Augmented Cross‐Sectional Prevalence Testing for Estimating HIV Incidence

Summary Estimation of an HIV incidence rate based on a cross‐sectional sample of individuals evaluated with both a sensitive and less‐sensitive diagnostic test offers important advantages to incidence estimation based on a longitudinal cohort study. However, the reliability of the cross‐sectional approach has been called into question because of two major concerns. One is the difficulty in obtaining a reliable external approximation for the mean “window period” between detectability of HIV infection with the sensitive and less‐sensitive test, which is used in the cross‐sectional estimation procedure. The other is how to handle false negative results with the less‐sensitive diagnostic test; that is, subjects who may test negative—implying a recent infection—long after they are infected. We propose and investigate an augmented design for cross‐sectional incidence estimation studies in which subjects found in the recent infection state are followed for transition to the nonrecent infection state. Inference is based on likelihood methods that account for the length‐biased nature of the window periods of subjects found in the recent infection state, and relate the distribution of their forward recurrence times to the population distribution of the window period. The approach performs well in simulation studies and eliminates the need for external approximations of the mean window period and, where applicable, the false negative rate.     

NIMH Project Accept (HPTN 043): Results from In-Depth Interviews with a Longitudinal Cohort of Community Members

Introduction

NIMH Project Accept (HPTN 043) is a community- randomized trial to test the safety and efficacy of a community-level intervention designed to increase testing and lower HIV incidence in Tanzania, Zimbabwe, South Africa and Thailand. The evaluation design included a longitudinal study with community members to assess attitudinal and behavioral changes in study outcomes including HIV testing norms, HIV-related discussions, and HIV-related stigma.

Methods

A cohort of 657 individuals across all sites was selected to participate in a qualitative study that involved 4 interviews during the study period. Baseline and 30-month data were summarized according to each outcome, and a qualitative assessment of changes was made at the community level over time.

Results

Members from intervention communities described fewer barriers and greater motivation for testing than those from comparison communities. HIV-related discussions in intervention communities were more grounded in personal testing experiences. A change in HIV-related stigma over time was most pronounced in Tanzania and Zimbabwe. Participants in the intervention communities from these two sites attributed community-level changes in attitudes to project specific activities.

Discussion

The Project Accept intervention was associated with more favorable social norms regarding HIV testing, more personal content in HIV discussions in all study sites, and qualitative changes in HIV-related stigma in two of five sites.     

Creating an African HIV Clinical Research and Prevention Trials Network: HIV Prevalence,Incidence and Transmission

HIV epidemiology informs prevention trial design and program planning. Nine clinical research centers (CRC) in sub-Saharan Africa conducted HIV observational epidemiology studies in populations at risk for HIV infection as part of an HIV prevention and vaccine trial network. Annual HIV incidence ranged from below 2% to above 10% and varied by CRC and risk group, with rates above 5% observed in Zambian men in an HIV-discordant relationship, Ugandan men from Lake Victoria fishing communities, men who have sex with men, and several cohorts of women. HIV incidence tended to fall after the first three months in the study and over calendar time. Among suspected transmission pairs, 28% of HIV infections were not from the reported partner. Volunteers with high incidence were successfully identified and enrolled into large scale cohort studies. Over a quarter of new cases in couples acquired infection from persons other than the suspected transmitting partner.     

Structural determinants of child mortality in sub‐Saharan Africa: A cross‐national study of economic and social influences from 1970 to 1997

Abstract

This cross‐national study seeks to understand the lagging child mortality declines in sub‐Saharan Africa by using World Bank data to investigate social and economic factors at three points in time: 1970, 1985, and 1997. Women's education, foreign debt‐to‐export ratio, and GNP per capita are among the strongest correlates of under five mortality over time. Cross‐sectional and longitudinal results suggest that female education is the best overall predictor of child mortality. Average national income does not emerge as a strong predictor, particularly since 1985. Increasing levels of foreign debt are associated with a substantial excess mortality burden. In 1997, the effect of adult HIV prevalence on child mortality was moderate and statistically significant. The study concludes that, although future gains in social factors such as female education will likely be beneficial, without simultaneously addressing high levels of foreign debt and high HIV prevalence, it may be difficult to improve child mortality rates across sub‐Saharan Africa.     

