1
|
Azuri E, Wax M, Gozlan Y, Wagner T, Mor O. Recent HIV-1 infection in Israel 2017-2021: Evaluation of geenius and HIV-1/2 combo assays for identifying recent infection detected by Sedia assay and assessment of factors related to recent infection: Recent HIV-1 infection in Israel. J Clin Virol 2024; 170:105624. [PMID: 38118239 DOI: 10.1016/j.jcv.2023.105624] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2023] [Revised: 11/20/2023] [Accepted: 11/27/2023] [Indexed: 12/22/2023]
Abstract
BACKGROUND Estimating HIV-1 recency of infection for incidence and local outbreaks detection usually involves specifically designed assays. Here, we established an approach to identify recent infections, estimate their rate, and assess potential risk factors. METHODS Randomly selected HIV-1 positive samples (n = 382) collected in 2017-2021 were tested by Sedia and compared to the results of Geenius recency algorithm and the S/CO values of the HIV-1/2 Combo assay. Using Geenius and Combo recency verdict, we assessed all cases diagnosed in 2017-2021. Related factors were further assessed. RESULTS While Geenius and Combo had a sensitivity of 65.9 % and 89.30 %, respectively, and specificity of 96 % and 90 %, respectively, compared to Sedia, higher concordance (97.2 %) and kappa (>0.9) were observed when the verdict of both assays together was compared to Sedia. Using this approach, 15.3 % (238/1548) of individuals diagnosed in 2017-2021 were defined as recently infected. In multivariate analysis, recent diagnosis was mainly associated with men who have sex with men (MSM) and with birthplace in Israel, Western/Central Europe, or North America. CONCLUSIONS Only 15.3 % of infections in 2017-2021, mainly in MSM and Israeli/Western countries-born individuals, were diagnosed early. Regular diagnostic assays have a potential to identify and monitor trends in recent infections.
Collapse
Affiliation(s)
- Eyal Azuri
- Faculty of Medicine, Tel-Aviv University, Israel
| | - Marina Wax
- National HIV and Viral Hepatitis Reference Laboratory, Chaim Sheba Medical Center, Ministry of Health, Ramat Gan, Israel
| | - Yael Gozlan
- National HIV and Viral Hepatitis Reference Laboratory, Chaim Sheba Medical Center, Ministry of Health, Ramat Gan, Israel
| | - Tali Wagner
- Faculty of Medicine, Tel-Aviv University, Israel
| | - Orna Mor
- Faculty of Medicine, Tel-Aviv University, Israel; National HIV and Viral Hepatitis Reference Laboratory, Chaim Sheba Medical Center, Ministry of Health, Ramat Gan, Israel.
| |
Collapse
|
2
|
Di Germanio C, Yufenyuy EL, Hampton DC, Thorbrogger C, Parekh BS, Norris PJ. A Stable Dried Tube Specimen for Quality Assurance and Training Programs for HIV Rapid Test for Recent Infection. Microbiol Spectr 2023; 11:e0339822. [PMID: 36648237 PMCID: PMC9927143 DOI: 10.1128/spectrum.03398-22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2022] [Accepted: 12/19/2022] [Indexed: 01/18/2023] Open
Abstract
The HIV epidemic is still one of the world's most serious public health challenges, affecting about 38 million people worldwide, especially in sub-Saharan African and Southeast Asian countries. In recent years, tests have been developed to discriminate recent from long-term infection in HIV-infected populations, and these tools can help identify new outbreaks and networks of transmission and target prevention and treatment plans. New rapid tests for recent infection are being deployed in point-of-care settings; however, quality assurance programs need to be implemented to ensure consistency and reliability of the results. We have developed a dried tube specimen (DTS) stabilized with disaccharide trehalose as a quality control reagent for rapid recency testing that can be stored unrefrigerated prior to reconstitution at temperatures up to 37°C for up to 12 weeks. Analysis of 10 trehalose-stabilized DTSs showed that they maintained the same recency classification in all of the samples stored at 4°C and 37°C up to 12 weeks and at 56°C for 2 weeks, while the DTSs prepared without trehalose changed their classification from long-term to recent or recent to negative after storage at 37°C for 12 weeks. Development of DTS quality control reagents will facilitate proficiency and training programs, particularly in settings without cold chain capability in field environments. IMPORTANCE Implementation of stabilized dried tube specimens (DTSs) for quality control and training would facilitate HIV recency programs, especially in point-of-care settings without cold chain availability. This study shows that addition of the disaccharide trehalose to DTSs prior to drying the samples increased stability of the samples across a range of temperatures. This finding provides an affordable way to increase the availability of these key reagents for quality control in resource-constrained settings.
