Improved detection of acute HIV-1 infection in sub-Saharan Africa: development of a risk score algorithm.

OBJECTIVE: Individuals with acute (preseroconversion) HIV infection (AHI) are important in the spread of HIV. The identification of AHI requires the detection of viral proteins or nucleic acids with techniques that are often unaffordable for routine use. To facilitate the efficient use of these tests, we sought to develop a risk score algorithm for identifying likely AHI cases and targeting the tests towards those individuals. DESIGN: A cross-sectional study of 1448 adults attending a sexually transmitted infections (STI) clinic in Malawi. METHODS: Using logistic regression, we identified risk behaviors, symptoms, HIV rapid test results, and STI syndromes that were predictive of AHI. We assigned a model-based score to each predictor and calculated a risk score for each participant. RESULTS: Twenty-one participants (1.45%) had AHI, 588 had established HIV infection, and 839 were HIV-negative. AHI was strongly associated with discordant rapid HIV tests and genital ulcer disease (GUD). The algorithm also included diarrhea, more than one sexual partner in 2 months, body ache, and fever. Corresponding predictor scores were 1 for fever, body ache, and more than one partner; 2 for diarrhea and GUD; and 4 for discordant rapid tests. A risk score of 2 or greater was 95.2% sensitive and 60.5% specific in detecting AHI. CONCLUSION: Using this algorithm, we could identify 95% of AHI cases by performing nucleic acid or protein tests in only 40% of patients. Risk score algorithms could enable rapid, reliable AHI detection in resource-limited settings.

Trichomoniasis in men and HIV infection: data from 2 outpatient clinics at Lilongwe Central Hospital, Malawi.

BACKGROUND: Little is known about the epidemiologic profile of trichomoniasis in men and its relationship to human immunodeficiency virus (HIV) infection. Among men presenting for care for symptomatic sexually transmitted infections (STIs) in Malawi, trichomoniasis is not considered for first-line treatment. METHODS: We conducted a cross-sectional survey of 1187 men attending either a dermatology or STI outpatient clinic in the capital of Malawi. Men were interviewed, and the etiologies of the STIs were determined. RESULTS: At the STI clinic (n = 756 men), we identified 150 men (20%) with Trichomonas vaginalis infection, 358 men (47%) with HIV infection, and 335 men (44%) with Neisseria gonorrhoeae infection. At the dermatology clinic (n = 431 men), we identified 54 (13%), 118 (27%), and 2 (0.5%) men, respectively. At both clinics, a lower education level and reporting never having used a condom were predictive of T. vaginalis infection. Only at the dermatology clinic was older age associated with infection, and only at the STI clinic were marital, genital ulcer disease, and HIV-infection status associated with T. vaginalis infection. At the STI clinic, urethral symptoms attributable to trichomoniasis were more severe among HIV-positive men than among HIV-negative men. CONCLUSIONS: Given its high prevalence and the increased risk for HIV transmission, T. vaginalis infection should be reconsidered for inclusion in the Malawi STI-treatment regimen for men.