Mortality incidence estimation using federal death certificate and natality data with an application to Tay–Sachs disease

For confidentiality reasons, US federal death certificate data are incomplete with regards to the dates of birth and death for the decedents, making calculation of total lifetime of a decedent impossible and thus estimation of mortality incidence difficult. This paper proposes the use of natality data and an imputation‐based method to estimate age‐specific mortality incidence rates in the face of this missing information. By utilizing previously determined probabilities of birth, a birth date and death date are imputed for every decedent in the dataset. Thus, the birth cohort of each individual is imputed, and the total on‐study time can be calculated. This idea is implemented in two approaches for estimation of mortality incidence rates. The first is an extension of a person‐time approach, while the second is an extension of a life table approach. Monte Carlo simulations showed that both approaches perform well in comparison to the ideal complete data methods, but that the person‐time method is preferred. An application to Tay–Sachs disease is demonstrated. It is concluded that the imputation methods proposed provide valid estimates of the incidence of death from death certificate data without the need for additional assumptions under which usual mortality rates provide valid estimates.     

High Incidence Is Not High Exposure: What Proportion of Prevention Trial Participants Are Exposed to HIV?

Objective

Randomized clinical trials of HIV prevention in high-risk populations of women often assume that all participants have similar exposure to HIV. However, a substantial fraction of women enrolled in the trial may have no or low exposure to HIV. Our objective was to estimate the proportion of women exposed to HIV throughout a hypothetical high-risk study population.

Methods

A stochastic individual-based model was developed to simulate the sexual behavior and the risk of HIV acquisition for a cohort of sexually active HIV-uninfected women in high HIV prevalence settings. Key behavior and epidemic assumptions in the model were based on published studies on HIV transmission in South Africa. The prevalence of exposure, defined as the proportion of women who have sex with HIV-infected partner, and HIV incidence were evaluated.

Results

Our model projects that in communities with HIV incidence rate of 1 per 100 person years, only 5-6% of women are exposed to HIV annually while in communities with an HIV incidence of 5 per 100 person years 20-25% of women are exposed to HIV. Approximately 70% of the new infections are acquired from partners with asymptomatic HIV.

Conclusions

Mathematical models suggest that a high proportion of women enrolled in HIV prevention trials may be unexposed to HIV even when incidence rates are high. The relationship between HIV exposure and other risk factors should be carefully analyzed when future clinical trials are planned.     

Geographic signatures in species turnover: decoupling colonization and extinction across a latitudinal gradient

High latitude communities have low species richness and are rapidly warming with climate change. Thus, temporal changes in community composition are expected to be greatest at high latitudes. However, at the same time traits such as body size can also change with latitude, potentially offsetting or increasing changes to community composition over time. We tested how zooplankton communities (copepods and cladocerans) have changed over a 25–75 year time span by assessing colonization and extinction rates from lakes across an 1800 km latitudinal gradient, and further tested whether species traits predict rates of community change over time. Lake‐level dissimilarity, measured with Sorenson distance, decreased at higher latitudes. This decrease was due to higher colonization rates of cladocerans in lower latitude lakes and consistent extinction rates across the latitudinal gradient. At the species level, colonization increased with regional occupancy, and tended to be higher for smaller bodied, locally abundant, species. Local extinction rates were negatively correlated with local abundance and regional occupancy, but were not influenced by body size. None of these species‐specific characteristics changed predictably with latitude. Contrary to our expectations, low‐latitude zooplankton communities changed more rapidly than high‐latitude communities by becoming more species rich, not by losing species that were historically present. Moreover, colonization and extinction trends suggest that lakes have become increasingly dominated by species with smaller body sizes and that are already common locally and regionally. Together, these findings indicate that rates of species turnover in freshwater lakes across a latitudinal gradient are not predicted by rates of temperature change, but that turnover is nonetheless resulting in trait‐shifts that favour small, generalist species.     

Light at Night Co‐distributes with Incident Breast but not Lung Cancer in the Female Population of Israel

Recent studies of shift‐working women have reported that excessive exposure to light at night (LAN) may be a risk factor for breast cancer. However, no studies have yet attempted to examine the co‐distribution of LAN and breast cancer incidence on a population level with the goal to assess the coherence of these earlier findings with population trends. Coherence is one of Hill's “criteria” (actually, viewpoints) for an inference of causality. Nighttime satellite images were used to estimate LAN levels in 147 communities in Israel. Multiple regression analysis was performed to investigate the association between LAN and breast cancer incidence rates and, as a test of the specificity of our method, lung cancer incidence rates in women across localities under the prediction of a link with breast cancer but not lung cancer. After adjusting for several variables available on a population level, such as ethnic makeup, birth rate, population density, and local income level, a strong positive association between LAN intensity and breast cancer rate was revealed (p<0.05), and this association strengthened (p<0.01) when only statistically significant factors were filtered out by stepwise regression analysis. Concurrently, no association was found between LAN intensity and lung cancer rate. These results provide coherence of the previously reported case‐control and cohort studies with the co‐distribution of LAN and breast cancer on a population basis. The analysis yielded an estimated 73% higher breast cancer incidence in the highest LAN exposed communities compared to the lowest LAN exposed communities.     

