of White persons in 2021. Increased testing and innovative efforts are needed to address HIV-related disparities.

HIV testing in jails: Comparing strategies to maximize engagement in HIV treatment and prevention.

Despite 15,000 people enter US jails yearly with undiagnosed HIV infection, routine HIV testing is not standard. Maximizing the yield and speed of HIV testing in short-term detention facilities could promote rapid entry or re-entry of people living with HIV (PLWH) into care. The goal of this study was to evaluate the impact of third generation, rapid point-of-care (rPOC) vs. fourth generation, laboratory-based antigen/antibody (LBAg/Ab) testing on the HIV care cascade in a large urban jail during a planned transition. We used aggregate historical data to compare rPOC testing and LBAg/Ab testing in the D.C. Department of Corrections. We examined two time periods, January to August 2019 when rPOC testing was performed, and October 2019 to January 2020 after LBAg/Ab testing began. We calculated monthly rates of HIV tests performed, HIV test results received, HIV test results received among those tested, antiretroviral therapy (ART) initiation, and proportion of PLWH receiving discharge planning prior to release. We then conducted an interrupted time series analysis to assess the differences between testing periods. There were 14,237 entrants during the first time period and 7,569 entrants during the second. Transitioning from rPOC to LBAg/Ab testing increased the rate of test uptake by 38.5% (95% CI: 14.0, 68.3), decreased the rate of test results received among those tested by 13.1% (95% CI: -14.0, -12.1), and increased the combined rate of HIV tests performed and results received by 20.4% (95% CI: 1.5, 42.8). Although the rate of HIV testing was greater under LBAg/Ab, PLWH received results immediately through rPOC testing, which is critically important in short-stay enviroments. Increasing rPOC uptake would increase its value and combined testing may maximize the detection of HIV and receipt of results among persons passing through jails.

Reaching Populations at Risk for HIV Through Targeted Facebook Advertisements: Cost-Consequence Analysis

An undiagnosed HIV infection remains a public health challenge. In the digital era, social media and digital health communication have been widely used to accelerate research, improve consumer health, and facilitate public health interventions including HIV prevention. We aimed to evaluate and compare the projected cost and efficacy of different simulated Facebook (FB) advertisement (ad) approaches targeting at-risk populations for HIV based on new HIV diagnosis rates by age group and geographic region in the United States. We used the FB ad platform to simulate (without actually launching) an automatically placed video ad for a 10-day duration targeting at-risk populations for HIV. We compared the estimated total ad audience, daily reach, daily clicks, and cost. We tested ads for the age group of 13 to 24 years (in which undiagnosed HIV is most prevalent), other age groups, US geographic regions and states, and different campaign budgets. We then estimated the ad cost per new HIV diagnosis based on HIV positivity rates and the average health care industry conversion rate. On April 20, 2021, the potential reach of targeted ads to at-risk populations for HIV in the United States was approximately 16 million for all age groups and 3.3 million for age group 13 to 24 years, with the highest potential reach in California, Texas, Florida, and New York. When using different FB ad budgets, the daily reach and daily clicks per US dollar followed a cumulative distribution curve of an exponential function. Using multiple US $10 ten-day ads, the cost per every new HIV diagnosis ranged from US $13.09 to US $37.82, with an average cost of US $19.45. In contrast, a 1-time national ad had a cost of US $72.76 to US $452.25 per new HIV diagnosis (mean US $166.79). The estimated cost per new HIV diagnosis ranged from US $13.96 to US $55.10 for all age groups (highest potential reach and lowest cost in the age groups 20-29 and 30-39 years) and from US $12.55 to US $24.67 for all US regions (with the highest potential reach of 6.2 million and the lowest cost per new HIV diagnosis at US $12.55 in the US South). Targeted personalized FB ads are a potential means to encourage at-risk populations for HIV to be tested, especially those aged 20 to 39 years in the US South, where the disease burden and potential reach on FB are high and the ad cost per new HIV diagnosis is low. Considering the cost efficiency of ads, the combined cost of multiple low-cost ads may be more economical than a single high-cost ad, suggesting that local FB ads could be more cost-effective than a single large-budget national FB ad.

Incident HIV acquisition among pregnant women in Botswana: findings from the Tsepamo birth outcomes surveillance study.

