Post rotavirus vaccine introduction in Mozambique (September 2015), we documented a decline in rotavirus-associated diarrhoea and genotypes changes in our diarrhoeal surveillance spanning 2008-2021. This study aimed to perform whole-genome sequencing of rotavirus strains from 2009 to 2012 (pre-vaccine) and 2017-2018 (post-vaccine). Rotavirus strains previously detected by conventional PCR as G2P[4], G2P[6], G3P[4], G8P[4], G8P[6], and G9P[6] from children with moderate-to-severe and less-severe diarrhoea and without diarrhoea (healthy community controls) were sequenced using Illumina MiSeq(®) platform and analysed using bioinformatics tools. All these G and P-type combinations exhibited DS-1-like constellation in the rest of the genome segments as, I2-R2-C2-M2-A2-N2-T2-E2-H2. Phylogenetic analysis revealed that strains from children with and without diarrhoea clustered together with other Mozambican and global strains. Notably, the NSP4 gene of strains G3P[4] and G8P[4] in children with diarrhoea clustered with animal strains, such as bovine and caprine, with similarity identities ranging from 89.1 to 97.0% nucleotide and 89.5-97.0% amino acids. Our findings revealed genetic similarities among rotavirus strains from children with and without diarrhoea, as well as with animal strains, reinforcing the need of implementing studies with One Health approach in our setting, to elucidate the genetic diversity of this important pathogen.

Oral pre-exposure prophylaxis (PrEP) reduces HIV acquisition risk from sex by 99% and from injection drug use by ≥74% when used as recommended. The Joint United Nations Programme on HIV/AIDS (UNAIDS) has set a goal of 21.2 million persons using (initiating or continuing) PrEP globally in 2025. In 2016, CDC, with the U.S. President's Emergency Plan for AIDS Relief, joined ministries of health to implement PrEP globally. PrEP is beneficial for persons at substantial risk for acquiring HIV, including but not limited to key populations, which include female sex workers, men who have sex with men, persons in prisons and other enclosed settings, persons who inject drugs, and transgender persons. Annual country targets were used to guide scale-up. In 2023, CDC supported 856,816 PrEP initiations, which represents nearly one quarter of the 3.5 million persons globally who either initiated or continued PrEP that year. During 2017-2023, CDC supported PrEP initiations for 2,278,743 persons, 96.0% of whom were in sub-Saharan Africa. More than one half (64.0%) were female and 44.9% were aged 15-24 years. Overall, CDC achieved 118.7% of its PrEP initiation targets for the 7-year period. Among PrEP initiations for key populations, the majority in sub-Saharan Africa were female sex workers, whereas in Southeast Asia, Eurasia, and the Americas, the majority were men who have sex with men. Continued rapid scale-up is needed to meet the UNAIDS goal to end HIV as a public health threat.

BACKGROUND: Sub-Saharan Africa region bears the highest chronic hepatitis B virus (HBV) infection burden worldwide. National estimates of HBV burden are necessary for a viral hepatitis program planning. This study estimated the national prevalence of HBV infection in Kenya among people aged 15-64 years. METHODS: Of 27,745 participants age 15-64 years in the Kenya Population-based HIV Impact Assessment (KENPHIA) 2018 household survey, we analyzed data for all persons living with HIV (PLHIV; n = 1,521) and a random sample of HIV-negative persons (n = 1,551), totaling to 3,072 participants. We tested whole blood samples for hepatitis B surface antigen (HBsAg) using Determine™ HBsAg rapid test and used population projections to estimate national disease burden. Pearson chi square was performed and the weighted prevalence proportions presented. FINDINGS: Of the 3,072 participants,124 tested HBsAg positive, resulting in a weighted national HBV prevalence of 3.0% (95% CI: 2.2-3.9%). This translated to an HBV infection burden of 810,600 (95% CI: 582,700-1,038,600) persons age 15-64 years in Kenya. Distribution of HBV prevalence varied widely (p<0.001) by geography, ranging from 0.1% in Eastern Kenya regions to over 5% in northern and western Kenya. Prevalence of HBV infection was higher in PLHIV (4.7%; 95% CI: 3.3-6.0%) compared to HIV-negative persons (3.0%; 95% CI: 2.1-3.9%), and was highest among persons: age 45-54 years (6.4%; 95% CI: 3.3-9.5%), those who reported no formal education (10.7%; 95% CI: 5.1-16.4%), in polygamous marriages (6.8%; 95% CI: 1.7-11.8%), and in the lowest wealth quintile (5.3%; 95% CI: 2.8-7.7). When adjusted for covariates, lack of formal education (aOR = 4.2; 95% CI: 1.5-12.6) was significantly associated with HBV infection. In stratified analysis by HIV status, residing in rural areas and history of blood transfusion were independently associated with HBV infection among PLHIV, while lack of formal education and no history of blood transfusion were associated with HBV infection among HIV-negative participants (p<0.05). INTERPRETATION: HBV prevalence among persons aged 15-64 years in Kenya was 3.0%. Higher prevalence was documented among persons without formal education, in the lowest wealth quintile, and those living in Kenya's North-Eastern, Rift Valley-North and Nyanza regions. Targeted programmatic measures to strengthen interventions against HBV infections including newborn vaccination and treatment of infected adults to limit mother-to-child transmission, would be helpful in reducing burden of HBV-associated viral hepatitis.

During population-based HIV impact assessments (PHIAs), some participants who self-reported testing HIV-positive (PSRP) tested negative in one or more subsequent survey HIV tests. These unexpected discrepancies between their self-reported results and the survey results draw into question the validity of either the self-reported status or the test results. We analyzed PSRP with negative test results aged 15-59 years old using data collected from 2015 to 2021 in 13 countries, assessing prevalence, self-report status, survey HIV status, viral load, rapid tests and confirmatory tests, and answers to follow-up questions (such as years on treatment). Across these surveys, 19,026 participants were PSRP, and 256 (1.3%) of these were concluded to be HIV-negative after additional survey-based testing and review. PSRP determined to be HIV-negative trended higher in countries with a higher HIV prevalence, but their number was small enough that accepting self-reported HIV-positive status without testing would not have significantly affected the prevalence estimates for HIV or viral load suppression. Additionally, using more detailed information for Uganda, we examined 107 PSRP with any negative test results and found no significant correlation with years on treatment or age. Using these details, we examined support for the possible reasons for these discrepancies beyond misdiagnosis and false reporting. These findings suggest that those conducting surveys would benefit from a nuanced understanding of HIV testing among PSRP to conduct surveys ethically and produce high-quality results.