Collapse
Affiliation(s)
- Clara Di Germanio
- Vitalant Research Institute, San Francisco, California, USA
- Department of Laboratory Medicine, University of California, San Francisco, San Francisco, California, USA
| | - Ernest L. Yufenyuy
- Division of Global HIV and TB, Center for Global Health, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | | | | | - Bharat S. Parekh
- Division of Global HIV and TB, Center for Global Health, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Philip J. Norris
- Vitalant Research Institute, San Francisco, California, USA
- Department of Laboratory Medicine, University of California, San Francisco, San Francisco, California, USA
| |
Collapse
|
3
|
Parkin N, Gao F, Grebe E, Cutrell A, Das M, Donnell D, Duerr A, Glidden DV, Hughes JP, Murray J, Robertson MN, Zinserling J, Lau J, Miller V. Facilitating Next-Generation Pre-Exposure Prophylaxis Clinical Trials Using HIV Recent Infection Assays: A Consensus Statement from the Forum HIV Prevention Trial Design Project. Clin Pharmacol Ther 2022. [PMID: 36550769 DOI: 10.1002/cpt.2830] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2022] [Accepted: 12/08/2022] [Indexed: 12/24/2022]
Abstract
Standard-of-care HIV pre-exposure prophylaxis (PrEP) is highly efficacious, but uptake of and persistence on a daily oral pill is low in many settings. Evaluation of alternate PrEP products will require innovation to avoid the unpractically large sample sizes in noninferiority trials. We propose estimating HIV incidence in people not on PrEP as an external counterfactual to which on-PrEP incidence in trial subjects can be compared. HIV recent infection testing algorithms (RITAs), such as the limiting antigen avidity assay plus viral load used on specimens from untreated HIV positive people identified during screening, is one possible approach. Its feasibility is partly dependent on the sample size needed to ensure adequate power, which is impacted by RITA performance, the number of recent infections identified, the expected efficacy of the intervention, and other factors. Screening sample sizes to support detection of an 80% reduction in incidence for 3 key populations are more modest, and comparable to the number of participants in recent phase III PrEP trials. Sample sizes would be significantly larger in populations with lower incidence, where the false recency rate is higher or if PrEP efficacy is expected to be lower. Our proposed counterfactual approach appears to be feasible, offers high statistical power, and is nearly contemporaneous with the on-PrEP population. It will be important to monitor the performance of this approach during new product development for HIV prevention. If successful, it could be a model for preventive HIV vaccines and prevention of other infectious diseases.
Collapse
Affiliation(s)
- Neil Parkin
- Data First Consulting, Sebastopol, California, USA
| | - Fei Gao
- Fred Hutchinson Cancer Research Center, Seattle, Washington, USA
| | - Eduard Grebe
- Vitalant Research Institute, San Francisco, California, USA.,Edward Grebe Consulting, Cape Town, South Africa
| | - Amy Cutrell
- ViiV Healthcare, Research Triangle Park, North Carolina, USA
| | - Moupali Das
- Gilead Sciences, Foster City, California, USA
| | - Deborah Donnell
- Fred Hutchinson Cancer Research Center, Seattle, Washington, USA
| | - Ann Duerr
- Fred Hutchinson Cancer Research Center, Seattle, Washington, USA
| | | | | | | | | | - Joerg Zinserling
- Federal Institute for Drugs and Medical Devices (Bundesinstitut für Arzneimittel und Medizinprodukte, BfArM), Bonn, Germany
| | - Joseph Lau
- Forum for Collaborative Research, Washington, DC, USA
| | | | | |
Collapse
|
4
|
Kin-On Lau J, Murdock N, Murray J, Justman J, Parkin N, Miller V. A systematic review of limiting antigen avidity enzyme immunoassay for detection of recent HIV-1 infection to expand supported applications. J Virus Erad 2022; 8:100085. [PMID: 36124229 PMCID: PMC9482108 DOI: 10.1016/j.jve.2022.100085] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2022] [Accepted: 09/01/2022] [Indexed: 11/18/2022] Open
Abstract
Introduction The need for detection of new and recent HIV infections is essential for surveillance and assessing interventions in controlling the epidemic. HIV recency assays are one way of providing reliable incidence estimates by determining recent versus non-recent infection. The objective of this study was to review the current body of knowledge of the limiting antigen avidity enzyme immunoassay to expand supported applications through an assessment of what is known and the gaps. Methods A search for peer-reviewed literature in PubMed, Embase, and Web of Science Core Collection was conducted using the search term “human immunodeficiency virus and avidity”. Non-peer reviewed published reports from the Population-based HIV Impact Assessment Project were also included. These were limited to literature published in English between January 2010 and August 2021. Results This search resulted in 2080 publications and 14 reports, with 137 peer-reviewed studies and 14 non-peer reviewed reports that met the inclusion criteria, yielding a total of 151 studies for the final review. There were similar findings among studies that compared the performances of assay manufacturers