Acceptability of Long-Acting Injectable Antiretroviral Therapy Among People with HIV Receiving Care at Three Ryan White Funded Clinics in the United States.

Understanding the acceptability of long-acting injectable antiretroviral therapy (LAI-ART) among people with HIV (PWH), especially priority populations, is essential for effective implementation. We conducted semi-structured interviews with patients in three Ryan White-funded HIV clinics in San Francisco, Chicago, and Atlanta. We employed maximal variation sampling across age, gender, race, ethnicity, and time living with HIV and oversampled for individuals with suboptimal clinical engagement. An 8-step hybrid deductive and inductive thematic analysis approach guided data analysis. Between August 2020 and July 2021, we conducted 72 interviews. Median age was 46 years; 28% were ciswomen, 7% transwomen, 44% Black/African-American and 35% Latinx, 43% endorsed a psychiatric diagnosis, 35% were experiencing homelessness/unstable housing, and 10% had recent substance use. Approximately 24% were sub-optimally engaged in care. We observed a spectrum of LAI-ART acceptability, ranging from enthusiasm to hesitancy to rejection. We also characterized four emergent orientations towards LAI-ART: innovator, pragmatist, deliberator, and skeptic. Overall, the majority of participants expressed favorable initial reactions towards LAI-ART. Most approached LAI-ART pragmatically, but acceptability was not static, often increasing over the course of the interview. Participants considered their HIV providers as essential for affirming personal relevance. HIV stigma, privacy concerns, and medical mistrust had varied impacts, sometimes facilitating and other times hindering personal relevance. These findings held across priority populations, specifically young adults, cis/trans women, racial/ethnic minorities, and individuals with suboptimal clinical engagement. Further research is needed to explore the transition from hypothetical acceptance to uptake and to confirm the actual benefits and drawbacks of this treatment.

RESUMEN: La aceptabilidad de la terapia antirretroviral inyectable de acción prolongada (LAI-ART, por su sigla en inglés) entre personas con VIH es esencial para una implementación efectiva. Durante el periodo de agosto de 2020 a julio de 2021, realizamos 72 entrevistas semiestructuradas con personas con VIH en clínicas públicas ubicadas en San Francisco, Chicago y Atlanta. Un análisis temático, tanto deductivo como inductivo, guio nuestra investigación. Observamos un espectro de aceptabilidad de LAI-ART que va desde el entusiasmo hasta la indecisión y el rechazo. También caracterizamos cuatro orientaciones actitudinales emergentes hacia LAI-ART: innovadora, pragmática, deliberativa y escéptica. Los participantes también señalaron la importancia de sus proveedores de VIH para validar su relevancia personal. El estigma asociado al VIH, preocupaciones sobre la privacidad y desconfianza en el sistema médico tuvieron diversos impactos, a veces facilitando y otras veces obstaculizando la relevancia personal. Entre las poblaciones prioritarias del estudio, los resultados fueron consistentes.

An automated best practice advisory increases both routine HIV screening and HIV cotesting with sexually transmitted infections in the emergency department.

BACKGROUND: There is increasing interest in improving routine HIV screening in emergency departments and increasing HIV cotesting rates among patients tested for sexually transmitted infections (STIs), who are considered at elevated risk of acquiring HIV. METHODS: This is a retrospective review of all ED encounters at a large, urban emergency departments with an existing HIV screening program for seven months before (November 1, 2018, to May 30, 2019) and after (June 1 to December 31, 2019) the implementation of a best practice advisory prompting universal HIV and syphilis screening. RESULTS: The study included 14,767 unique encounters, with 3,982 pre-implementation encounters and 10,785 post-implementation. After implementation, HIV testing increased 242%, from 2,851 tests to 9,757, and syphilis testing increased 326%, from 2,191 tests to 9,330. The proportion of encounters for urogenital STI testing without HIV cotesting decreased by 10.3%, from 43.6% to 33.3%. DISCUSSION: An automated electronic medical record (EMR) prompt can have a huge impact on both HIV and syphilis testing rates, as well as the rate of missed opportunities for cotesting among patients undergoing STI testing. CONCLUSIONS: Hospitals should support screening with automated alerts to help meet quality metrics, improve screening rates, and reduce missed opportunities for screening in vulnerable patients.

Filling in the Gaps: Updates on Doxycycline Prophylaxis for Bacterial Sexually Transmitted Infections.