Biomarker-based HIV incidence in a community sample of men who have sex with men in Paris, France

BACKGROUND: Population-based estimates of HIV incidence in France have revealed that men who have sex with men (MSM) are the most affected population and contribute to nearly half of new infections each year. We sought to estimate HIV incidence among sexually active MSM in Paris gay community social venues. METHODOLOGY/ PRINCIPAL FINDINGS: A cross-sectional survey was conducted in 2009 in a sample of commercial venues such as bars, saunas and backrooms. We collected a behavioural questionnaire and blood sample. Specimens were tested for HIV infection and positive specimens then tested for recent infection by the enzyme immunoassay for recent HIV-1 infection (EIA-RI). We assessed the presence of antiretroviral therapy among infected individuals to rule out treated patients in the algorithm that determined recent infection. Biomarker-based cross-sectional incidence estimates were calculated. We enrolled 886 MSM participants among which 157 (18%) tested HIV positive. In positive individuals who knew they were infected, 75% of EIA-RI positive results were due to ART. Of 157 HIV positive specimens, 15 were deemed to be recently infected. The overall HIV incidence was estimated at 3.8% person-years (py) [95%CI: 1.5-6.2]. Although differences were not significant, incidence was estimated to be 3.5% py [0.1-6.1] in men having had a negative HIV test in previous year and 4.8% py [0.1-10.6] in men having had their last HIV test more than one year before the survey, or never tested. Incidence was estimated at 4.1% py [0-8.3] in men under 35 years and 2.5% py [0-5.4] in older men. CONCLUSIONS/ SIGNIFICANCE: This is the first community-based survey to estimate HIV incidence among MSM in France. It includes ART detection and reveals a high level of HIV transmission in sexually active individuals, despite a high uptake of HIV testing. These data call for effective prevention programs targeting MSM engaged in high-risk behaviours.     

A General HIV Incidence Inference Scheme Based on Likelihood of Individual Level Data and a Population Renewal Equation

We derive a new method to estimate the age specific incidence of an infection with a differential mortality, using individual level infection status data from successive surveys. The method consists of a) an SI-type model to express the incidence rate in terms of the prevalence and its derivatives as well as the difference in mortality rate, and b) a maximum likelihood approach to estimate the prevalence and its derivatives. Estimates can in principle be obtained for any chosen age and time, and no particular assumptions are made about the epidemiological or demographic context. This is in contrast with earlier methods for estimating incidence from prevalence data, which work with aggregated data, and the aggregated effect of demographic and epidemiological rates over the time interval between prevalence surveys. Numerical simulation of HIV epidemics, under the presumption of known excess mortality due to infection, shows improved control of bias and variance, compared to previous methods. Our analysis motivates for a) effort to be applied to obtain accurate estimates of excess mortality rates as a function of age and time among HIV infected individuals and b) use of individual level rather than aggregated data in order to estimate HIV incidence rates at times between two prevalence surveys.     

The assembly of tropical tree communities – the advances and shortcomings of phylogenetic and functional trait analyses

Tropical tree communities present one of the most challenging systems for studying the processes underlying community assembly. Most community assembly hypotheses consider the relative importance of the ecological similarity of co‐occurring species. Quantifying this similarity is a daunting and potentially impossible task in species‐rich assemblages. During the past decade tropical tree ecologists have increasingly utilized phylogenetic trees and functional traits to estimate the ecological similarity of species in order to test mechanistic community assembly hypotheses. A large amount of work has resulted with many important advances having been made along the way. That said, there are still many outstanding challenges facing those utilizing phylogenetic and functional trait approaches to study community assembly. Here I review the conceptual background, major advances and major remaining challenges in phylogenetic‐ and trait‐based approaches to community ecology with a specific focus on tropical trees. I argue that both approaches tremendously improve our understanding of tropical tree community ecology, but neither approach has fully reached its potential thus far.     