and sample types. Studies that evaluated various assay algorithms and thresholds were heterogeneous, illustrating the need for context-specific test characteristics for classifying recent infections. Most studies estimated subtype-specific test characteristics for HIV subtypes A, B, C, and D. This was further illustrated when looking only at studies that compared HIV incidence estimates from recency assay algorithms and longitudinal cohorts. Conclusions These findings suggest that the current body of knowledge provides important information that contributes towards distinguishing recent and non-recent infection and incidence estimation. However, there are knowledge gaps with respect to factors that influence the test characteristics (e.g., HIV-1 subtype, population characteristics, assay algorithms and thresholds). Further studies are needed to estimate and establish context-specific test characteristics that consider these influencing factors to improve and expand the use of this assay for detection of recent HIV infection.
Collapse
Affiliation(s)
- Joseph Kin-On Lau
- Forum for Collaborative Research, 1608 Rhode Island Avenue NW, Suite 212, Washington, DC, 20036, USA
| | - Nicholas Murdock
- Forum for Collaborative Research, 1608 Rhode Island Avenue NW, Suite 212, Washington, DC, 20036, USA
| | - Jeffrey Murray
- Forum for Collaborative Research, 1608 Rhode Island Avenue NW, Suite 212, Washington, DC, 20036, USA
| | - Jessica Justman
- ICAP Columbia University Mailman School of Public Health, 722 West 168 Street, New York, NY, 10032, USA
| | - Neil Parkin
- Data First Consulting, Inc, Sebastopol, CA, USA
| | - Veronica Miller
- Forum for Collaborative Research, 1608 Rhode Island Avenue NW, Suite 212, Washington, DC, 20036, USA
- Corresponding author.
| |
Collapse
|
5
|
Facente SN, Grebe E, Maher AD, Fox D, Scheer S, Mahy M, Dalal S, Lowrance D, Marsh K. Use of HIV Recency Assays for HIV Incidence Estimation and Other Surveillance Use Cases: Systematic Review. JMIR Public Health Surveill 2022; 8:e34410. [PMID: 35275085 PMCID: PMC8956992 DOI: 10.2196/34410] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2021] [Revised: 01/16/2022] [Accepted: 02/02/2022] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND HIV assays designed to detect recent infection, also known as "recency assays," are often used to estimate HIV incidence in a specific country, region, or subpopulation, alone or as part of recent infection testing algorithms (RITAs). Recently, many countries and organizations have become interested in using recency assays within case surveillance systems and routine HIV testing services to measure other indicators beyond incidence, generally referred to as "non-incidence surveillance use cases." OBJECTIVE This review aims to identify published evidence that can be used to validate methodological approaches to recency-based incidence estimation and non-incidence use cases. The evidence identified through this review will be used in the forthcoming technical guidance by the World Health Organization (WHO) and United Nations Programme on HIV/AIDS (UNAIDS) on the use of HIV recency assays for identification of epidemic trends, whether for HIV incidence estimation or non-incidence indicators of recency. METHODS To identify the best methodological and field implementation practices for the use of recency assays to estimate HIV incidence and trends in recent infections for specific populations or geographic areas, we conducted a systematic review of the literature to (1) understand the use of recency testing for surveillance in programmatic and laboratory settings, (2) review methodologies for implementing recency testing for both incidence estimation and non-incidence use cases, and (3) assess the field performance characteristics of commercially available recency assays. RESULTS Among the 167 documents included in the final review, 91 (54.5%) focused on assay or algorithm performance or methodological descriptions, with high-quality evidence of accurate age- and sex-disaggregated HIV incidence estimation at national or regional levels in general population settings, but not at finer geographic levels for prevention prioritization. The remaining 76 (45.5%) described the field use of incidence assays including field-derived incidence (n=45), non-incidence (n=25), and both incidence and non-incidence use cases (n=6). The field use of incidence assays included integrating RITAs into routine surveillance and assisting with molecular genetic analyses, but evidence was generally weaker or only reported on what was done, without validation data or findings related to effectiveness of using non-incidence indicators calculated through the use of recency assays as a proxy for HIV incidence. CONCLUSIONS HIV recency assays have been widely validated for estimating HIV incidence in age- and sex-specific populations at national and subnational regional levels; however, there is a lack of evidence validating the accuracy and effectiveness of using recency assays to identify epidemic trends in non-incidence surveillance use cases. More research is needed to validate the use of recency assays within HIV testing services, to ensure findings can be accurately interpreted to guide prioritization of public health programming.
