h Dried blood spots (DBS) are an alternative specimen type for HIV drug resistance genotyping in resource-limited settings. Data relating to the impact of DBS storage and shipment conditions on genotyping efficiency under field conditions are limited. We compared the genotyping efficiencies and resistance profiles of DBS stored and shipped at different temperatures to those of plasma specimens collected in parallel from patients receiving antiretroviral therapy in Uganda. Plasma and four DBS cards from anti-coagulated venous blood and a fifth card from finger-prick blood were prepared from 103 HIV patients with a median viral load (VL) of 57,062 copies/ml (range, 1,081 to 2,964,191). DBS were stored at ambient temperature for 2 or 4 weeks or frozen at ؊80°C and shipped from Uganda to the United States at ambient temperature or frozen on dry ice for genotyping using a broadly sensitive in-house method. Plasma (97.1%) and DBS (98.1%) stored and shipped frozen had similar genotyping efficiencies. DBS stored frozen (97.1%) or at ambient temperature for 2 weeks (93.2%) and shipped at ambient temperature also had similar genotyping efficiencies. Genotyping efficiency was reduced for DBS stored at ambient temperature for 4 weeks (89.3%, P ‫؍‬ 0.03) or prepared from finger-prick blood and stored at ambient temperature for 2 weeks (77.7%, P < 0.001) compared to DBS prepared from venous blood and handled similarly. Resistance profiles were similar between plasma and DBS specimens. This report delineates the optimal DBS collection, storage, and shipping conditions and opens a new avenue for cost-saving ambient-temperature DBS specimen shipments for HIV drug resistance (HIVDR) surveillances in resource-limited settings.

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Background World Health Organisation recommends screening for the cryptococcal antigen (CrAg), a predictor of cryptococcal meningitis, among antiretroviral therapy (ART) naïve people living with HIV (PLHIV) with CD4 &lt;100 cells/mm 3. CrAg positivity among ART-experienced PLHIV with viral load (VL) non-suppression is not well established, yet high VLs are associated with cryptococcal meningitis independent of CD4 count. We compared the frequency and positivity yield of CrAg screening among ART-experienced PLHIV with VL non-suppression and ART-naïve PLHIV with CD4 &lt;100 cells/mm 3 attending rural public health facilities in Uganda. Methods We reviewed routinely generated programmatic reports on cryptococcal disease screening from 104 health facilities in eight rural districts of Uganda from January 2018 to July 2019. A lateral flow assay (IMMY CrAg®) was used to screen for cryptococcal disease. PLHIV were eligible for CrAg screening if they were ART-naïve with CD4 &lt;100 cell/mm 3 or ART-experienced with an HIV VL &gt;1,000 copies/ml after at least 6 months of ART. We used Pearson’s chi-square test to compare the frequency and yield of CrAg screening. Results Of 71,860 ART-experienced PLHIV, 7210 (10.0%) were eligible for CrAg screening. Among 15,417 ART-naïve PLHIV, 5,719 (37.1%) had a CD4 count measurement, of whom 937 (16.4%) were eligible for CrAg screening. The frequency of CrAg screening was 11.5% (830/7,210) among eligible ART-experienced PLHIV compared to 95.1% (891/937) of eligible ART- naïve PLHIV (p&lt;0.001). The CrAg positivity yield was 10.5% among eligible ART-experienced PLHIV compared to 13.8% ART-naïve PLHIV (p=0.035). Conclusion The low frequency and high positivity yield of CrAg screening among ART-experienced PLHIV with VL non-suppression suggest a need for VL- directed CrAg screening in this population. Studies are needed to evaluate the cost-effectiveness and impact of CrAg screening and fluconazole prophylaxis on the outcomes of ART – experienced PLHIV with VL non-suppression.

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