We compared characteristics of HIV diagnosis and recent HIV infection (i.e., likely acquired within the last year) in Cambodia. We included individuals ≥ 15 years old accessing HIV testing. From August/2020-August/2022, 53,031 people were tested for HIV, 6,868 were newly diagnosed, and 192 were recently infected. We found differences in geographical burden and risk behaviors with diagnosis and recency (e.g., men who have sex with men, transgender women, and entertainment workers had a nearly two-fold increased odds of testing recent compared to being diagnosed with HIV). Recent infection surveillance may provide unique insights into ongoing HIV acquisition to inform programs.

BACKGROUND: Coinciding with the COVID-19 pandemic, global influenza virus circulation decreased, possibly due to widespread community mitigation measures. Cambodia eased some COVID-19 mitigation measures in June and July 2020. On Aug 20th a cluster of respiratory illnesses among residents of a pagoda included persons that had tested positive for influenza A, and none that were positive for SARS-CoV-2. METHODS: On Aug 25, a response team deployed. Persons with influenza-like illness (ILI) were asked questions on demographics, illness, personal prevention measures, and residential arrangements. Respiratory swabs were tested for influenza and SARS-Cov-2 by RT-PCR; viruses were sequenced. Sentinel surveillance data were analyzed to assess recent trends in influenza circulation in the community. RESULTS: Influenza A(H3N2) viruses were identified in sentinel surveillance in Cambodia in July 2020, prior to the reported pagoda outbreak. Among the 362 pagoda residents, 73(20.2%) ILI cases were identified; 40 were tested with 33/40 (82.5%) confirmed positive for influenza A(H3N2). All 40 were negative for SARS-CoV-2. Among 73 residents with ILI, none were vaccinated against influenza, 47 (64%) clustered in 3 of 8 sleeping quarters; 20 (27%) reported often wearing a mask; 27 (36%) reported often washing hands; and 11 (15%) reported practicing social distancing. All viruses clustered within clade 3c2.A1 close to strains circulating in Australia in 2020. CONCLUSIONS: Circulation of influenza viruses began in the community following a relaxing of national COVID-19 mitigation measures, and prior to this outbreak in a pagoda with limited social distancing. Continued surveillance and influenza vaccination remain needed to limit the impact of influenza globally.

INTRODUCTION: Great strides in responding to the HIV epidemic have led to improved access to and uptake of HIV services in Guyana, a lower-middle-income country with a generalized HIV epidemic. Despite efforts to scale up HIV treatment and adopt the test and start strategy, little is known about costs of HIV services across the care cascade. METHODS: We collected cost data from the national laboratory and nine selected treatment facilities in five of the country's ten Regions, and estimated the costs associated with HIV testing and services (HTS) and antiretroviral therapy (ART) from a provider perspective from January 1, 2016 to December 31, 2016. We then used the unit costs to construct four resource allocation scenarios. In the first two scenarios, we calculated how close Guyana would currently be to its 2020 targets if the allocation of funding across programs and regions over 2017-2020 had (a) remained unchanged from latest-reported levels, or (b) been optimally distributed to minimize incidence and deaths. In the next two, we estimated the resources that would have been required to meet the 2020 targets if those resources had been distributed (a) according to latest-reported patterns, or (b) optimally to minimize incidence and deaths. RESULTS: The mean cost per test was US$15 and the mean cost per person tested positive was US$796. The mean annual cost per of maintaining established adult and pediatric patients on ART were US$428 and US$410, respectively. The mean annual cost of maintaining virally suppressed patients was US$648. Cost variation across sites may suggest opportunities for improvements in efficiency, or may reflect variation in facility type and patient volume. There may also be scope for improvements in allocative efficiency; we estimated a 28% reduction in the total resources required to meet Guyana's 2020 targets if funds had been optimally distributed to minimize infections and deaths. CONCLUSIONS: We provide the first estimates of costs along the HIV cascade in the Caribbean and assessed efficiencies using novel context-specific data on the costs associated with diagnostic, treatment, and viral suppression. The findings call for better targeting of services, and efficient service delivery models and resource allocation, while scaling up HIV services to maximize investment impact.

In the Caribbean region, HIV prevalence is high among key population (KP) groups, such as sex workers and men who have sex with men. However, there is a lack of high-quality, population-level data estimating HIV prevalence and population sizes of KPs. The President's Emergency Plan for AIDS Relief has funded and completed five bio-behavioral surveillance (BBS) surveys using respondent-driven sampling methodology to target KP in the English-speaking Caribbean region. We describe the experience of implementing bio-behavioral surveys in the Caribbean region and document the context, processes, successes, and challenges, and make recommendations for future survey implementation. Successes include the provision of estimates of nationally representative HIV data and KP size estimates to improve HIV programming and provision of tools for routinization of BBS. Challenges include small KP sizes, the legal context, and the cost and speed of implementation. Future bio-behavioral surveys should include well-planned formative assessments and stakeholder involvement.