BACKGROUND: In 2019, WHO recommended dolutegravir (DTG) as a backbone for first- and second-line antiretroviral therapy (ART) regimens for people living with HIV (PLHIV). According to the 2018 Uganda's HIV treatment guidelines, patients with viral non-suppression (≥1,000 copies/mL) should receive intensive adherence counseling (IAC) with repeat viral load (VL) within 6 months. This analysis focused on the prevalence and factors associated with viral suppression following IAC among PLHIV on DTG-based regimens (DBRs) with an initial episode of viral non-suppression (VNS) in Uganda. METHODS: We conducted a retrospective analysis for PLHIV on DBRs with an initial episode of VNS (≥1,000 copies/mL) in Uganda during October 2019-September 2020 who had a follow up VL test result during September 2020-July 2021. Data were abstracted from the Central Public Health Laboratory (CPHL) database, including patient demographics and VL results. Viral non-suppression (VNS) was defined as a VL test result of ≥1,000 copies/mL. We characterized PLHIV on DBRs and used logistic regression models to determine factors associated with VL suppression after an initial episode of VNS. RESULTS: A total of 564 PLHIV on DBRs with an initial episode of VNS were followed up and 43 were excluded due to missing data. Of the 521, 220 (42.2%) were children (<15 years) and 231 (44.3%) were female. Median age was 28 years (interquartile range [IQR]: 12-43 years), and median duration on DBRs was 12 months (IQR: 6-15 months). Overall, 80.8% (421/521) PLHIV had a suppressed viral load at first follow up testing (children = 74.5% [164/220]; adults = 85.4% [257/301]). Children with initial VL results ≥5,000 copies/mL were less likely to achieve viral suppression at follow up testing compared to those with <5,000 copies/mL (AOR: 0.38; 95% CI: 0.20-0.71; p = 0.002). CONCLUSIONS: In a programmatic setting, most adults and children suppressed following an initial episode of VNS on DBRs. High rates of suppression after VNS suggest adherence challenges, rather than drug resistance. Continuation of DBRs should be considered before regimen switch.

OBJECTIVE: To describe the scale-up of cervical cancer screening and treatment for women living with human immunodeficiency virus (HIV), aged 25-49 years in Uganda, and to analyse the programme data. METHODS: The health ministry targeted existing HIV clinics in a 2-year scale-up of cervical cancer screening services from October 2020. In preparation, we trained health workers to assess women attending HIV clinics for screening eligibility, provided either by human papillomavirus (HPV) testing and/or visual inspection with acetic acid. Clinic staff treated women with precancerous cervical lesions with thermocoagulation or referred women with suspected cancer to external services. We analysed data reported every 6 months for the number of clinics offering screening, screening uptake, the number of positive diagnoses and the number of women who received treatment. FINDINGS: The number of HIV clinics offering cervical cancer screening services increased from 11, before the programme launch, to 1571. During the programme, screening uptake increased from 5.0% (6506/130 293) to 107.3% (151 872/141 527) of targets. The cumulative proportion of positive diagnoses was 5.9% (23 970/407 323) overall, but was much lower for screening offering visual inspection only compared with clinics offering HPV testing. Although the proportion of women receiving treatment if positive increased from 12.8% (53/413) to 84.3% (8087/9592), the World Health Organization target of 90% was not reached. CONCLUSION: We demonstrated marked increases, potentially replicable by other countries, in screening and treatment. These increases could be improved further by expanding HPV testing and same-day treatment of precancerous lesions.

As antiretroviral treatment (ART) coverage for people living with HIV (PLHIV) increases, HIV programmes require up-to-date information about evolving HIV risk behaviour and transmission risk, including those with low-level viremia (LLV; >50 to ≤1000 copies/mL), to guide prevention priorities. We aimed to assess differences in sexual risk behaviours, distribution of viral load (VL) and proportion of transmission across PLHIV subgroups. We analysed data from Population-based HIV Impact Assessment surveys in 14 sub-Saharan African countries during 2015-2019. We estimated adjusted prevalence ratios (aPR) of self-reported HIV high-risk behaviour (multiple partners and condomless sex) across cascade stages via generalised estimation equations. We modelled the proportions of transmission from each subgroup using relative self-reported sexual risk, a Hill function for transmission rate by VL, and proportions within cascade stages from surveys and UNAIDS country estimates for 2010-2020. Compared to PLHIV with undetectable VL (≤50 copies/mL), undiagnosed PLHIV (aPR women: 1.28 [95% CI: 1.08-1.52]; men: 1.61 [1.33-1.95]) and men diagnosed but untreated (2.06 [1.52-2.78]) were more likely to self-report high-risk sex. High-risk behaviour was not significantly associated with LLV. Mean VL was similar among undiagnosed, diagnosed but untreated, and on ART but non-suppressed sub-groups. Across surveys, undiagnosed and diagnosed but untreated contributed most to transmission (40-91% and 1-41%, respectively), with less than 1% from those with LLV. Between 2010 and 2020, the proportion of transmission from individuals on ART but non-suppressed increased. In settings with high ART coverage, effective HIV testing, ART linkage, and retention remain priorities to reduce HIV transmission. Persons with LLV are an increasing share of PLHIV but their contribution to HIV transmission was small. Improving suppression among PLHIV on ART with VL ≥1000 copies/mL will become increasingly important.