Collapse
Affiliation(s)
- Shelley N Facente
- Department of Laboratory Medicine, University of California San Francisco, San Francisco, CA, United States.,Facente Consulting, Richmond, CA, United States.,Vitalant Research Institute, San Francisco, CA, United States
| | - Eduard Grebe
- Department of Laboratory Medicine, University of California San Francisco, San Francisco, CA, United States.,Vitalant Research Institute, San Francisco, CA, United States.,South African Centre for Epidemiological Modeling and Analysis (SACEMA), Stellenbosch University, Stellenbosch, South Africa
| | - Andrew D Maher
- South African Centre for Epidemiological Modeling and Analysis (SACEMA), Stellenbosch University, Stellenbosch, South Africa.,Institute for Global Health Sciences, University of California San Francisco, San Francisco, CA, United States
| | - Douglas Fox
- Facente Consulting, Richmond, CA, United States
| | | | - Mary Mahy
- Strategic Information Department, The Joint United Nations Programme on HIV/AIDS (UNAIDS), Geneva, Switzerland
| | - Shona Dalal
- Global HIV, Hepatitis and Sexually Transmitted Infections Programmes, World Health Organisation, Geneva, Switzerland
| | - David Lowrance
- Global HIV, Hepatitis and Sexually Transmitted Infections Programmes, World Health Organisation, Geneva, Switzerland
| | - Kimberly Marsh
- Strategic Information Department, The Joint United Nations Programme on HIV/AIDS (UNAIDS), Geneva, Switzerland
| |
Collapse
|
6
|
Klock E, Wilson E, Fernandez RE, Piwowar-Manning E, Moore A, Kosloff B, Bwalya J, Bell-Mandla N, James A, Ayles H, Bock P, Donnell D, Fidler S, Hayes R, Eshleman SH, Laeyendecker O. Validation of population-level HIV-1 incidence estimation by cross-sectional incidence assays in the HPTN 071 (PopART) trial. J Int AIDS Soc 2021; 24:e25830. [PMID: 34897992 PMCID: PMC8666582 DOI: 10.1002/jia2.25830] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2021] [Accepted: 09/10/2021] [Indexed: 11/10/2022] Open
Abstract
Introduction Cross‐sectional incidence testing is used to estimate population‐level HIV incidence and measure the impact of prevention interventions. There are limited data evaluating the accuracy of estimates in settings where antiretroviral therapy coverage and levels of viral suppression are high. Understanding cross‐sectional incidence estimates in these settings is important as viral suppression can lead to false recent test results. We compared the accuracy of multi‐assay algorithms (MAA) for incidence estimation to that observed in the community‐randomized HPTN 071 (PopART) trial, where the majority of participants with HIV infection were virally suppressed. Methods HIV incidence was assessed during the second year of the study, and included only individuals who were tested for HIV at visits 1 and 2 years after the start of the study (2016–2017). Incidence estimates from three MAAs were compared to the observed incidence between years 1 and 2 (MAA‐C: LAg‐Avidity <2.8 ODn + BioRad Avidity Index <95% + VL >400 copies/ml; LAg+VL MAA: LAg‐Avidity <1.5 ODn + VL >1000 copies/ml; Rapid+VL MAA: Asanté recent rapid result + VL >1000 copies/ml). The mean duration of recent infection (MDRI) used for the three MAAs was 248, 130 and 180 days, respectively. Results and discussion The study consisted of: 15,845 HIV‐negative individuals; 4406 HIV positive at both visits; and 221 who seroconverted between visits. Viral load (VL) data were available for all HIV‐positive participants at the 2‐year visit. Sixty four (29%) of the seroconverters and 3227 (72%) prevelant positive participants were virally supressed (<400 copies/ml). Observed HIV incidence was 1.34% (95% CI: 1.17–1.53). Estimates of incidence were similar to observed incidence for MAA‐C, 1.26% (95% CI: 1.02–1.51) and the LAg+VL MAA, 1.29 (95% CI: 0.97–1.62). Incidence estimated by the Rapid+VL MAA was significantly lower than observed incidence (0.92%, 95% CI: 0.69–1.15, p<0.01). Conclusions MAA‐C and the LAg+VL MAA provided accurate point estimates of incidence in this cohort with high levels of viral suppression. The Rapid+VL significantly underestimated incidence, suggesting that the MDRI recommended by the manufacturer is too long or the assay is not accurately detecting enough recent infections.