Over the past two decades, cases of sexually transmitted infections (STIs) due to syphilis, gonorrhea, and chlamydia have been rising in the United States, disproportionately among gay, bisexual, and other men who have sex with men (MSM), as well as racial and ethnic minorities of all genders. In this review, we address updates about the evidence on doxycycline post-exposure prophylaxis (doxy-PEP) for prevention of bacterial STIs, including efficacy, safety, antimicrobial resistance (AMR), acceptability, modeling population impact, and evolving guidelines for use. Equitable implementation of doxy-PEP will require evaluation of who is offered and initiates it, understanding patterns of use and longer-term STI incidence and AMR, provider training, and tailored community education.

Reflex Human Immunodeficiency Virus (HIV) Type 1 RNA Testing Enables Timely Differentiation of False-Positive Results From Acute HIV Infection.

Accurate, timely human immunodeficiency virus (HIV) diagnosis is critical. Routine HIV screening program data were examined before and after reflex HIV type 1 RNA testing. Reflex testing facilitated confirmation of reactive HIV screening assays (as true or false positives) (odds ratio, 23.7 [95% confidence interval, 6.7-83.4]; P < .0001), improving detection of acute HIV and reducing unconfirmed discordant results.

Multi-Level and Intersectional Stigma Experienced by Black Transgender Women in Chicago: a Qualitative Study to Inform Sociostructural Interventions for Reducing Stigma and Improving Health Outcomes.

BACKGROUND: Stigma contributes to health disparities including increased HIV vulnerability among minority communities. Black transgender women experience multiple forms of stigma (e.g., anticipated, experienced), which can result in poor HIV-related outcomes. We utilized an adapted social ecological model (ASEM) to better understand the levels at which stigma is encountered and its impact on lived experience, particularly related to making healthcare decisions. METHODS: Semi-structured interviews and two focus groups (n = 38) were conducted with Black transgender women and Black transfeminine individuals in Chicago from 2016 to 2017. Participants were asked about discrimination in the community, healthcare experiences, and their thoughts and decision-making process with their healthcare provider regarding HIV pre-exposure prophylaxis. We conducted thematic analysis and organized our findings based on the levels of the ASEM: individual, interpersonal, organizational, community, and structural. RESULTS: Participants experienced and anticipated stigma at each ASEM level. Stigma was not experienced in isolation: stigma experienced at one level caused anticipated stigma at other levels and internalized stigma leading to negative self-image. In each case, stigma adversely impacted health outcomes (e.g., medication nonadherence, disengagement from care). Stigma within healthcare settings, medication-related stigma, and stigma directed at appearance and identity are particularly detrimental to shared decision-making with a healthcare provider. CONCLUSIONS: Recognizing and valuing Black transgender women's experience with stigma are essential for developing social and structural interventions that may work collaboratively across multiple levels of lived experience to reduce stigma and healthcare disparities faced by Black transgender women.

Concurrent Testing for COVID-19 and HIV Infection at 6 High-Volume Emergency Departments in a Priority Jurisdiction for Ending the HIV Epidemic in the United States.

BACKGROUND: The COVID-19 pandemic caused disruptions in access to routine HIV screening. SETTING: We assess HIV and severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) testing across 6 emergency departments (EDs) in Cook County, Illinois. METHODS: We retrospectively analyzed the number of SARS-CoV-2 tests, HIV screens, and the proportion of concurrent tests (encounters with both SARS-CoV-2 and HIV testing), correlating with diagnoses of new and acute HIV infection. RESULTS: Five sites reported data from March 1, 2020, to February 28, 2021, and 1 site from September 1, 2020, to February 28, 2021. A total of 1,13,645 SARS-CoV-2 and 36,094 HIV tests were performed; 17,469 of these were concurrent tests. There were 102 new HIV diagnoses, including 25 acute infections. Concurrent testing proportions ranged from 6.7% to 37% across sites (P < 0.001). HIV testing volume correlated with the number of new diagnoses (r = 0.66, P < 0.01). HIV testing with symptomatic SARS-CoV-2 testing was strongly correlated with diagnosis of acute infections (r = 0.87, P < 0.001); this was not statistically significant when controlling for HIV testing volumes (r = 0.59, P = 0.056). Acute patients were more likely to undergo concurrent testing (21/25) versus other new diagnoses (29/77; odds ratio = 8.69, 95% CI: 2.7 to 27.8, P < 0.001). CONCLUSIONS: Incorporating HIV screening into SARS-CoV-2 testing in the ED can help maintain HIV screening volumes. Although all patients presenting to the ED should be offered opt-out HIV screening, testing individuals with symptoms of COVID-19 or other viral illness affords the opportunity to diagnose symptomatic acute and early HIV infection, rapidly link to care, and initiate treatment.

