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.

Context: In response to the COVID-19 pandemic, the Centers for Disease Prevention and Control (CDC) clinicians provided real-time telephone consultation to healthcare providers, public health practitioners, and health department personnel. Objective: To describe the demographic and public health characteristics of inquiries, trends, and correlation of inquiries with national COVID-19 case reports. We summarize the results of real-time CDC clinician consultation service provided during 11 March to 31 July 2020 to understand the impact and utility of this service by CDC for the COVID-19 pandemic emergency response and for future outbreak responses. Design: Clinicians documented inquiries received including information about the call source, population for which guidance was sought, and a detailed description of the inquiry and resolution. Descriptive analyses were conducted, with a focus on characteristics of callers as well as public health and clinical content of inquiries. Setting: Real-time telephone consultations with CDC Clinicians in Atlanta, GA. Participants: Health care providers and public health professionals who called CDC with COVID-19 related inquiries from throughout the United States. Main Outcome Measures: Characteristics of inquiries including topic of inquiry, inquiry population, resolution, and demographic information. Results: A total of 3154 COVID-19 related telephone inquiries were answered in real-time. More than half (62.0%) of inquiries came from frontline healthcare providers and clinical sites, followed by 14.1% from state and local health departments. The majority of inquiries focused on issues involving healthcare workers (27.7%) and interpretation or application of CDC’s COVID-19 guidance (44%). Conclusion: The COVID-19 pandemic resulted in a substantial number of inquiries to CDC, with the large majority originating from the frontline clinical and public health workforce. Analysis of inquiries suggests that the ongoing focus on refining COVID-19 guidance documents is warranted, which facilitates bidirectional feedback between the public, medical professionals, and public health authorities.

Introduction Despite antiretroviral therapy (ART) scale‐up among people living with HIV (PLHIV), those with advanced HIV disease (AHD) (defined in adults as CD4 count <200 cells/mm 3 or clinical stage 3 or 4), remain at high risk of death from opportunistic infections. The shift from routine baseline CD4 testing towards viral load testing in conjunction with “Test and Treat” has limited AHD identification. Methods We used official estimates and existing epidemiological data to project deaths from tuberculosis (TB) and cryptococcal meningitis (CM) among PLHIV‐initiating ART with CD4 <200 cells/mm 3 , in the absence of select World Health Organization recommended diagnostic or therapeutic protocols for patients with AHD. We modelled the reduction in deaths, based on the performance of screening/diagnostic testing and the coverage and efficacy of treatment/preventive therapies for TB and CM. We compared projected TB and CM deaths in the first year of ART from 2019 to 2024, with and without CD4 testing. The analysis was performed for nine countries: South Africa, Kenya, Lesotho, Mozambique, Nigeria, Uganda, Zambia, Zimbabwe and the Democratic Republic of Congo. Results The effect of CD4 testing comes through increased identification of AHD and consequent eligibility for protocols for AHD prevention, diagnosis and management; algorithms for CD4 testing avert between 31% and 38% of deaths from TB and CM in the first year of ART. The number of CD4 tests required per death averted varies widely by country from approximately 101 for South Africa to 917 for Kenya. Conclusions This analysis supports retaining baseline CD4 testing to avert deaths from TB and CM, the two most deadly opportunistic infections among patients with AHD. However, national programmes will need to weigh the cost of increasing CD4 access against other HIV‐related priorities and allocate resources accordingly.

BackgroundIdentifying populations with high HIV transmission rates is important for prevention and treatment strategies. Persons with recently acquired HIV infection are drivers of HIV transmission due to high levels of HIV viral load (VL). We assessed annual HIV transmission rates and factors associated with recent infection to inform targeted interventions in a hyperendemic region in Kenya.MethodsThe Ndhiwa HIV impact assessment was a population-based survey among persons aged 15–59 years living in South Nyanza, Kenya in 2012. Respondents were tested for HIV using rapid tests per national guidelines and provided blood for centralized testing. Specimens from HIV+ persons were tested for VL and recent infection. Recent infection was defined as normalized optical density value <1.5 on the Limiting Antigen Enzyme Immunoassay, VL >1,000 copies/mL, and no report of HIV treatment. The annual HIV transmission rate per 100 persons living with HIV (PLHIV) was calculated as HIV incidence divided by HIV prevalence, multiplied by 100. Annualized HIV incidence was estimated, assuming a mean duration of recent infection of 141 days (confidence interval [CI] 123–160). Multivariate analysis identified independent factors associated with recent infection. Estimates were adjusted for survey design.ResultsOf 6,076 persons tested, 1,457 were HIV+, and 28 were recently infected. HIV incidence and prevalence were 1.7% (CI 1.5–2.0) and 24.1% (CI 22.6–25.5), respectively. Per 100 PLHIV, the annual HIV transmission rate was 7.0 and varied by sex (4.6 male vs. 8.3 female), age (5.2 aged 30+ vs. 10.4 aged <30), and residence (1.4 Kobama vs. 12.0 Riana vs. 12.1 Pala divisions). After controlling for age, sex, and residence, recently infected persons were significantly more likely to reside in Pala division (AOR 8.3, CI 1.1–62.9) than HIV-uninfected persons.ConclusionApproximately 7 in 100 PLHIV transmitted to HIV-uninfected persons in South Nyanza in 2012, similar to national rates observed in the 2012 Kenya AIDS Indicator Survey. HIV transmission rates were higher in females than males, younger than older, and Riana and Pala than other divisions. Residence in Pala was a risk factor for recent infection. These findings could guide prioritization of interventions to interrupt HIV transmission in this hyperendemic setting.Disclosures All authors: No reported disclosures.

A 57-year-old previously healthy man from Minnesota presented for evaluation of chronic intermittent diarrhea, cough, and sweats of 6 months' duration. The symptoms started while he was in Fiji (to which he travels to annually) with an urticarial, nontender, nonvesicular rash sparing mucosal surfaces that resolved after 2 days. One week after the rash resolved, he experienced intermittent productive cough, dyspnea, malaise, and diarrhea. Chest radiography in Fiji revealed a left pulmonary infiltrate. He received antibiotics without improvement. He also continued to have watery, nonbloody diarrhea, about 10 bowel movements per day. Because of his illness, he returned to the United States. His condition transiently improved for about 10 days after his return, but the symptoms, including cough, fever, chills, and diarrhea, recurred. He therefore presented to our clinic for further evaluation.In Fiji, his exposures included consuming rainwater and raw fish, walking barefoot on the lawn, and swimming in the ocean and local rivers. His 2 dogs were frequently infected with "dog fluke." Other travel included trips to Mexico, Australia, and New Zealand. He had no ill contacts. He had no risk factors for human immunodeficiency virus or hepatitis B or C and no history of inflammatory bowel disease or asthma. He took no medications regularly.Laboratory tests from an outside institution revealed persistent eosinophilia ranging from 21.7% to 33.1% (reference range, 0%-7%) with normal lymphocytes and neutrophils. His erythrocyte sedimentation rate was 92 mm/h (reference range, 0-22 mm/h), and his C-reactive protein level was elevated at 23.3 mg/L (reference range, Յ8 mg/L). Stool studies were negative for ova and parasites, as were test results for Cyclospora and Giardia antigen, Clostridium difficile toxin, and special bacterial cultures (Salmonella, Shigella, Yersinia, Campylobacter, Escherichia coli 0157). Purified protein derivative (tuberculin) skin testing yielded negative results.