The Role of Viral Introductions in Sustaining Community-Based HIV Epidemics in Rural Uganda: Evidence from Spatial Clustering,Phylogenetics, and Egocentric Transmission Models

Background

It is often assumed that local sexual networks play a dominant role in HIV spread in sub-Saharan Africa. The aim of this study was to determine the extent to which continued HIV transmission in rural communities—home to two-thirds of the African population—is driven by intra-community sexual networks versus viral introductions from outside of communities.

Methods and Findings

We analyzed the spatial dynamics of HIV transmission in rural Rakai District, Uganda, using data from a cohort of 14,594 individuals within 46 communities. We applied spatial clustering statistics, viral phylogenetics, and probabilistic transmission models to quantify the relative contribution of viral introductions into communities versus community- and household-based transmission to HIV incidence. Individuals living in households with HIV-incident (n = 189) or HIV-prevalent (n = 1,597) persons were 3.2 (95% CI: 2.7–3.7) times more likely to be HIV infected themselves compared to the population in general, but spatial clustering outside of households was relatively weak and was confined to distances <500 m. Phylogenetic analyses of gag and env genes suggest that chains of transmission frequently cross community boundaries. A total of 95 phylogenetic clusters were identified, of which 44% (42/95) were two individuals sharing a household. Among the remaining clusters, 72% (38/53) crossed community boundaries. Using the locations of self-reported sexual partners, we estimate that 39% (95% CI: 34%–42%) of new viral transmissions occur within stable household partnerships, and that among those infected by extra-household sexual partners, 62% (95% CI: 55%–70%) are infected by sexual partners from outside their community. These results rely on the representativeness of the sample and the quality of self-reported partnership data and may not reflect HIV transmission patterns outside of Rakai.

Conclusions

Our findings suggest that HIV introductions into communities are common and account for a significant proportion of new HIV infections acquired outside of households in rural Uganda, though the extent to which this is true elsewhere in Africa remains unknown. Our results also suggest that HIV prevention efforts should be implemented at spatial scales broader than the community and should target key populations likely responsible for introductions into communities. Please see later in the article for the Editors'' Summary     

Beyond Race and Place: Distal Sociological Determinants of HIV Disparities

Informed behavior change as an HIV prevention tool has yielded unequal successes across populations. Despite decades of HIV education, some individuals remain at high risk. The mainstream media often portrays these risk factors as products of race and national borders; however, a rich body of recent literature proposes a host of complex social factors that influence behavior, including, but not limited to: poverty, income inequality, stigmatizing social institutions and health care access. We examined the relationship between numerous social indicators and HIV incidence across eighty large U.S. cities in 1990 and 2000. During this time, major correlating factors included income inequality, poverty, educational attainment, residential segregation and marriage rates. However, these ecological factors were weighted differentially across risk groups (e.g. heterosexual, intravenous drug use, men who have sex with men (MSM)). Heterosexual risk rose significantly with poor economic indicators, while MSM risk depended more heavily on anti-homosexual stigma (as measured by same-sex marriage laws). HIV incidence among black individuals correlated significantly with numerous economic factors but also with segregation and imbalances in the male:female ratio (often an effect of mass incarceration). Our results support an overall model of HIV ecology where poverty, income inequality and social inequality (in the form of institutionalized racism and anti-homosexual stigma) have over time developed into synergistic drivers of disease transmission in the U.S., inhibiting information-based prevention efforts. The relative weights of these distal factors vary over time and by HIV risk group. Our testable model may be more generally applicable within the U.S. and beyond.     

The influence of habitat heterogeneity on freshwater bacterial community composition and dynamics

Multiple forces structure natural microbial communities, but the relative roles and interactions of these drivers are poorly understood. Gradients of physical and chemical parameters can be especially influential. In traditional ecological theory, variability in environmental conditions across space and time represents habitat heterogeneity, which may shape communities. Here we used aquatic microbial communities as a model to investigate the relationship between habitat heterogeneity and community composition and dynamics. We defined spatial habitat heterogeneity as vertical temperature and dissolved oxygen (DO) gradients in the water column, and temporal habitat heterogeneity as variation throughout the open-water season in these environmental parameters. Seasonal lake mixing events contribute to temporal habitat heterogeneity by destroying and re-creating these gradients. Because of this, we selected three lakes along a range of annual mixing frequency (polymictic, dimictic, meromictic) for our study. We found that bacterial community composition (BCC) was distinct between the epilimnion and hypolimnion within stratified lakes, and also more variable within the epilimnia through time. We found stark differences in patterns of epilimnion and hypolimnion dynamics over time and across lakes, suggesting that specific drivers have distinct relative importance for each community.     