Many statistical models have been proposed in the literature for the analysis of longitudinal data. One may propose to model two or more correlated longitudinal processes simultaneously, with a goal of understanding their association over time. Joint modeling is then required to carefully study the association structure among the outcomes as well as drawing joint inferences about the different outcomes. In this study, we sought to model the associations among six nutrition outcomes while circumventing the computational challenge posed by their clustered and high-dimensional nature. We analyzed data from a 2  ×  2 randomized crossover trial conducted in Kenya, to compare the effect of high-dose and low-dose iodine in household salt on systolic blood pressure (SBP) and diastolic blood pressure (DBP) in women of reproductive age and their household matching pair of school-aged children. Two additional outcomes, namely, urinary iodine concentration (UIC) in women and children were measured repeatedly to monitor the amount of iodine excreted through urine. We extended the model proposed by Mwangi et al. (2021, Communications in Statistics: Case Studies, Data Analysis and Applications, 7(3), 413-431) allowing flexible piecewise joint models for six outcomes to depend on separate random effects, which are themselves correlated. This entailed fitting 15 bivariate general linear mixed models and deriving inference for the joint model using pseudo-likelihood theory. We analyzed the outcomes separately and jointly using piecewise linear mixed-effects (PLME) model and further validated the results using current state-of-the-art Jones and Kenward methodology (JKME model) used for analyzing randomized crossover trials. The results indicate that high-dose iodine in salt significantly reduced blood pressure (BP) compared to low-dose iodine in salt. Estimates for the random effects and residual error components showed that SBP and DBP had strong positive correlation, with effect of the random slope indicating that significantly related outcomes are strongly associated in their evolution. There was a moderately strong inverse relationship between evolutions of UIC and BP both in women and children. These findings confirmed the original hypothesis that high-dose iodine salt has significant lowering effect on BP. We further sought to evaluate the performance of our proposed PLME model against the widely used JKME model, within the multivariate joint modeling framework through a simulation study mimicking a 2 × 2 crossover design. From our findings, the multivariate joint PLME model performed exceptionally well both in estimation of random-effects matrix (G) and Hessian matrix (H), allowing satisfactory model convergence during estimation. It allowed a more complex fit to the data with both random intercepts and slopes effects compared to the multivariate joint JKME model that allowed for random intercepts only. When a hierarchical viewpoint is adopted, in the sense that outcomes are specified conditionally upon random effects, the variance-covariance matrix of the random effects must be positive definite. In some cases, additional random effects could explain much variability in the data, thus improving precision in estimation of the estimands (effect size) parameters. The key highlight in this evaluation shows that multivariate joint JKME model is a powerful tool especially while fitting mixed models with random intercepts only, in crossover design settings. Addition of random slopes may lead to model complexities in most cases, resulting in unsatisfactory model convergence during estimation. To circumvent convergence pitfalls, extention of JKME model to PLME model allows a more flexible fit to the data (generated from crossover design settings), especially in the multivariate joint modeling framework.

Advanced HIV disease (AHD) remains a significant burden, despite the widespread use of antiretroviral therapy (ART) programs. Individuals with AHD are at a high risk of death even after starting ART. We characterized treatment naïve and treatment experienced clients presenting with AHD in western Kenya to inform service delivery and program improvement. We conducted a retrospective study using routinely collected program data from October 2016 to September 2019 for AHD clients in eight facilities in Homa Bay County, Kenya. Demographic and clinical data were abstracted from the medical records of AHD clients, defined as HIV-positive clients aged ≥ 5 years with documented CD4 count < 200 cells/mm3 and/or WHO clinical stage II/IV. Associations were assessed using Pearson's chi-square and Mann-Whitney Rank-Sum tests at 5% level of significance. Of the 19,427 HIV clients at the eight facilities, 6649 (34%) had a CD4 count < 200 cells/mm3 or a WHO III/IV stage. Of these, 1845 were randomly selected for analysis. Over half (991) of participants were aged 45 + years and 1040 (56%) were female. The median age was 46.0 years (interquartile range: 39.2-54.5); 1553 (84%) were in care at county and sub-county hospitals; and 1460 (79%) were WHO stage III/IV at enrollment. At ART initiation, 241 (13%) had tuberculosis, 192 (10%) had chronic diarrhea, and 94 (5%) had Pneumocystis jiroveci pneumonia. At the time of data collection, 89 (5%) participants had died and 140 (8%) were lost to follow-up. Eighteen percent (330) of participants were ART-experienced (on ART for ≥ 3 months). The proportions of ART-experienced and -naïve clients regarding age, sex and marital status were similar. However, a higher proportion of ART-experienced clients received care at primary care facilities, (93(28%) vs. 199 (13%); P < .001); were WHO stage 3/4 at AHD diagnosis, 273 (84%) vs. 1187 (79%) (P = .041); and had died or been LTFU, (124 (38%) vs. 105 (7%); P < .001). With increasing prevalence of patients on ART, the proportion of AHD treatment-experienced clients may increase without effective interventions to ensure that these patients remain in care.

Natural planned exposure (NPE) remains one of the most common methods in swine herds to boost lactogenic immunity against rotaviruses. However, the efficacy of NPE protocols in generating lactogenic immunity has not been investigated before. A longitudinal study was conducted to investigate the dynamics of genotype-specific antibody responses to different doses (3, 2 and 1) of Rotavirus A (RVA) NPE (genotypes G4, G5, P[7] and P[23]) in gilts and the transfer of lactogenic immunity to their piglets. Group 1 gilts received three doses of NPE at 5, 4 and 3 weeks pre-farrow (WPF), group 2 received two doses at 5 and 3 WPF, group 3 received one dose at 5 WPF, and group 4 received no NPE (control group). VP7 (G4 and G5) and truncated VP4* (P[7] and P[23]) antigens of RVA were expressed in mammalian and bacterial expression systems, respectively, and used to optimize indirect ELISAs to determine antibody levels against RVA in gilts and piglets. In day-0 colostrum samples, group 1 had significantly higher IgG titers compared to the control group for all four antigens, and either significantly or numerically higher IgG titers than groups 2 and 3. Group 1 also had significantly higher colostrum IgA levels than the control group for all antigens (except G4), and either significantly or numerically higher IgA levels compared to groups 2 and 3. In piglet serum, group 1 piglets had higher IgG titers for all four antigens at day 0 than the other groups. Importantly, RVA NPE stimulated antibodies in all groups regardless of the treatment doses and prevented G4, G5, P[7] and P[23] RVA fecal shedding prior to weaning in piglets in the absence of viral challenge. The G11 and P[34] RVA genotypes detected from pre-weaning piglets differed at multiple amino acid positions with parent NPE strains. In conclusion, the results of this study suggest that the group 1 NPE regimen (three doses of NPE) resulted in the highest anti-RVA antibody (IgG and IgA) levels in the colostrum/milk, and the highest IgG levels in piglet serum.