Scientific evidence showing the benefits of early initiation of antiretroviral therapy (ART) prompted World Health organization (WHO) to recommend that all persons diagnosed HIV-positive should commence ART irrespective of CD4 count and disease progression. Based on this recommendation, countries should adopt and implement the HIV "Treat All" policy to achieve the UNAIDS 90-90-90 targets and ultimately reach epidemic control. Attaining this goal along the HIV treatment cascade depends on the laboratory to monitor progress and measure impact. The laboratory plays an important role in HIV diagnosis to attain the first 90 and in viral load (VL) and HIV drug resistance testing to reinforce adherence, improve viral suppression, and measure the third 90. Countries in the Caribbean region have endorsed the WHO HIV "Treat all" recommendation; however, they are faced with diminishing financial resources to support laboratory testing, seen as a rate-limiting factor to achieving this goal. To improve laboratory coverage with fewer resources in the Caribbean there is the need to optimise laboratory operations to ensure the implementation of high quality, less expensive, evidence-based approaches that will result in more efficient and effective service delivery. Suggested practical and innovative approaches to achieve this include: 1) targeted testing within HIV hotspots; 2) strengthening sample referral systems for VL; 3) better laboratory data collection systems; and 4) use of treatment cascade data for programmatic decision making. Furthermore, strengthening quality improvement and procurement systems will minimize diagnostic errors and guarantee a continuum of uninterrupted testing which is critical for routine monitoring of patients to meet the stated goal.

Background: Implementing quality management systems and accrediting laboratories in the Caribbean has been a challenge. Objectives: We report the development of a stepwise process for quality systems improvement in the Caribbean Region. Methods: The Caribbean Laboratory Stakeholders met under a joint Pan American Health Organization/US Centers for Disease Control and Prevention initiative and developed a userfriendly framework called 'Laboratory Quality Management System - Stepwise Improvement Process (LQMS-SIP) Towards Accreditation' to support countries in strengthening laboratory services through a stepwise approach toward fulfilling the ISO 15189: 2012 requirements. Results: This approach consists of a three-tiered framework. Tier 1 represents the minimum requirements corresponding to the mandatory criteria for obtaining a licence from the Ministry of Health of the participating country. The next two tiers are quality improvement milestones that are achieved through the implementation of specific quality management system requirements. Laboratories that meet the requirements of the three tiers will be encouraged to apply for accreditation. The Caribbean Regional Organisation for Standards and Quality hosts the LQMS-SIP Secretariat and will work with countries, including the Ministry of Health and stakeholders, including laboratory staff, to coordinate and implement LQMS-SIP activities. The Caribbean Public Health Agency will coordinate and advocate for the LQMS-SIP implementation. Conclusion: This article presents the Caribbean LQMS-SIP framework and describes how it will be implemented among various countries in the region to achieve quality improvement.

In 2008 HIV rapid testing (HIV RT) was only minimally used in the Caribbean region. Collaboration with countries and international partners since then has resulted in greater availability and use of HIV RT services. Surveys were conducted in 2012 and 2014 among 11 selected Caribbean countries to inform stakeholders of progress made since 2008 and to identify strategies to further improve access and uptake of high-quality HIV RT in community- and facility-based settings in support of the UNAIDS 90-90-90 targets. Key accomplishments during this period include: 1) presence of in-country national HIV RT algorithms; 2) use of the dried tube specimen (DTS) as an external quality assessment (EQA) program; 3) use of standardized logbooks for data collection and monitoring; and, 4) use of oral fluid for HIV RT, particularly for key population surveys. Although progress has been made since 2008 to increase access and improve the quality of HIV RT among countries in the Caribbean some work remains to be done. This includes the development of new policies and implementation of existing ones, task shifting, quality and access to testing, testing strategies, and integration of HIV RT into HIV Testing Services (HTS).

BACKGROUND: Past efforts to improve laboratory quality systems and to achieve accreditation for better patient care in the Caribbean Region have been slow. OBJECTIVE: To describe the impact of the Strengthening of Laboratory Management Toward Accreditation (SLMTA) training programme and mentorship amongst five clinical laboratories in the Caribbean after 18 months. METHOD: Five national reference laboratories from four countries participated in the SLMTA programme that incorporated classroom teaching and implementation of improvement projects. Mentors were assigned to the laboratories to guide trainees on their improvement projects and to assist in the development of Quality Management Systems (QMS). Audits were conducted at baseline, six months, exit (at 12 months) and post-SLMTA (at 18 months) using the Stepwise Laboratory Quality Improvement Process Towards Accreditation (SLIPTA) checklist to measure changes in implementation of the QMS during the period. At the end of each audit, a comprehensive implementation plan was developed in order to address gaps. RESULTS: Baseline audit scores ranged from 19% to 52%, corresponding to 0 stars on the SLIPTA five-star scale. After 18 months, one laboratory reached four stars, two reached three stars and two reached two stars. There was a corresponding decrease in nonconformities and development of over 100 management and technical standard operating procedures in each of the five laboratories. CONCLUSION: The tremendous improvement in these five Caribbean laboratories shows that SLMTA coupled with mentorship is an effective, user-friendly, flexible and customisable approach to the implementation of laboratory QMS. It is recommended that other laboratories in the region consider using the SLMTA training programme as they engage in quality systems improvement and preparation for accreditation.