Rising Levels of HIV Infection in Older Adults in Eastern Zimbabwe

BackgroundWith the scale-up of antiretroviral treatment across Africa, many people are living longer with HIV. Understanding the ageing of the HIV cohort and sexual behaviour among older adults are important for appropriately responding to the changing demographics of people living with HIV.MethodsWe used data from a large population-based open cohort in eastern Zimbabwe to examine HIV prevalence trends and incidence among those aged 45 years and older. Five survey rounds have been completed between 1998 and 2011. Incidence was analysed using midpoint between last negative and first positive HIV test.ResultsAcross the survey rounds, 13,071 individuals were followed for 57,676 person years. While HIV prevalence among people aged 15–44 has fallen across the five rounds, HIV prevalence among those aged 45–54 has increased since the 2006–08 survey round. In the 2009–11 round, HIV prevalence among men aged 45–54 was 23.4% compared to 11.0% among those aged 15–44. HIV positive people aged 45–54 now represent more than 20% of all those living with HIV in Manicaland. Among those aged 45 years and older, there were 85 seroconversions in 11,999 person years for an HIV incidence of 0.708 per 100 person years. Analysis of cohort data and assessment of behavioural risk factors for HIV infection among older people shows significantly lower levels of condom use among older adults and a number of seroconversions past the age of 50.ConclusionsThe cohort of people living with HIV is ageing in Zimbabwe and the behaviour of older adults puts them at risk of HIV infection. Older adults must be included in both HIV prevention and treatment programs.     

Impact of High-Risk Sex and Focused Interventions in Heterosexual HIV Epidemics: A Systematic Review of Mathematical Models

Background

The core-group theory of sexually transmitted infections suggests that targeting prevention to high-risk groups (HRG) could be very effective. We aimed to quantify the contribution of heterosexual HRGs and the potential impact of focused interventions to HIV transmission in the wider community.

Methods

We systematically identified studies published between 1980 and 2011. Studies were included if they used dynamical models of heterosexual HIV transmission, incorporated behavioural heterogeneity in risk, and provided at least one of the following primary estimates in the wider community (a) the population attributable fraction (PAF) of HIV infections due to HRGs, or (b) the number per capita or fraction of HIV infections averted, or change in HIV prevalence/incidence due to focused interventions.

Findings

Of 267 selected articles, 22 were included. Four studies measured the PAF, and 20 studies measured intervention impact across 265 scenarios. In low-prevalence epidemics (≤5% HIV prevalence), the estimated impact of sex-worker interventions in the absence of risk compensation included: 6–100% infections averted; 0.9–6.2 HIV infections averted per 100,000 adults; 11–94% and 4–47% relative reduction in prevalence and incidence respectively. In high-prevalence epidemics (>5% HIV prevalence), sex-worker interventions were estimated to avert 6.8–40% of HIV infections and up to 564 HIV infections per 100,000 adults, and reduce HIV prevalence and incidence by 13–27% and 2–14% respectively. In both types of epidemics, greater heterogeneity in HIV risk was associated with a larger impact on the fraction of HIV infections averted and relative reduction in HIV incidence.

Conclusion

Focused interventions, as estimated by mathematical models, have the potential to reduce HIV transmission in the wider community across low- and high-prevalence regions. However, considerable variability exists in estimated impact, suggesting that a targeted approach to HIV prevention should be tailored to local epidemiological context.     

Lifetime weight patterns in male physicians: the effects of cohort and selective survival

Objective: The natural history of lifetime weight change is not well understood because of conflicting evidence from cross‐sectional and longitudinal studies. Cross‐sectional analyses find that adult weight is highest at ～60 years of age and lower thereafter. Longitudinal analyses have not found this pattern. Our objective was to test whether cohort effects and selective survival may explain the differences observed between cross‐sectional and longitudinal studies. Research Methods and Procedures: We analyzed data on white men from the Johns Hopkins Precursors Study (n = 1197). Weight and height were measured at enrollment during medical school. The Precursors Study collected subsequent weight measurements by self‐report and follows all participants for mortality. Results: In preliminary analyses that ignored cohort and survival effects, average weight increased 0.16 kg/yr to age 65 (p < 0.001) and declined 0.10 kg/yr thereafter (p = 0.002). When controlling for differing rates of weight change by cohort and survival group, the apparent decline after 65 years of age was mostly explained. Discussion: These data suggest that, in white men, weight increases steadily until age 65 and then plateaus. These findings emphasize the necessity of longitudinal rather than cross‐sectional data to describe lifetime weight patterns.     