INTRODUCTION: The African Center for Integrated Laboratory Training (ACILT) in Johannesburg, South Africa offered a laboratory biosafety program to improve laboratory biosafety practices in 22 President's Emergency Plan for AIDS Relief (PEPFAR) supported countries. This manuscript evaluates the transference of newly gained knowledge and skills to the participants' place of employment for HIV and TB diagnostic laboratory programs. It also serves as a follow-on to a previously published manuscript that measured training effectiveness for all courses offered at ACILT. METHODS: ACILT offered 20 Laboratory Biosafety and Infrastructure courses (2008-2014), also referred as biosafety course/course comprising of 14 core laboratory safety elements to 402 participants from 22 countries. In 2015, participants received 22 e-questions divided into four categories: (1) Safety Policies, (2) Management's Engagement, (3) Safety Programs and (4) Assessments of Safety Practices to determine retrospectively the training effectiveness of biosafety practices in their place of employment 6 months before and after attending their course. We used Kirkpatrick model to assess the transference of knowledge, skills and obstructive factors. RESULTS: 20% (81/402) of the participants completed the e-questionnaire. The overall percentage of positive responses indicating implementation of new safety practices increased from 50% to 84%. Improvement occurred in all four categories after attending the course, with the greatest increases in Safety Policies (67-94%) and Safety Programs (43-91%). Creating a safety committee, allocating resources, and establishing a facility safety policy were important drivers for implementing and maintaining laboratory safety practices. In addition, accredited laboratories and countries with national safety regulations or policies had a higher percentage of improvements. The most reported challenges were inadequate funding and lack of management enforcement. CONCLUSIONS: PEPFAR and other partners' investments in training institutions, such as ACILT, were effective in building sustainable country ownership to strengthen biosafety practices and were leveraged to combat zoonotic diseases and COVID-19. Although support continues at the national/regional level, a standardized, coordinated and continent-wide sustainable approach to offer a biosafety program-like ACILT is missing. Continuous offerings of biosafety programs similar to ACILT could contribute to sustainable strengthening of laboratory biosafety, QMS and pandemic preparedness.

BACKGROUND: Routine program data indicates positivity rates under 2% from HIV testing services (HTS) at sites supported by Centre for Health Solutions-Kenya in Central Kenya. Achieving the UNAIDS 95:95:95 goals requires continuous identification of people living with HIV in an environment of diminishing resources. We assessed non-clinical and clinical characteristics of persons who tested HIV-positive aimed at improving the process of HTS through Provider-Initiated HIV Testing & Counseling (PITC). METHODS: We conducted a retrospective analysis of routine PITC program data collected between October 2018 and September 2019 from six health facilities located in three counties in central Kenya. Stratification was based on county and facility volume. A multivariable logistic regression model, clustered adjusted for facility using robust standard errors, was used to determine predictors of a positive HIV result. RESULTS: The total sample was 80,693 with an overall positivity rate of 1.2%. Most, (65.5%), were female and 6.1% were < 15 years. Most clients, 55,464 (68.7%), had previously tested for HIV. Client characteristics associated with a higher odds of positivity on multivariable analysis included: being female (adjusted odds ratio [aOR] 1.27, 95% confidence interval [CI] (1.03-1.57); adults 15 years and above compared to children < 15 years, divorced and married polygamous compared to married monogamous [aOR 3.98, 95% CI (2.12-7.29) and aOR 2.41 95% CI (1.48-3.94) respectively]; clients testing for the first time compared to repeat testers in less than 12 months [aOR 1.39, 95% CI (1.27-1.51)]. Similarly, repeat testers in more than 12 months compared to repeat testers in less than 12 months [aOR 1.90, 95% CI (1.55-2.32)]; presumptive TB clients compared to those without signs of TB [aOR 16.25, 95% CI (10.63-24.84)]. Clients tested at inpatient departments (IPD) were more likely to get a positive HIV result compared to those tested at outpatient departments (OPD), and other departments. CONCLUSIONS: The study findings highlight client characteristics such as age, marital status, HIV test entry point, first-time test, repeat test after 12 months, and TB status as factors that could influence PITC results and could be used to develop a screening tool to target eligible clients for HTS in low HIV prevalence settings.

Following a four-year annual praziquantel treatment campaign the resulting prevalence of S. mansoni was seen to differ among individual villages along the Kenyan shore of Lake Victoria. We have investigated possible inherent differences in snail-related aspects of transmission among such 10 villages, including six persistent hotspot (PHS) villages (≤30% reduction in prevalence following repeated treatments) located along the west-facing shore of the lake, and four PZQ-responding (RESP) villages (&gt;30% prevalence reduction following repeated treatment) along Winam Gulf. When taking into account all sampling sites and times and water hyacinth presence/absence, shoreline-associated B. sudanica from PHS and RESP villages did not differ in relative abundance or prevalence of S. mansoni infection. Water hyacinth intrusions were associated with increased B. sudanica abundance. The deeper water snail Biomphalaria choanomphala was significantly more abundant in the PHS villages and prevalence of S. mansoni among villages both before and after control was positively correlated with B. choanomphala abundance. Worm recoveries from sentinel mice did not differ between PHS and RESP villages, and abundance of non-schistosome trematode species was not associated with S. mansoni abundance. Biomphalaria choanomphala provides an alternative, deepwater mode of transmission that may favor greater persistence of S. mansoni in PHS villages. As we found evidence for ongoing S. mansoni transmission in all 10 villages, we conclude conditions conducive for transmission and reinfection occur ubiquitously. This argues for an integrated, basin-wide plan for schistosomiasis control to counteract rapid reinfections facilitated by large snail populations and movements of infected people around the lake.

Mozambique introduced the rotavirus vaccine (Rotarix®; GlaxoSmithKline Biologicals, Rixensart, Belgium) in 2015, and since then, the Centro de Investigação em Saúde de Manhiça has been monitoring its impact on rotavirus-associated diarrhea and the trend of circulating strains, where G3P[8] was reported as the predominant strain after the vaccine introduction. Genotype G3 is among the most commonly detected Rotavirus strains in humans and animals, and herein, we report on the whole genome constellation of G3P[8] detected in two children (aged 18 months old) hospitalized with moderate-to-severe diarrhea at the Manhiça District Hospital. The two strains had a typical Wa-like genome constellation (I1-R1-C1-M1-A1-N1-T1-E1-H1) and shared 100% nucleotide (nt) and amino acid (aa) identities in 10 gene segments, except for VP6. Phylogenetic analysis demonstrated that genome segments encoding VP7, VP6, VP1, NSP3, and NSP4 of the two strains clustered most closely with porcine, bovine, and equine strains with identities ranging from 86.9-99.9% nt and 97.2-100% aa. Moreover, they consistently formed distinct clusters with some G1P[8], G3P[8], G9P[8], G12P[6], and G12P[8] strains circulating from 2012 to 2019 in Africa (Mozambique, Kenya, Rwanda, and Malawi) and Asia (Japan, China, and India) in genome segments encoding six proteins (VP2, VP3, NSP1-NSP2, NSP5/6). The identification of segments exhibiting the closest relationships with animal strains shows significant diversity of rotavirus and suggests the possible occurrence of reassortment events between human and animal strains. This demonstrates the importance of applying next-generation sequencing to monitor and understand the evolutionary changes of strains and evaluate the impact of vaccines on strain diversity.