In Botswana, where almost all pregnant women known to have HIV receive antiretroviral therapy, a large proportion of vertical HIV transmission may occur among women with incident undiagnosed HIV infection during pregnancy. Botswana guidelines recommend repeat HIV testing every 3 months in pregnancy, with at least one test in the third trimester. We evaluated the rate of repeat HIV testing, calculated HIV incidence during pregnancy and estimated missed seroconversions. In the Botswana Tsepamo Study, we abstracted HIV test dates and results from obstetric records of all women who delivered at maternity wards in 18 communities between 7th May 2017 and 20th August 2021. We defined seroconversion as an initial negative/indeterminate HIV test in pregnancy followed by a positive test during pregnancy/at delivery. The incidence rate (IR) of seroconversion was calculated among women with > = 2 known test dates. Missed seroconversions were estimated among women without a test in the third trimester by applying the IR to the time after the last HIV test until delivery. Among 103,529 women delivering in the study period testing negative at the first test and with known conception and HIV test dates, 29,085 (28%) were tested in one trimester of pregnancy, 73,156 (71%) were tested in ≥2 trimesters of pregnancy and 9628 (9%) had a test in all trimesters. A total of 78,162 (75%) women had a third-trimester test. There were 223 seroconversions (2.58/1000 pregnancies, 0.26%) among those with ≥2 known HIV test dates, yielding an IR of 0.69/100 person-years. Among 25,289 women who did not have a test in the third trimester, we estimate approximately 58 seroconversions may have been missed during pregnancy due to a lack of repeat testing. Factors associated with seroconversion during pregnancy included younger age, less education and not being married. More than two-thirds of women had repeat HIV testing in pregnancy and HIV incidence was low. However, an estimated 21% of seroconversions in pregnancy were likely missed due to a lack of re-testing. To reach the goal of zero new paediatric HIV infections, Botswana will need to intensify repeat HIV testing in the third trimester of pregnancy.

Epidemiological and viral characteristics of undiagnosed HIV infections in Botswana

BackgroundHIV-1 is endemic in Botswana. The country’s primary challenge is identifying people living with HIV who are unaware of their status. We evaluated factors associated with undiagnosed HIV infection using HIV-1 phylogenetic, behavioural, and demographic data.MethodsAs part of the Botswana Combination Prevention Project, 20% of households in 30 villages were tested for HIV and followed from 2013 to 2018. A total of 12,610 participants were enrolled, 3596 tested HIV-positive at enrolment, and 147 participants acquired HIV during the trial. Extensive socio-demographic and behavioural data were collected from participants and next-generation sequences were generated for HIV-positive cases. We compared three groups of participants: (1) those previously known to be HIV-positive at enrolment (n = 2995); (2) those newly diagnosed at enrolment (n = 601) and (3) those who tested HIV-negative at enrolment but tested HIV-positive during follow-up (n = 147). We searched for differences in demographic and behavioural factors between known and newly diagnosed group using logistic regression. We also compared the topology of each group in HIV-1 phylogenies and used a genetic diversity-based algorithm to classify infections as recent (< 1 year) or chronic (≥ 1 year).ResultsBeing male (aOR = 2.23) and younger than 35 years old (aOR = 8.08) was associated with undiagnosed HIV infection (p < 0.001), as was inconsistent condom use (aOR = 1.76). Women were more likely to have undiagnosed infections if they were married, educated, and tested frequently. For men, being divorced increased their risk. The genetic diversity-based algorithm classified most incident infections as recent (75.0%), but almost none of known infections (2.0%). The estimated proportion of recent infections among new diagnoses was 37.0% (p < 0.001).ConclusionOur results indicate that those with undiagnosed infections are likely to be young men and women who do not use condoms consistently. Among women, several factors were predictive: being married, educated, and testing frequently increased risk. Men at risk were more difficult to delineate. A sizeable proportion of undiagnosed infections were recent based on a genetic diversity-based classifier. In the era of “test and treat all”, pre-exposure prophylaxis may be prioritized towards individuals who self-identify or who can be identified using these predictors in order to halt onward transmission in time.

Undiagnosed HIV Infections May Drive HIV Transmission in the Era of "Treat All": A Deep-Sampling Molecular Network Study in Northeast China during 2016 to 2019.

Universal antiretroviral therapy (ART, “treat all”) was recommended by the World Health Organization in 2015; however, HIV-1 transmission is still ongoing. This study characterizes the drivers of HIV transmission in the “treat all” era. Demographic and clinical information and HIV pol gene were collected from all newly diagnosed cases in Shenyang, the largest city in Northeast China, during 2016 to 2019. Molecular networks were constructed based on genetic distance and logistic regression analysis was used to assess potential transmission source characteristics. The cumulative ART coverage in Shenyang increased significantly from 77.0% (485/630) in 2016 to 93.0% (2598/2794) in 2019 (p < 0.001). Molecular networks showed that recent HIV infections linked to untreated individuals decreased from 61.6% in 2017 to 28.9% in 2019, while linking to individuals with viral suppression (VS) increased from 9.0% to 49.0% during the same time frame (p < 0.001). Undiagnosed people living with HIV (PLWH) hidden behind the links between index cases and individuals with VS were likely to be male, younger than 25 years of age, with Manchu nationality (p < 0.05). HIV transmission has declined significantly in the era of “treat all”. Undiagnosed PLWH may drive HIV transmission and should be the target for early detection and intervention.