School closures are used to reduce seasonal and pandemic influenza transmission, yet evidence of their effectiveness is sparse. In Argentina, annual winter school breaks occur during the influenza season, providing an opportunity to study this intervention. We used 2005-2008 national weekly surveillance data of visits to a health care provider for influenza-like illness (ILI) from all provinces. Using Serfling-specified Poisson regressions and population-based census denominators, we developed incidence rate ratios (IRRs) for the 3 weeks before, 2 weeks during, and 3 weeks after the break. For persons 5-64 years of age, IRRs were <1 for at least 1 week after the break. Observed rates returned to expected by the third week after the break; overall decrease among persons of all ages was 14%. The largest decrease was among children 5-14 years of age during the week after the break (37% lower IRR). Among adults, effects were weaker and delayed. Two-week winter school breaks significantly decreased visits to a health care provider for ILI among school-aged children and nonelderly adults.

BACKGROUND: School closures were widely implemented in Argentina during the 2009 H1N1 influenza virus pandemic. OBJECTIVES: To assess the economic impact of school closures on households, their effectiveness in preventing children from engaging in social group activities, and parental attitudes toward them. METHODS: Three schools that closed for 2 weeks in response to the pandemic were identified in two socioeconomically distinct cities in Argentina. All households with children enrolled in these schools were surveyed. Direct and indirect costs attributable to closures were estimated from the household perspective. Other information collected included children activities during the closures and parental attitudes toward the intervention. RESULTS: Completed questionnaires were returned by 45% of surveyed households. Direct and indirect costs due to closures represented 11% of imputed monthly household income in the city with lower socioeconomic status, and 3% in the other city (P = 0.01). Non-childcare expenses and loss of workdays were more common in the city with lower socioeconomic status. Childcare expenses were less common and were experienced by a similar percentage of households in both cities. About three-quarters of respondents in both cities agreed with the closures. The main concern among those who disagreed with closures was their negative impact on education. Children in more than two-thirds of affected households left their home at least once during the closures to spend time in public places. CONCLUSION: School closures may more significantly impact low-income households. Authorities should consider the range of economic impacts of school closures among families when planning their implementation.

SETTING: Persons in whom targeted testing for latent tuberculosis infection (LTBI) is recommended in Seattle, Washington; Atlanta, Georgia; and central North Carolina, United States. OBJECTIVE: To compare the performance of an interferon-gamma release assay (QuantiFERON(R)-TB Gold In-Tube [QFT-GIT]) with the tuberculin skin test (TST) among foreign-born, homeless, human immunodeficiency virus (HIV) infected and substance abuse persons tested for LTBI. DESIGN: A cross-sectional study requiring participants to have a blood test, a TST and data collected. RESULTS: Of 1653 persons, 19.5% were TST-positive and 14.0% were QFT-GIT-positive. Overall concordance was moderate (kappa 0.53; 95%CI 0.47-0.58). Compared to concordant positive results, TST+/QFT-GIT- discordance was associated with HIV infection and sex, while TST-/QFT-GIT+ discordance was associated with HIV and inversely associated with foreign birth. Compared to concordant negative results, TST-/QFT-GIT+ discordance was associated with foreign birth and age ≥50 years, while TST+/QFT-GIT-discordance was associated with foreign birth, age 30-49 years, being Black and inversely associated with HIV. HIV infection was significantly associated with indeterminate QFT-GIT results. CONCLUSION: QFT-GIT may be an improvement over the TST for diagnosing LTBI in foreign-born and older persons, and may be as useful as the TST in HIV-infected persons. The sensitivity of both tests may be low in HIV-infected persons.

At a major referral hospital in the Southern Hemisphere, the 2009 influenza A (H1N1) pandemic brought increased critical care demand and more unscheduled nursing absences. Because of careful preparedness planning, including rapid expansion and redistribution of the numbers of available beds and staff, hospital surge capacity was not exceeded.

This article describes two large, multisite infectious disease programs: the Tuberculosis Epidemiologic Studies Consortium (TBESC) and the Emerging Infections Programs (EIPs). The links between biological anthropology and applied public health are highlighted using these programs as examples. Funded by the Centers for Disease Control and Prevention (CDC), the TBESC and EIPs conduct applied public health research to strengthen infectious disease prevention and control efforts in the United States. They involve collaborations among CDC, public health departments, and academic and clinical institutions. Their unique role in national infectious disease work, including their links to anthropology, shared elements, key differences, strengths and challenges, is discussed.