Assessing readiness to implement long-acting injectable HIV antiretroviral therapy: provider and staff perspectives.

BACKGROUND: Long-acting injectable antiretroviral therapy (LAI-ART) represents the next innovation in HIV therapy. Pre-implementation research is needed to develop effective strategies to ensure equitable access to LAI-ART to individuals living with HIV. METHODS: We conducted focus group discussions (FGDs) with providers and staff affiliated with HIV clinics in San Francisco, Chicago, and Atlanta to understand barriers to and facilitators of LAI-ART implementation. Participants also completed a short survey about implementation intentions. FGDs were held via video conference, recorded, transcribed, and thematically analyzed using domains associated with the Consolidated Framework for Implementation Research (CFIR). RESULTS: Between September 2020 and April 2021, we led 10 FDGs with 49 participants, of whom ~60% were prescribing providers. Organizational readiness for implementing change was high, with 85% agreeing to being committed to figuring out how to implement LAI-ART. While responses were influenced by the unique inner and outer resources available in each setting, several common themes, including implementation mechanisms, dominated: (1) optimism and enthusiasm about LAI-ART was contingent on ensuring equitable access to LAI-ART; (2) LAI-ART shifts the primary responsibility of ART adherence from the patient to the clinic; and (3) existing clinic systems require strengthening to meet the needs of patients with adherence challenges. Current systems in all sites could support the use of LAI-ART in a limited number of stable patients. Scale-up and equitable use would be challenging or impossible without additional personnel. Participants outlined programmatic elements necessary to realize equitable access including centralized tracking of patients, capacity for in-depth, hands-on outreach, and mobile delivery of LAI-ART. Sites further specified unknown logistical impacts on implementation related to billing/payer source as well as shipping and drug storage. CONCLUSIONS: Among these HIV care sites, clinic readiness to offer LAI-ART to a subset of patients is high. The main challenges to implementation include concerns about unequal access and a recognition that strengthening the clinic system is critical.

PrEP Persistence Support and Monitoring in Areas of High HIV Burden in the Midwestern United States.

Monitoring pre-exposure prophylaxis (PrEP) metrics can guide service delivery yet does not occur routinely. We developed a survey to understand current practices for monitoring PrEP at PrEP-providing organizations in Illinois and Missouri. The survey was distributed from September through November 2020; 26 organizations participated. Most respondents indicated ongoing efforts to screen for PrEP eligibility (66.7%), link to care (87.5%), and retain clients in care (70.8%); 70.8% reported collecting data on PrEP initiation, 41.7% on retention in care, and 37.5% on missed visits. Barriers to monitoring PrEP metrics included lack of IT support (69.6%), manual processes (69.6%), and lack of staff resources (65.2%). Most respondents offered clients support for PrEP retention and adherence and wanted to expand interventions for PrEP persistence, yet fewer monitored corresponding metrics. To enhance PrEP implementation, organizations should improve monitoring and evaluation of PrEP metrics along the entire continuum and respond with appropriate services to support clients.

Ending the HIV Epidemic: Identifying Barriers and Facilitators to Implement Molecular HIV Surveillance to Develop Real-Time Cluster Detection and Response Interventions for Local Communities.

The rapid implementation of molecular HIV surveillance (MHS) has resulted in significant challenges for local health departments to develop real-time cluster detection and response (CDR) interventions for priority populations impacted by HIV. This study is among the first to explore professionals' strategies to implement MHS and develop CDR interventions in real-world public health settings. Methods: Semi-structured qualitative interviews were completed by 21 public health stakeholders in the United States' southern and midwestern regions throughout 2020-2022 to identify themes related to the implementation and development of MHS and CDR. Results for the thematic analysis revealed (1) strengths and limitations in utilizing HIV surveillance data for real-time CDR; (2) limitations of MHS data due to medical provider and staff concerns related to CDR; (3) divergent perspectives on the effectiveness of partner services; (4) optimism, but reluctance about the social network strategy; and (5) enhanced partnerships with community stakeholders to address MHS-related concerns. Conclusions: Enhancing MHS and CDR efforts requires a centralized system for staff to access public health data from multiple databases to develop CDR interventions; designating staff dedicated to CDR interventions; and establishing equitable meaningful partnerships with local community stakeholders to address MHS concerns and develop culturally informed CDR interventions.