Collapse
Affiliation(s)
- Ethan Klock
- Division of Infectious Diseases, Department of Medicine, School of Medicine, Johns Hopkins University, Baltimore, Maryland, USA
| | - Ethan Wilson
- Fred Hutchinson Cancer Research Center, Seattle, Washington, USA
| | - Reinaldo E Fernandez
- Division of Infectious Diseases, Department of Medicine, School of Medicine, Johns Hopkins University, Baltimore, Maryland, USA
| | - Estelle Piwowar-Manning
- Division of Infectious Diseases, Department of Medicine, School of Medicine, Johns Hopkins University, Baltimore, Maryland, USA
| | | | - Barry Kosloff
- Zambart, Lusaka, Zambia.,Clinical Research Department, London School of Hygiene and Tropical Medicine, London, UK
| | | | - Nomtha Bell-Mandla
- Desmond Tutu Tuberculosis Center, Department of Pediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Anelet James
- Desmond Tutu Tuberculosis Center, Department of Pediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Helen Ayles
- Zambart, Lusaka, Zambia.,Clinical Research Department, London School of Hygiene and Tropical Medicine, London, UK
| | - Peter Bock
- Desmond Tutu Tuberculosis Center, Department of Pediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Deborah Donnell
- Fred Hutchinson Cancer Research Center, Seattle, Washington, USA
| | | | - Richard Hayes
- Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, UK
| | - Susan H Eshleman
- Department of Pathology, School of Medicine, Johns Hopkins University, Baltimore, Maryland, USA
| | - Oliver Laeyendecker
- Division of Infectious Diseases, Department of Medicine, School of Medicine, Johns Hopkins University, Baltimore, Maryland, USA.,National Institute of Allergy and Infectious Diseases, National Institutes of Medicine, Bethesda, Maryland, USA
| | -
- Division of Infectious Diseases, Department of Medicine, School of Medicine, Johns Hopkins University, Baltimore, Maryland, USA
| |
Collapse
|
7
|
de Wit MM, Rice B, Risher K, Welty S, Waruiru W, Magutshwa S, Motoku J, Kwaro D, Ochieng B, Reniers G, Cowan F, Rutherford G, Hargreaves JR, Murphy G. 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. BMC Health Serv Res 2021; 21:596. [PMID: 34158047 PMCID: PMC8220670 DOI: 10.1186/s12913-021-06619-6] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2021] [Accepted: 06/04/2021] [Indexed: 11/10/2022] Open
Abstract
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.
Collapse
Affiliation(s)
| | - Brian Rice
- London School of Hygiene and Tropical Medicine, London, UK
| | - Kathryn Risher
- London School of Hygiene and Tropical Medicine, London, UK
| | - Susie Welty
- University of California, San Francisco, USA
| | | | | | - John Motoku
- Eastern Deanery AIDS Relief Programme, Nairobi, Kenya
| | | | | | | | - Frances Cowan
- Centre for Sexual Health and HIV/AIDS Research, Harare, Zimbabwe
- Liverpool School of Tropical Medicine, Liverpool, UK
| | | | | | - Gary Murphy
- Independent consultant in HIV laboratory diagnostics, London, UK
| |
Collapse
|