INTRODUCTION: We assessed progress in HIV viral load (VL) scale up across seven sub-Saharan African (SSA) countries and discussed challenges and strategies for improving VL coverage among patients on anti-retroviral therapy (ART). METHODS: A retrospective review of VL testing was conducted in Côte d'Ivoire, Kenya, Lesotho, Malawi, Namibia, Tanzania, and Uganda from January 2016 through June 2018. Data were collected and included the cumulative number of ART patients, number of patients with ≥ 1 VL test result (within the preceding 12 months), the percent of VL test results indicating viral suppression, and the mean turnaround time for VL testing. RESULTS: Between 2016 and 2018, the proportion of PLHIV on ART in all 7 countries increased (range 5.7%-50.2%). During the same time period, the cumulative number of patients with one or more VL test increased from 22,996 to 917,980. Overall, viral suppression rates exceeded 85% for all countries except for Côte d'Ivoire at 78% by June 2018. Reported turnaround times for VL testing results improved in 5 out of 7 countries by between 5.4 days and 27.5 days. CONCLUSIONS: These data demonstrate that remarkable progress has been made in the scale-up of HIV VL testing in the seven SSA countries.

The US President's Emergency Plan for AIDS Relief (PEPFAR) supports molecular HIV and tuberculosis diagnostic networks and information management systems in low- and middle-income countries. We describe how national programs leveraged these PEPFAR-supported laboratory resources for SARS-CoV-2 testing during the COVID-19 pandemic. We sent a spreadsheet template consisting of 46 indicators for assessing the use of PEPFAR-supported diagnostic networks for COVID-19 pandemic response activities during April 1, 2020, to March 31, 2021, to 27 PEPFAR-supported countries or regions. A total of 109 PEPFAR-supported centralized HIV viral load and early infant diagnosis laboratories and 138 decentralized HIV and TB sites reported performing SARS-CoV-2 testing in 16 countries. Together, these sites contributed to >3.4 million SARS-CoV-2 tests during the 1-year period. Our findings illustrate that PEPFAR-supported diagnostic networks provided a wide range of resources to respond to emergency COVID-19 diagnostic testing in 16 low- and middle-income countries.

HIV-positive children and adolescents face gaps in viral load (VL) testing. To understand trends in pediatric/adolescent VL testing, 7 countries collected data from Laboratory Information Management Systems. Results showed increasing proportion of VL tests done through dried blood spot (DBS) and decreased sample rejection rates for DBS compared with plasma, supporting use of DBS VL when skilled phlebotomy is unavailable.

OBJECTIVE: To describe the implementation strategies of the index testing program across Nairobi County in Kenya, assess outcomes along the HIV index testing cascade (acceptance, elicitation ratio, HIV positivity, and linkage to treatment), and assess annual changes along the HIV index testing cascade during the first two years of implementation. METHODS: Retrospective analysis of programmatic aggregate data collected from October 2017 to September 2019 after the roll-out of index testing services in 48 health facilities in Nairobi County. Proportions and ratios were calculated for acceptance, elicitation ratio, testing uptake, and HIV positivity. We compared these outcomes between years using a chi-squared test, Fisher's exact test, or Wilcoxon sign test, and we assessed trends using the Mann-Kendall test. RESULTS: Testing among eligible partners increased from 42.4% (1,471/3,470) to 74.9% (6,114/8,159) in the general population, and the positivity yield remained high across both years (25.2% in year 1 and 24.1% in year 2). Index testing positivity yield remained significantly higher than other testing modalities (24.3% versus 1.3%, p<0.001). The contribution of index testing services to the total number of HIV-positive individuals identified increased from 7.5% in the first year to 28.6% in the second year (p<0.001). More men were tested, but the positivity yield was higher among women (30.0%) and those aged 50 years or older (32.4%). Testing eligible partners in key populations decreased from 52.4% (183/349) to 40.7% (109/268) (p=0.674); however, the HIV positivity yield increased from 8.6% to 23.9% (p<0.001) by the second year of implementation. The HIV positivity yield from index testing remained higher than other testing modalities (14% vs. 0.9%, p<0.001) for key populations. CONCLUSION: Index testing was well-accepted and effective in identifying individuals living with HIV in a Kenyan urban setting across both general populations and key populations. Ongoing adaptations to the strategies deployed as part of index testing services helped improve most of the outcomes along the index testing cascade. This article is protected by copyright. All rights reserved.

Viral suppression is suboptimal among children and adolescents on antiretroviral therapy (ART) in Kenya. We implemented and evaluated a standardized enhanced adherence counseling (SEAC) package to improve viral suppression in children and adolescents with suspected treatment failure in Homa Bay and Turkana. The SEAC package, implemented from February 2019 to September 2020, included: standard procedures operationalizing the enhanced adherence counseling (EAC) process; provider training on psychosocial support and communication skills for children living with HIV and their caregivers; mentorship to providers and peer educators on EAC processes; and individualized case management. We enrolled children and adolescents aged 0 to 19 years with suspected treatment failure (viral load [VL] >1000 copies/mL) who received EAC before standardization as well as those who received SEAC in a pre-post evaluation of the SEAC package conducted in 6 high-volume facilities. Pre-post standardization comparisons were performed using Wilcoxon-Mann-Whitney and Pearson's chi-square tests at a 5% level of significance. Multivariate logistic regression was performed to identify factors associated with viral resuppression. The study enrolled 741 participants, 595 pre- and 146 post-SEAC implementation. All post-SEAC participants attended at least 1 EAC session, while 17% (n = 98) of pre-SEAC clients had no record of EAC attendance. Time to EAC following the detection of high VL was reduced by a median of 8 days, from 49 (interquartile range [IQR]: 23.0-102.5) to 41 (IQR: 20.0-67.0) days pre- versus post-SEAC (P = .006). Time to completion of at least 3 sessions was reduced by a median of 12 days, from 59.0 (IQR: 36.0-91.0) to 47.5 (IQR: 33.0-63.0) days pre- versus post-SEAC (P = .002). A greater percentage of clients completed the recommended minimum 3 EAC sessions at post-SEAC, 88.4% (n = 129) versus 61.1% (n = 363) pre-SEAC, P < .001. Among participants with a repeat VL within 3 months following the high VL, SEAC increased viral suppression from 34.6% (n = 76) to 52.5% (n = 45), P = .004. Implementation of the SEAC package significantly reduced the time to initiate EAC and time to completion of at least 3 EAC sessions, and was significantly associated with viral suppression in children and adolescents with suspected treatment failure.