"Everything Fell Apart Once COVID-19 Hit"-Leveraging the COVID-19 Response to Strengthen Public Health Activities toward Ending the HIV Epidemic: A Qualitative Study.

COVID-19 caused widespread disruption of activities for Ending the HIV Epidemic (EHE). In this study we assessed public health perspectives on leveraging the COVID-19 response to advance the goals of EHE. We conducted a qualitative study with 33 public health partners in the Midwestern and Southern United States from October 2020 to February 2022. Participants were asked how the strategies developed for COVID-19 could be applied to the HIV epidemic. Interviews were recorded, transcribed, and examined using rapid qualitative analysis. Four themes emerged: (1) Rebuilding teams and adapting culture for success in EHE activities; (2) Recognizing and modernizing the role of disease intervention specialists (DIS); (3) Enhanced community awareness of the public health role in disease response and prevention; and (4) Leveraging COVID-19 data systems and infrastructure for EHE activities. The COVID-19 pandemic called attention to the dearth of public health funding and outdated information technology (IT) infrastructure used for HIV activities. It also led to greater public health knowledge, including increased familiarity with partner services and molecular epidemiology of HIV, and opportunities to develop new data systems for surveillance that can be applied to efforts for EHE.

HIV testing in a high prevalence urban area in the US: Identifying missed opportunities two ways.

BACKGROUND: Routine opt-out HIV testing in healthcare settings is often not implemented to its fullest extent. We assessed factors contributing to missed HIV testing opportunities at an academic medical center in Chicago, Illinois, with a routine HIV screening program. METHODS: Retrospective analysis of HIV testing in clinical encounters was performed using multivariate regession models. Missed opportunities were defined as 1) an encounter during which an HIV test was not conducted on a patient later diagnosed with HIV, or 2) an encounter in which a bacterial STI test was performed without HIV testing. RESULTS: Of 122 people newly diagnosed with HIV from 2011-2018, 98 patients had 1215 prior encounters, of which 82.8% were missed opportunities. Female gender, persons not known to be men who have sex with men, and encounter location other than inpatient had higher odds of a missed opportunity. Nearly half (48.4%) of 104,678 bacterial STI testing encounters were missed opportunities. Female gender, older age, lack of syphilis testing, and location outside the emergency department had higher odds of a missed opportunity. CONCLUSIONS: We found a high number of missed HIV testing opportunities, which could be reduced by strengthening routine screening and increasing targeted testing concurrent with STI screening.

Are Patients and Their Providers Talking About Long-Acting Injectable Antiretroviral Therapy? Penetration into Clinical Encounters at Three U.S. Care Sites.

Use of long-acting injectable antiretroviral therapy depends on patient awareness, provider discussion, and patient willingness to use. We conducted a postvisit survey with patients at 3 HIV clinics in San Francisco, Chicago, and Atlanta in May 2021 to assess for inequities in these early implementation phases.

"Even if I'm undetectable, I just feel like I would die": a qualitative study to understand the psychological and socioeconomic impacts of the COVID-19 pandemic on women living with HIV (WLWH) in Chicago, IL.

BACKGROUND: The COVID-19 pandemic has affected the health and well-being of people worldwide, yet few studies have qualitatively examined its cumulative effects on ciswomen living with HIV (WLWH). We aimed to explore how the pandemic has impacted WLWH, including challenges related to HIV care, employment, finances, and childcare. We also investigated how HIV status and different psychosocial stressors affected their mental health. METHODS: We performed 25 semi-structured qualitative interviews with WLWH regarding the ways in which COVID-19 impacted their social determinants of health and physical well-being during the pandemic. 19 WLWH who received care at the University of Chicago Medicine (UCM) and 6 women who received care at Howard Brown Health, a federally qualified health center (FQHC) in Chicago, were interviewed remotely from June 2020 to April 2021. All interviews were audio recorded and transcribed. Interviews were thematically analyzed for commonalities regarding HIV-specific and general experiences of WLWH during the pandemic. RESULTS: The majority of participants reported COVID-19 impacted their HIV care, such as appointment cancellations and difficulties adhering to antiretroviral therapy. In addition to HIV care obstacles, almost all participants described perceived heightened vulnerability to or fear of COVID-19. The pandemic also affected the socioeconomic well-being of participants, with reported financial strains and employment disruptions. Some mothers took on additional childcare responsibilities, such as homeschooling. Increased mental health concerns and negative psychological effects from the social isolation associated with the pandemic were also experienced by most participants. CONCLUSIONS: We gained invaluable insight into how WLWH were challenged by and adapted to the COVID-19 pandemic, including its destabilizing effects on their HIV care and mental health. Women described how they undertook additional childcare responsibilities during the pandemic and how their HIV status compounded their concerns (e.g., perceived heightened vulnerability to COVID-19). Strategies to better support WLWH in maintaining their overall health throughout the pandemic include childcare assistance, access to affordable mental health services, support groups, and education from HIV care providers. These findings have significant implications for examining future health crises through the perspective of potential gender inequalities.