Is Monkeypox Being Underdiagnosed in Countries with More Stigmatizing Attitudes towards Men Who Have Sex with Men? A Simple Ecological Analysis.

It is not known why the recent outbreak of monkeypox (MPX) has been more extensive in certain European countries than others. Previous studies have found that European countries with more stigmatizing attitudes to homosexuality have more undiagnosed HIV infections in men who have sex with men (MSM). We hypothesized that MPX in MSM may be underdiagnosed in European countries with more stigmatizing attitudes to homosexuality and less access to sexually transmitted infection (STI) testing for MSM. To test this hypothesis, we used Spearman’s correlation to assess if the national incidence of MPX in European countries was negatively associated with the intensity of screening for STIs and a composite indicator of Lesbian Gay Bisexual Transgender Intersex (LGBTI) rights (the Rainbow Index). We found that the national cumulative incidence of MPX was positively correlated with the intensity of chlamydia/gonorrhoea screening (rho 0.68, p-value < 0.0001), syphilis screening (rho 0.62, p-value < 0.0001), and the Rainbow Index (rho 0.65, p-value < 0.0001). Our analysis thus suggests caution is required in interpreting the relatively lower incidence of MPX reported from several Eastern European countries. A key limitation of this analysis is that the incidence of MPX was calculated in the whole population and not limited to the MSM population.

Length of stay in Denmark before HIV diagnosis and linkage to care: a population-based study of migrants living with HIV, Denmark, 1995 to 2020.

BackgroundMigrants face an increased risk of HIV infection and late presentation for HIV care.AimTo examine delays in HIV diagnosis, linkage to care (LTC), and risk of late presentation for migrants living with HIV in Denmark.MethodsWe conducted a population-based, nationwide study of adult migrants (n = 2,166) presenting for HIV care between 1 January 1995 and 31 December 2020 in Denmark. Time from immigration to HIV diagnosis and from diagnosis to LTC, and late presentation were assessed, stratified by migrants’ geographical regions of origin, using descriptive statistics.ResultsThe demographics of the migrant population changed over time. Overall, migrants diagnosed with HIV after immigration to Denmark resided a median of 3.7 (IQR: 0.8–10.2) years in Denmark before diagnosis. Median time from HIV diagnosis to LTC was 6 (IQR: 0–24) days. Migrants diagnosed with HIV infection before immigration had a median of 38 (IQR: 0–105) days from arrival in Denmark to LTC. The corresponding median times for 2015–20 alone were 4.1 (IQR: 0.9–13.1) years, 0 (IQR: 0–8) days, and 62 (IQR: 25–152) days, respectively. The overall proportion of late presentation among migrants diagnosed with HIV after immigration was 60%, and highest among migrants from sub-Saharan Africa and East and South Asia.ConclusionHIV diagnosis is still substantially delayed in Danish migrants, while LTC is timely. The proportions with late presentation are high. These results call for targeted interventions to reduce the number of migrants with undiagnosed HIV infections and of late presenters.

How could HIV-1 drug resistance impact preexposure prophylaxis for HIV prevention?

To review current laboratory and clinical data on the frequency and relative risk of drug resistance and range of mutations selected from approved and investigational antiretroviral agents used for preexposure prophylaxis (PrEP) of HIV-1 infection, including tenofovir disproxil fumarate (TDF)-based oral PrEP, dapivirine ring, injectable cabotegravir (CAB), islatravir, lenacapavir and broadly neutralizing antibodies (bNAbs). The greatest risk of HIV-1 resistance from PrEP with oral TDF/emtricitabine (FTC) or injectable CAB is from starting or continuing PrEP after undiagnosed acute HIV infection. By contrast, the dapivirine intravaginal ring does not appear to select nonnucleoside reverse transcriptase inhibitor resistance in clinical trial settings. Investigational inhibitors including islatravir, lenacapavir, and bNAbs are promising for use as PrEP due to their potential for sustained delivery and low risk of cross-resistance to currently used antiretrovirals, but surveillance for emergence of resistance mutations in more HIV-1 gene regions (gag, env) will be important as the same drugs are being developed for HIV therapy. PrEP is highly effective in preventing HIV infection. Although HIV drug resistance from PrEP use could impact future options in individuals who seroconvert on PrEP, the current risk is low and continued monitoring for the emergence of resistance and cross-resistance during product development, clinical studies, and product roll-out is advised to preserve antiretroviral efficacy for both treatment and prevention.