BACKGROUND: Since 2010, Kenya has used SLIPTA to prepare and improve quality management systems in medical laboratories to achieve ISO 15189 accreditation. However, less than 10% of enrolled laboratories had done so in the initial seven years of SLMTA implementation. OBJECTIVE: We described Kenya's experience in accelerating medical laboratories on SLMTA to attain ISO 15189 accreditation. METHODS: From March 2017 to July 2017, an aggressive top-down approach through high-level management stakeholder engagement for buy-in, needs-based expedited SLIPTA mentorship and on-site support as a rapid results initiative (RRI) was implemented in 39 laboratories whose quality improvement process had stagnated for 2-7 years. In July 2017, SLIPTA baseline and exit audit average scores on quality essential elements were compared to assess performance. RESULTS: After RRI, laboratories achieving greater than a 2-star SLMTA rating increased significantly from 15 (38%) at baseline to 33 (85%) (p < 0.001). Overall, 34/39 (87%) laboratories received ISO 15189 accreditation within two years of RRI, leading to a 330% increase in the number of accredited laboratories in Kenya. The most improved of the 12 quality system essentials were Equipment Management (mean increase 95% CI: 5.31 ± 1.89) and Facilities and Biosafety (mean increase [95% CI: 4.05 ± 1.78]) (both: p < 0.0001). Information Management and Corrective Action Management remained the most challenging to improve, despite RRI interventions. CONCLUSION: High-level advocacy and targeted mentorship through RRI dramatically improved laboratory accreditation in Kenya. Similar approaches of strengthening SLIPTA implementation could improve SLMTA outcomes in other countries with similar challenges.

BACKGROUND: Retention of patients who are receiving antiretroviral therapy (ART) remains a challenge especially in the setting of rapid expansion of HIV services. Retention in care remains vital to the HIV care continuum, and has been associated with viral suppression and improved survival. This study aimed to ascertain survival rates, time to loss to follow-up (LTFU) or mortality events and factors associated with time to LTFU or mortality among patients enrolled on antiretroviral therapy at health facilities in central Kenya. METHODS: This was a retrospective cohort study among patients initiated on ART between 2004 and 2012 in central Kenya. Demographic characteristics, clinical characteristics and outcomes data were analyzed using Stata version 15.1. Competing risks regression analysis and cummulative incidence functions were used to estimate survival. RESULTS: A total of 31,346 patients were included, of whom 65.6% were female, 76.0% were aged between 20 and 50 years old, and 38.9% were diagnosed at WHO stage III. At 36 months, overall retention was 68.8%, LTFU was 27.1%, and mortality was 4.1%. The total person-years of follow up was 74,986. The incidence rate of LTFU was 9.99 per 100 person years for a total of 9383.25 person-years of follow up. The mortality rate was 1.25 per 100 person years for a total of 875.5 person-years among those who died. The median time to LTFU was 11 months (IQR 3-22) while median time to death was 3 months (IQR 0-13). Men, unmarried patients, patients presenting with advanced HIV, not on TB treatment, and enrolled into the HIV program in later cohorts, had a shorter time to mortality and LTFU. CONCLUSION: Our study demonstrated evidence of scale-up of HIV treatment programs in central Kenya. While most patients were enrolled at an advanced WHO clinical stage, overall 36-month mortality remained low, but occurred earlier during follow-up. Cohort LTFU at 36-months reduced in later years with the losses occurring within the 1st year of follow-up. Predictors of early mortality and LTFU included being male, single, separated or divorced, advanced WHO clinical stage, and among patients not on TB treatment.

Introduction: Kaposis sarcoma (KS) is the most common HIV-associated malignancy in Sub Saharan Africa. In 2018, it was the 7th most common cancer and the 10th most common cause of cancer death in Kenya. This study aimed to describe the baseline and clinical characteristics and treatment response observed following combined antiretroviral treatment (ART) and chemotherapy in KS patients. Methods: This was a descriptive analysis of patients aged 15 years treated for KS and HIV at 11 treatment hubs in Central Kenya between 2011 and 2014. Data on baseline and clinical characteristics, ART and chemotherapy regimens as well as treatment responses were collected from patient files and KS registers. Results: A total of 95 patients presenting with clinically suspected KS with no history of prior treatment with chemotherapy were reviewed. All had histological diagnostic samples taken with 67 (71%) having confirmed KS. All were on ART, either newly initiated or continuing on ART, and 63 of the 67 (94.0%) confirmed to have KS received chemotherapy. Among the 67 patients with confirmed KS, mean age was 37.2 years ( 13.2) and 40 (59.7%) were male. More than 80% had normal baseline and follow-up BMI, and 34 (50.7%) were on a TDF-based regimen, 52 (77.6%) were treated with the Adriamycin, bleomycin and vinblastine protocol, and 55 (82.1%) had KS diagnosis before HIV diagnosis. All 67 patients had mucocutaneous lesions. Complete, partial response and stable disease occurred in 27 (40.3%), 10 (14.9%) and 7 (10.4%), respectively, 11 (16.4%) defaulted care during treatment, six patients died during treatment, four patients died before treatment while two patients had progressive disease during chemotherapy. Conclusion: The diagnosis of KS preceded HIV in the majority of cases reviewed, with histology helpful to reduce misdiagnosis. Patients generally complied with their chemotherapy, with overall good response rate for this intervention implemented at primary health-care facilities. 2022 McLigeyo et al.