"When you have an immune disease like HIV and there is a pandemic, you still have to pay your bills": COVID-19-related challenges among people living with HIV and lessons for care delivery.

COVID-19 has disrupted routine medical care and increased psychosocial and economic stressors on a global scale, yet the full impact on people living with HIV (PLWH) and the HIV continuum of care remains unknown. As the pandemic continues to pose a significant threat to PLWH and their care, this research qualitatively aimed to elicit COVID-19-related challenges and perspectives of PLWH during the early phase of the pandemic and to identify lessons learned and impactful strategies for facilitating HIV care. We recruited 32 PLWH who receive care at a large academic medical center for semi-structured remote interviews to assess psychological/structural stressors experienced during the pandemic and to discern strategies for improving care. Most participants identified as Black (91%) and heterosexual (56%). Overall, PLWH reported exacerbated mental health stressors (e.g., anxiety, depression, substance use). Most participants cited no issues with antiretroviral therapy (ART) adherence or retention in care, yet five participants reported appointment cancellations or physician inaccessibility. Participants provided specific feedback for facilitating continued engagement in care during the pandemic, including telemedicine and education/patient empowerment. By seeking participant-provided solutions, this study centered on PLWH's experiences and emphasized proactive HIV care strategies for prioritizing patient empowerment and healthcare adaptability during a rapidly evolving pandemic.

Shared decision making for HIV pre-exposure prophylaxis (PrEP) with black transgender women.

Shared decision making is a collaborative process intended to develop a treatment plan that considers both the patient's preferences and the health provider's medical recommendations. It is one approach to reducing healthcare disparities by improving patient-provider communication and subsequent health outcomes. This study examines shared decision making about HIV pre-exposure prophylaxis (PrEP) with Black transgender women in Chicago, Illinois, USA, given high prevalence of HIV and disparities in PrEP use. Black transgender women were recruited online and in-person to participate in semi-structured interviews (n = 24) and focus groups (2; n = 14 total), conducted between 2016 and 2017. Iterative thematic content analysis took place. Analysis revealed that internalised transphobia and racism, combined with stigma from service providers, prevented disclosure of gender and sexual identity to providers. Stigma about PrEP as it relates to Black transgender women results in stereotype threat, which undermines patient-provider trust and deters shared decision making for PrEP. Shared decision making promotes cultural competence and humility and builds trust within the patient-provider relationship, leading to better communication and less stigma. The involvement of peers may be one way to mitigate stigma for Black transgender women around PrEP, promote cultural competence within organisations, and empower engagement in shared decision making for HIV prevention.

"That same stigma...that same hatred and negativity:" a qualitative study to understand stigma and medical mistrust experienced by people living with HIV diagnosed with COVID-19.

BACKGROUND: The COVID-19 and HIV epidemics have exacerbated existing inequities among vulnerable groups and severely impacted communities of color. People living with HIV (PLWH), who may already face stigma or discrimination, are at risk of experiencing further stigma as a result of COVID-19, which can result in medical mistrust. METHODS: We performed qualitative interviews between June and August 2020 among 32 PLWH, including 10 individuals diagnosed with COVID-19. A majority of participants perceived themselves as having an increased risk of contracting COVID-19 due to their HIV status. RESULTS: Of those who tested positive for COVID-19, the majority regarded their HIV diagnosis as having a more profound impact on their lives but found similarities between COVID-19 stigma and HIV-related stigma. Many participants also expressed mistrust. CONCLUSIONS: These results can be used to better understand the perspectives of PLWH during the COVID-19 pandemic and have important implications for potential COVID-19 vaccine hesitancy and future health crises.

SARS-CoV-2 percent positivity and risk factors among people with HIV at an urban academic medical center.

