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HIV testing services (HTS) among clients 13-14 years old in recent infection surveillance, Malawi 2019-2020

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BACKGROUND: Rapid tests for recent infection (RTRIs) and viral load (VL) testing comprise a recent infection testing algorithm (RITA) to characterize newly diagnosed HIV-1 infections as recent (<12 months) or long-term. RTRI recent with VL>1,000 copies/mL indicates RITA recent. Recent infection surveillance guidance recommends testing clients aged 15+. In Malawi, clients>13 years can access HTS independently and are included in recent infection surveillance. We reviewed Malawi's recent infection data'¯to describe newly HIV diagnosed 13-14 year-olds and their impact on recent HIV surveillance, detection, and response.
METHODS: Recent infection data was pooled from 155 facilities in 11 districts implementing from April 2019-April 2020. Clients reporting ART usage, previous HIV diagnosis, or had a VL<1,000 copies/mL were excluded. Among 13-14 year-olds, we calculated proportions ofRITA recent infections compared to those aged 15+, described their demographics, HTS modality, and previous testing history.
RESULTS: Of 15,032 newly diagnosed clients, 78 (0.5%) were 13-14 year-olds, of which one (1.3%, 95% Wilson Score CI: 0.2%, 6.9%) was RITA recent, accounting for 0.2% of all 519 RITA recent infections. Comparatively, among clients>15 years, 3.5% (518/14,954) were RITA recent. Among 13-14 year-olds, 49 (62.8%) were female, 3 (6.1%) were pregnant, and one (2.0%) was breastfeeding at time of diagnosis. Fifty-eight (74.4%) reported no previous testing history; 20 (25.6%) reported previous negative results, of whom 18 (90.0%) reported their negative result >1 year ago. Fifty-two (66.7%) accessed HTS at voluntary counseling and testing, 12 (15.4%) at outpatient departments, 4 (5.1%) at youth clinics, and 10 (12.8%) via other modalities. Forty-two (53.8%) were diagnosed in rural settings and 49 (62.8%) at primary facilities.
CONCLUSIONS: Results suggest the proportion of clients aged 13-14 with recent HIV infection is unlikely to meaningfully contribute to recent HIV surveillance, detection, and response. Per self-report, clients were unlikely to access HTS prior to diagnosis and were primarily accessing testing and being diagnosed at primary care facilities. Age of sexual debut and testing consent may be considered when deciding to include younger ages in recency surveillance. Younger adolescents with recent infections, particularly those pregnant and breastfeeding, may face additional vulnerabilities and should be linked to psychosocial support.