BACKGROUND: Hand hygiene (HH) is central in prevention of health care-associated infections. In low resource settings, models to improve HH compliance are needed. We implemented a continuous quality improvement (CQI) program targeting HH in two hospitals in Kenya. OBJECTIVE: To determine the impact of the HH CQI program and identify factors associated with HH compliance between 2018 and 2019. METHODS: A CQI project targeting the improvement of hand hygiene was implemented, including training and mentorship. Data were collected monthly between April 2018 and December 2019 in Thika and Kitale Hospitals. Healthcare workers trained on Infection Prevention and Control (IPC) observed and recorded HH opportunities and subsequent compliance among staff, including nurses, clinicians, and auxiliary staff, using the World Health Organization's "My Five Moments for Hand Hygiene" tool. Covariates were explored using mixed-effects logistic regression with random department-level intercepts. RESULTS: Hand hygiene compliance improved from 27% at baseline to 44% after 21 months. Indication/moment for HH was significantly associated with compliance. Adjusting for site, professional category and department, compliance was higher after a moment of body fluid exposure (aOR 1.43, 95% CI 1.17-1.74, p value < 0.001) and lower before an aseptic procedure (aOR 0.12, 95% CI 0.08-0.17, p value < 0.001) compared to after patient contact. Wearing of gloves often replaced proper HH in surgical departments, which although not significant, had lower compliance compared to departments for internal medicine (aOR 0.93, 95% CI 0.85-1.02). Adjusted HH compliance from all quarters improved from baseline, but comparing each quarter to the previous quarter, the improvement fluctuated over time. CONCLUSION: Training and mentorship on the importance of HH for all moments is needed to improve overall HH compliance. CQI with regular monitoring and feedback of HH performance can be an effective approach in improving HH compliance in public hospitals in Kenya.

BACKGROUND AND SETTING: About 20% of persons living with HIV aged 15-64years did not know their HIV status in Kenya, by 2018. Kenya adopted HIV self-testing (HIVST) to help close this gap. We examined the sociodemographic characteristics and outcomes of self-reported users of HIVST as our primary outcome. METHODS: We used data from a 2018 population-based cross-sectional household survey in which we included self-reported sociodemographic and behavioral characteristics and HIV test results. To compare weighted proportions, we used the Rao-Scott -square test and Jackknife variance estimation. In addition, we used logistic regression to identify associations of sociodemographic, behavioral, and HIVST utilization. RESULTS: Of the 23,673 adults who reported having ever tested for HIV, 937 (4.1%) had ever self-tested for HIV. There were regional differences in HIVST, with Nyanza region having the highest prevalence (6.4%), p<0.001. Factors independently associated with having ever self-tested for HIV were secondary education (adjusted odds ratio [aOR], 3.5 [95% (CI): 2.1-5.9]) compared to no primary education, being in the third (aOR, 1.7 [95% CI: 1.2-2.3]), fourth (aOR, 1.6 [95% CI: 1.1-2.2]), or fifth (aOR, 1.8 [95% CI: 1.2-2.7]) wealth quintiles compared to the poorest quintile and having one lifetime sexual partner (aOR, 1.8 [95% CI: 1.0-3.2]) or having2 partners (aOR, 2.1 [95% CI: 1.2-3.7]) compared to none. Participants aged50years had lower odds of self-testing (aOR, 0.6 [95% CI: 0.4-1.0]) than those aged 15-19years. CONCLUSION: Kenya has made progress in rolling out HIVST. However, geographic differences and social demographic factors could influence HIVST use. Therefore, more still needs to be done to scale up the use of HIVST among various subpopulations. Using multiple access models could help ensure equity in access to HIVST. In addition, there is need to determine how HIVST use may influence behavior change towardsaccess to prevention and HIV treatment services.

Expanded access to HIV treatment services has improved outcomes for children and adolescents living with HIV in Kenya. Minimal data are available on these outcomes. We describe temporal trends in outcomes for children and adolescents initiating antiretroviral therapy (ART) from 2004 to 2014 at sites supported by Centre for Health Solutions - Kenya in central Kenya. We retrospectively analysed data from children aged 0-9 years (n=3519) and adolescents aged 10-19 years (n=1663) living with HIV who newly initiated ART at 47 health facilities in central Kenya. Year cohorts were analysed from the Comprehensive Patient Application Database (CPAD) and International Quality Care (IQCare) electronic medical databases including temporal trends in outcomes and associated factors using multivariable competing risks regression analysis. There were more girls (2453 [52.7%]) than boys, with most enrolled at World Health Organisation (WHO) stage II (1813 [37.7%]) or III disease (1694 [35.1%]). Most of the children and adolescents (4,431 [96.4%]) did not have tuberculosis (TB) symptoms. Cumulative LTFU incidence at 6, 12, 24, and 36 months were 5.0%, 9.9%, 22.9%, and 33.1%, respectively. Cumulative mortality incidence at 6, 12, 24, and 36 months were 0.7%, 1.0%, 1.2%, and 1.5%, respectively. LTFU was higher among female children and adolescents, those initiated on tenofovir-based regimens, and those with presumptive TB symptoms. Mortality risk was higher among those with WHO stage III or IV disease, and children and adolescents on TB treatment or who had presumptive TB. Enrolment occurred at a young age and pediatric friendly ART regimens initiated at earlier WHO stages implying effective early infant diagnosis and treatment for all strategies resulting in improved treatment outcomes. The higher retention rates in recent years as well as the lower retention after many years of follow-up underscores the importance of implementing longitudinal follow-up strategies targeting this population.

BACKGROUND: Previous research has shown a high prevalence of violence among young people in Kenya. Violence is a known risk factor for HIV acquisition and these two public health issues could be viewed as a syndemic. In 2010, Kenya became the third country to implement the Violence Against Children and Youth Survey (VACS). The study found a high prevalence of violence in the country. Led by the Government of Kenya, stakeholders implemented several prevention and response strategies to reduce violence. In 2019, Kenya implemented a second VACS. This study examines the changes in violence and risk factors for violence and HIV between 2010 and 2019. METHODS: The 2010 and 2019 VACS used a similar sampling approach and measures. Both VACS were cross-sectional national household surveys of young people aged 13-24 years, designed to produce national estimates of physical, sexual, and emotional violence. Prevalence and changes in lifetime experiences of violence and risk factors for violence and HIV were estimated. The VACS uses a three-stage cluster sampling approach with random selection of enumeration areas as the first stage, households as the second stage, and an eligible participant from the selected household as the third stage. The VACS questionnaire contains sections on demographics, risk and protective factors, violence victimisation, violence perpetration, sexual behaviour, HIV testing and services, violence service knowledge and uptake, and health outcomes. For this study, the main outcome variables were violence victimisation, context of violence, and risk factors for violence. All analyses were done with the entire sample of 13-24-year-olds stratified by sex and survey year. FINDINGS: The prevalence of lifetime sexual, physical, and emotional violence significantly declined in 2019 compared with 2010, including unwanted sexual touching, for both females and males. Experience of pressured and forced sex among females also decreased between the surveys. Additionally, significantly more females sought and received services for sexual violence and significantly more males knew of a place to seek help in 2019 than in 2010. The prevalence of several risk factors for violence and HIV also declined, including infrequent condom use, endorsement of inequitable gender norms, endorsement of norms justifying wife beating, and never testing for HIV. INTERPRETATION: Kenya observed significant declines in the prevalence of lifetime violence and some risk factors for violence and HIV, and improvements in some service seeking indicators between 2010 and 2019. Continued prioritisation of preventing and responding to violence in Kenya could contribute to further reductions in violence and its negative outcomes. Other countries in the region that have made substantial investments and implemented similar violence prevention programmes could use repeat VACS data to monitor violence and related outcomes over time. FUNDING: None.