Testing independence between two sequential gap times in the presence of covariates

In the risk analysis of sequential events, the successive gap times are often correlated, e.g. as a result of an individual heterogeneity. Correlation is usually accounted for by using a shared gamma‐frailty model, where the variance φ of the random individual effect quantifies the correlation between gap times. This method is known to yield satisfactory estimates of covariate effects, but underestimates φ, which could result in a lack of power of the test of independence. We propose a new test of independence between two sequential gap times where the first is the time elapsed from the origin. The test is based on an approximation of the hazard of the second event given the first gap time in a frailty model, with a frailty distribution belonging to the power variance function family. Simulation results show an increased power of the new test compared with the test derived from the gamma‐frailty model. In the realistic case where hazards are event specific, and using event‐specific approaches, the proposed estimation of the variance of the frailty is less biased than the gamma‐frailty based estimation for a wide range of values ( with the set of parameters considered), and similar for higher values. As an illustration, the methods are applied to a previously analysed asthma prevention trial with results showing a significant positive association between the successive times to asthmatic events. We also analyse data from a cohort of HIV‐seropositive patients in order to assess the effect of risk factors on the occurrence of two successive markers of progression of the HIV disease. The results demonstrate the ability of the proposed model to account for negative correlations between gap times.     

A measure for spatial heterogeneity of a grassland vegetation based on the beta‐binomial distribution

Abstract. A method is proposed to estimate the frequency and the spatial heterogeneity of occurrence of individual plant species composing the community of a grassland or a plant community with a short height. The measure is based on the beta‐binomial distribution. The weighted average heterogeneity of all the species composing a community provides a measure of community‐level heterogeneity determining the spatial intricateness of community composition of existing species. As an example to illustrate the method, a sown grassland with grazing cows was analysed, on 102 quadrats of 50 cm × 50 cm, each of which divided into four small quadrats of 25 cm × 25 cm. The frequency of occurrence for all the species was recorded in each small quadrat. Good fits to the beta‐binomial series for most species of the community were obtained. These results indicate that (1) each species is distributed heterogeneously with respective spatial patterns, (2) the degree of heterogeneity is different from species to species, and (3) the beta‐binomial distribution can be applied for grassland communities. In most of the observed species spatial heterogeneity is often characterized by species‐specific propagating traits: seed‐propagating plant species exhibited a low heterogeneity/random pattern while clonal species exhibited a high heterogeneity/aggregated pattern. This measure can be applied to field surveys and to the estimation of community parameters for grassland diagnosis.     

Development of Methods for Cross-Sectional HIV Incidence Estimation in a Large,Community Randomized Trial

Background

Accurate methods of HIV incidence determination are critically needed to monitor the epidemic and determine the population level impact of prevention trials. One such trial, Project Accept, a Phase III, community-randomized trial, evaluated the impact of enhanced, community-based voluntary counseling and testing on population-level HIV incidence. The primary endpoint of the trial was based on a single, cross-sectional, post-intervention HIV incidence assessment.

Methods and Findings

Test performance of HIV incidence determination was evaluated for 403 multi-assay algorithms [MAAs] that included the BED capture immunoassay [BED-CEIA] alone, an avidity assay alone, and combinations of these assays at different cutoff values with and without CD4 and viral load testing on samples from seven African cohorts (5,325 samples from 3,436 individuals with known duration of HIV infection [1 month to >10 years]). The mean window period (average time individuals appear positive for a given algorithm) and performance in estimating an incidence estimate (in terms of bias and variance) of these MAAs were evaluated in three simulated epidemic scenarios (stable, emerging and waning). The power of different test methods to detect a 35% reduction in incidence in the matched communities of Project Accept was also assessed. A MAA was identified that included BED-CEIA, the avidity assay, CD4 cell count, and viral load that had a window period of 259 days, accurately estimated HIV incidence in all three epidemic settings and provided sufficient power to detect an intervention effect in Project Accept.

Conclusions

In a Southern African setting, HIV incidence estimates and intervention effects can be accurately estimated from cross-sectional surveys using a MAA. The improved accuracy in cross-sectional incidence testing that a MAA provides is a powerful tool for HIV surveillance and program evaluation.