Since the onset of the COVID-19 pandemic, it has been unclear how vulnerable people with HIV (PwH) are to SARS-CoV-2 infection. We sought to determine if PwH are more likely to test positive for SARS-CoV-2 than people without HIV, and to identify risk factors associated with SARS-CoV-2 positivity among PwH. We conducted a cross-sectional study in which we collected electronic medical record data for all patients who underwent SARS-CoV-2 PCR testing at an academic medical center. Presence of HIV and other chronic diseases were based on the presence of ICD-10 diagnosis codes. We calculated the percent positivity for SARS-CoV-2 among PwH and among people without HIV. Among PwH, we compared demographic factors, comorbidities, HIV viral load, CD4 T-cell count, and antiretroviral therapy (ART) regimens between those who tested positive for SARS-CoV-2 and those who tested negative. Comparisons were made using chi squared tests or Wilcoxon rank sum tests. Multivariate models were created using logistic regression. Among 69,763 people tested for SARS-CoV-2, 0.6% (431) were PwH. PwH were not significantly more likely to test positive for SARS-CoV-2 than people without HIV (7.2% (31/431) vs 8.4% (5820/69763), p = 0.35), but were more likely to be younger, Black, and male (p-values < .0001). There were no significant differences in HIV clinical factors, chronic diseases, or ART regimens among PwH testing positive for SARS-CoV-2 versus those testing negative. In our sample, PwH were not more likely to contract SARS-CoV-2, despite being more likely to be members of demographic groups known to be at higher risk for infection. Differences between PwH who tested positive for SARS-CoV-2 and those who tested negative were only seen in Hispanic/Latino ethnicity (non-Hispanic or Latino vs unknown Hispanic or Latino ethnicity (OR 0.2 95% CI (0.6, 0.9)) and site of testing(inpatient vs outpatient OR 3.1 95% CI (1.3, 7.4)).

Cording in Disseminated Mycobacterium chelonae Infection in an Immunocompromised Patient.

Cording is a phenomenon in which acid fast bacilli grow in parallel and was previously used as a means of presumptive microscopic identification of Mycobacterium tuberculosis (TB). However, this process has been shown in multiple other nontuberculous mycobacterial (NTM) species. Here we present the case of an immunocompromised adult who presented with wrist pain, weight loss, and cough. A positron emission tomography scan showed uptake in the right ulna, multiple soft tissue sites, and the left lung. Biopsies and cultures were obtained from multiple sites, and the patient was ultimately diagnosed with disseminated Mycobacterium chelonae infection. The organism showed cording in culture. As seen in this patient, cording may occur in multiple NTM species and is not reliable as the sole indicator of the presence of TB.

Comparison of effectiveness and cost for different HIV screening strategies implemented at large urban medical centre in the United States.

INTRODUCTION: Incident HIV infections persist in the United States (U.S.) among marginalized populations. Targeted and cost-efficient testing strategies can help in reaching HIV elimination. This analysis compares the effectiveness and cost of three HIV testing strategies in a high HIV burden area in the U.S. in identifying new HIV infections. METHODS: We performed a cost analysis comparing three HIV testing strategies in Chicago: (1) routine screening (RS) in an inpatient and outpatient setting, (2) modified partner services (MPS) among networks of the recently HIV infected and diagnosed, and (3) a respondent drive sampling (RDS)-based social network (SN) approach targeting young African-American men who have sex with men. All occurred at the same academic medical centre during the following times: routine testing, 2011 to 2016; MPS, 2013 to 2016; SN: 2013 to 2014. Costs were in 2016 dollars and included personnel, HIV testing, training, materials, overhead. Outcomes included cost per test, HIV-positive test and new diagnosis. Sensitivity analyses were performed to assess the impact of population demographics. RESULTS: The RS programme completed 57,308 HIV tests resulting in 360 (0.6%) HIV-positive tests and 165 new HIV diagnoses (0.28%). The MPS completed 146 HIV tests, resulting in 79 (54%) HIV-positive tests and eight new HIV diagnoses (5%). The SN strategy completed 508 HIV tests, resulting in 210 (41%) HIV-positive tests and 37 new HIV diagnoses (7.2%). Labour accounted for the majority of costs in all strategies. The estimated cost per new HIV diagnosis was $16,773 for the RS programme, $61,418 for the MPS programme and $15,683 for the SN testing programme. These costs were reduced for the RS and MPS strategies in sensitivity analyses limiting testing efficacy to the highest prevalence patient populations ($2,841 and $33,233 respectively). CONCLUSIONS: The SN strategy yielded the highest proportion of new diagnoses, followed closely by the MPS programme. Both the SN strategy and RS programme were comparable in the cost per new diagnosis. A simultaneous approach that consists of RS in combination with SN testing may be most effective for identifying new HIV infections in settings with heterogeneous epidemics with both high rates of HIV prevalence and HIV testing.