BACKGROUND: Retention of patients who did not initiate antiretroviral therapy (ART) has been persistently low compared to those who initiated ART. Understanding the temporal trends in clinical outcomes prior to ART initiation may inform interventions targeting patients who do not initiate ART immediately after diagnosis. METHODS: A retrospective cohort analysis of known HIV-infected patients who did not initiate ART from healthcare facilities in Central Kenya was done to investigate temporal trends in characteristics, retention, and mortality outcomes. The data were sourced from the Comprehensive Care Clinic Patient Application Database (CPAD) and IQ care electronic patient-level databases for those enrolled between 2004 and 2014. RESULTS: A total of 13,779 HIV-infected patients were assessed, of whom 30.7% were men.There were statisitically significant differences in temporal trends relating to marital status, WHO clinical stage, and tuberculosis (TB) status from 2004 to 2014. The proportion of widowed patients decreased from 9.1 to 6.0%. By WHO clinical stage at enrollment in program, those in WHO stage I increased over time from 8.7 to 43.1%, while those in WHO stage III and IV reduced from 28.5 to 10.8% and 4.0 to 1.1% respectively. Those on TB treatment during their last known visit reduced from 8.3 to 3.9% while those with no TB signs increased from 58.5 to 86.8%. Trends in 6 and 12 month retention in the program, loss to follow-up (LTFU) and mortality were statistically significant. At 6 months, program retention ranged between 36.0% in 2004 to a high of 54.1% in 2013. LTFU at 6 months remained around 50.0% for most of the cohorts, while mortality at 6 months was 7.5% in 2004 but reduced to 3.8% in 2014. At 12 months, LTFU was above 50.0% across all the cohorts while mortality rate reached 3.9% in 2014. CONCLUSION: Trends in pre ART enrollment suggested higher enrollment among patients who were women and at earlier WHO clinical stages. Retention and mortality outcomes at 6 and 12 months generally improved over the 11 year follow-up period, though dipped as enrollment in asymptomatic disease stage increased.

One component of the Joint United Nations Programme on HIV/AIDS (UNAIDS) goal to end the HIV/AIDS epidemic by 2030, is that 95% of all persons receiving antiretroviral therapy (ART) achieve viral suppression.(†) Thus, testing all HIV-positive persons for viral load (number of copies of viral RNA per mL) is a global health priority (1). CDC and other U.S. government agencies, as part of the U.S. President's Emergency Plan for AIDS Relief (PEPFAR), together with other stakeholders, have provided technical assistance and supported the cost for multiple countries in sub-Saharan Africa to expand viral load testing as the preferred monitoring strategy for clinical response to ART. The individual and population-level benefits of ART are well understood (2). Persons receiving ART who achieve and sustain an undetectable viral load do not transmit HIV to their sex partners, thereby disrupting onward transmission (2,3). Viral load testing is a cost-effective and sustainable programmatic approach for monitoring treatment success, allowing reduced frequency of health care visits for patients who are virally suppressed (4). Viral load monitoring enables early and accurate detection of treatment failure before immunologic decline. This report describes progress on the scale-up of viral load testing in eight sub-Saharan African countries from 2013 to 2018 and examines the trajectory of improvement with viral load testing scale-up that has paralleled government commitments, sustained technical assistance, and financial resources from international donors. Viral load testing in low- and middle-income countries enables monitoring of viral load suppression at the individual and population level, which is necessary to achieve global epidemic control. Although there has been substantial achievement in improving viral load coverage for all patients receiving ART, continued engagement is needed to reach global targets.

CDC and the U.S. President’s Emergency Plan for AIDS Relief (PEPFAR) are committed to maintaining an international response to the HIV epidemic even as countries face the challenge of controlling the COVID-19 pandemic (1). The Joint United Nations Programme on HIV/AIDS has set the following 95-95-95 targets for HIV infection control by 2030: 1) ensure that 95% of HIV-positive persons are aware of their HIV status, 2) ensure that 95% of these persons receive antiretroviral treatment (ART) and 3) facilitate viral load testing and suppression (viral load ≤1,000 HIV RNA copies per mL of blood) among 95% of persons with HIV infection (2). PEPFAR and international donors support 50 countries by investing in diagnostic testing, ART, and viral load testing to monitor treatment outcomes. Recent COVID-19–related stay-at-home orders and travel restrictions have affected essential HIV services worldwide. In the face of these challenges, CDC and PEPFAR are committed to sustaining the momentum necessary to achieve the target goal of facilitating testing and viral suppression among 95% of persons with HIV.

BACKGROUND: WHO revised their HIV drug resistance (HIVDR) monitoring strategy in 2014, enabling countries to generate nationally representative HIVDR prevalence estimates from surveys conducted using this methodology. In 2016, we adopted this strategy in Uganda and conducted an HIVDR survey among adults initiating or reinitiating ART. METHODS: A cross-sectional survey of adults aged ≥18 years initiating or reinitiating ART was conducted at 23 sites using a two-stage cluster design sampling method. Participants provided written informed consent prior to enrolment. Whole blood collected in EDTA vacutainer tubes was used for preparation of dried blood spot (DBS) specimens or plasma. Samples were shipped from the sites to the Central Public Health Laboratory (CPHL) for temporary storage before transfer to the Uganda Virus Research Institute (UVRI) for genotyping. Prevalence of HIVDR among adults initiating or reinitiating ART was determined. RESULTS: Specimens from 491 participants (median age 32 years and 61.5% female) were collected between August and December 2016. Specimens from 351 participants were successfully genotyped. Forty-nine had drug resistance mutations, yielding an overall weighted HIVDR prevalence of 18.2% with the highest noted for NNRTIs at 14.1%. CONCLUSIONS: We observed a high HIVDR prevalence for NNRTIs among adults prior to initiating or reinitiating ART in Uganda. This is above WHO's recommended threshold of 10% when countries should consider changing from NNRTI- to dolutegravir-based first-line regimens. This recommendation was adopted in the revised Ugandan ART guidelines. Dolutegravir-containing ART regimens are preferred for first- and second-line ART regimens.