Experiences and lessons learned from the real-world implementation of an HIV recent infection testing algorithm in three routine service-delivery settings in Kenya and Zimbabwe.

INTRODUCTION: Testing for recent HIV infection can distinguish recently acquired infection from long-standing infections. Given current interest in the implementation of recent infection testing algorithms (RITA), we report our experiences in implementing a RITA in three pilot studies and highlight important issues to consider when conducting recency testing in routine settings. METHODS: We applied a RITA, incorporating a limited antigen (LAg) avidity assay, in different routine HIV service-delivery settings in 2018: antenatal care clinics in Siaya County, Kenya, HIV testing and counselling facilities in Nairobi, Kenya, and female sex workers clinics in Zimbabwe. Discussions were conducted with study coordinators, laboratory leads, and facility-based stakeholders to evaluate experiences and lessons learned in relation to implementing recency testing. RESULTS: In Siaya County 10/426 (2.3%) of women testing HIV positive were classified as recent, compared to 46/530 (8.7%) of women and men in Nairobi and 33/313 (10.5%) of female sex workers in Zimbabwe. Across the study setting, we observed differences in acceptance, transport and storage of dried blood spot (DBS) or venous blood samples. For example, the acceptance rate when testing venous blood was 11% lower than when using DBS. Integrating our study into existing services ensured a quick start of the study and kept the amount of additional resources required low. From a laboratory perspective, the LAg avidity assay was initially difficult to operationalise, but developing a network of laboratories and experts to work together helped to improve this. A challenge that was not overcome was the returning of RITA test results to clients. This was due to delays in laboratory testing, the need for multiple test results to satisfy the RITA, difficulties in aligning clinic visits, and participants opting not to return for test results. CONCLUSION: We completed three pilot studies using HIV recency testing based on a RITA in Kenya and Zimbabwe. The main lessons we learned were related to sample collection and handling, LAg avidity assay performance, integration into existing services and returning of test results to participants. Our real-world experience could provide helpful guidance to people currently working on the implementation of HIV recency testing in sub-Saharan Africa

Can HIV recent infection surveillance help us better understand where primary prevention efforts should be targeted? Results of three pilots integrating a recent infection testing algorithm into routine programme activities in Kenya and Zimbabwe.

INTRODUCTION: Surveillance of recent HIV infections in national testing services has the potential to inform primary prevention programming activities. Focusing on procedures required to accurately determine recent infection, and the potential for recent infection surveillance to inform prevention efforts, we present the results of three independent but linked pilots of recency testing. METHODS: To distinguish recently acquired HIV infection from long-standing infection, in 2018 we applied a Recent Infection Testing Algorithm that combined a laboratory-based Limiting Antigen Avidity Enzyme Immunoassay with clinical information (viral-load; history of prior HIV diagnosis; antiretroviral therapy-exposure). We explored potential misclassification of test results and analysed the characteristics of participants with recent infection. We applied the algorithm in antenatal clinics providing prevention of mother-to-child transmission services in Siaya County, Kenya, outreach sites serving female sex workers in Zimbabwe, and routine HIV testing and counselling facilities in Nairobi, Kenya. In Nairobi, we also conducted recency testing among partners of HIV-positive participants. RESULTS: In Siaya County, 2.3% (10/426) of HIV-positive pregnant women were classified as recent. A risk factor analysis comparing women testing recent with those testing HIV-negative found women in their first trimester were significantly more likely to test recent than those in their second or third trimester. In Zimbabwe, 10.5% (33/313) of female sex workers testing HIV-positive through the outreach programme were classified recent. A risk factor analysis of women testing recent versus those testing HIV-negative, found no strong evidence of an association with recent infection. In Nairobi, among 532 HIV-positive women and men, 8.6% (46) were classified recent. Among partners of participants, almost a quarter of those who tested HIV-positive were classified as recent (23.8%; 5/21). In all three settings, the inclusion of clinical information helped improve the positive predictive value of recent infection testing by removing cases that were likely misclassified. CONCLUSIONS: We successfully identified recently acquired infections among persons testing HIV-positive in routine testing settings and highlight the importance of incorporating additional information to accurately classify recent infection. We identified a number of groups with a significantly higher proportion of recent infection, suggesting recent infection surveillance, when rolled-out nationally, may help in further targeting primary prevention efforts

A Review of Events That Expose Children to Elemental Mercury in the United States

Concern for children exposed to elemental mercury prompted the Agency for Toxic Substances and Disease Registry and the Centers for Disease Control and Prevention to review the sources of elemental mercury exposures in children, describe the location and proportion of children affected, and make recommendations on how to prevent these exposures. In this review, we excluded mercury exposures from coal-burning facilities, dental amalgams, fish consumption, medical waste incinerators, or thimerosal-containing vaccines. We reviewed federal, state, and regional programs with data on mercury releases along with published reports of children exposed to elemental mercury in the United States. We selected all mercury-related events that were documented to expose (or potentially expose) children. Primary exposure locations were at home, at school, and at others such as industrial property not adequately remediated or medical facilities. Exposure to small spills from broken thermometers was the most common scenario; however, reports of such exposures are declining. The information reviewed suggests that most releases do not lead to demonstrable harm if the exposure period is short and the mercury is properly cleaned up. Primary prevention should include health education and policy initiatives

Committing Planning Suicide: Economic Competitiveness, Political Wranglings, and the Demise of Growth Management in Twenty First Century Florida

In June of 2011, Florida Governor Rick Scott signed into law a piece of legislation, HB7207, that severely curtailed the landmark Growth Management Act of 1985 (GMA), which through a policy combining consistency, concurrency, and compact development, had aimed to ensure the proper balancing of development and growth controls to promote socially responsible growth in the state for years to come (Pittman 2011). With his signature, Gov. Scott rendered toothless a piece of growth management legislation which had pioneered state growth efforts (along with the Oregon Land Use Act of 1973) and served as a model for numerous other states seeking to limit the deleterious environmental and social impacts of urban sprawl and wasteful land consumption and eliminated the agency, the Department of Community Affairs (DCA), that oversaw its implementation (Pittman 2011; Ben-Zadok 2005, 2167). While much has been written debating the GMA’s effectiveness in managing growth, its potential impact on housing affordability, and its broader impacts of Florida’s economic competitiveness, at this critical juncture in Florida’s history, it is appropriate to reflect upon the preceding four decades of planning for growth in the state. The act broadly sought to protect agricultural lands, environmentally sensitive lands, and natural areas from the pressures of development, instead directing growth to locations of higher density, thought more suitable to the long-term objectives of the public welfare. An added benefit of these efforts, of course, was the protection of taxpayers from financial strains of sprawling infrastructure

The Economic Impact of Sea Level Rise on Port of Savannah's Garden City Terminal & City of Darien

The Garden City Terminal at the Port of Savannah is one of the largest and fastest growing container ports in the country, making it an economic engine locally and nationally. The Terminal is an integral economic component on several scales: locally, it supports many households in and around Chatham County; regionally, the port supports wider distribution networks and regional agriculture and manufacturing; and nationally, the port serves as a gateway to access markets across the globe. Therefore rising sea levels projected over the next 100 years make port disruptions an important economic threat on a variety of scales. This report describes the economic threat that sea level rise poses to port and port-related operations through permanent inundation, worsening storm surge, and other environmental changes at local, regional and statewide scales. The team drew on research by Keating and Habeeb (2012) and created new tools for assessing the potential impacts on jobs, property, transportation links, and other businesses. The intent is to provide actionable projections for business leaders, policy makers, and individuals in areas that may eventually have to respond to the effects of sea level rise