INTRODUCTION
Acute HIV infection (AHI) cannot be detected with routine point-of-care antibody tests and is rarely diagnosed in resource-limited settings. However, characteristics of AHI, including its non-specific clinical presentation accompanied by high levels of plasma viraemia, may contribute to uncontrolled onward transmission within high-prevalence settings. Improving early detection of AHI in such settings could conceivably contribute to reducing onward transmission and thus impact on HIV elimination goals. We aimed to assess the programmatic feasibility of identifying and treating AHI patients in Eswatini, which has already achieved 90-90-90 targets.

METHODS
From March to December 2019, adults aged 16-49 years and attending outpatient departments at Nhlangano Health Center were screened for symptoms suggestive of AHI, including fever, sore throat, and current symptoms of a sexually transmitted infection. Individuals were enrolled into the study on testing negative or inconclusive for HIV using serial rapid diagnostic tests (RDT) Alere Determine™ HIV-1/2 (Abbott, USA) and Uni-Gold™ HIV (Trinity Biotech, Ireland), and on referral from HIV pre- and post-exposure prophylaxis programmes, if AHI was suspected. AHI was diagnosed using the Xpert platform (Cepheid, Sunnyvale, USA) to perform quantitative HIV RNA detection. Patients with AHI were offered immediate initiation of antiretroviral therapy (ART), follow-up care, and assisted partner notification.

ETHICS
This study was approved by the National Health Research and Review Board, Eswatini, and the MSF Ethics Review Board.

RESULTS
Of 2177 patients initially screened, 997 (46%) had symptoms suggestive of AHI. Of those, 611 (61%) patients were enrolled and tested with Xpert to assay HIV RNA viral load; this included n=586 because their HIV RDT test was negative; n=12 because HIV RDT was inconclusive; and seven and six were presumptive AHI cases identified in the pre- and post-exposure prophylaxis programmes respectively. Of those enrolled, 26 (4.3%) had a detectable HIV viral load. Median viral load was 4.70 log10 (interquartile range (IQR), 3.70-5.96). The most common complaints of those with AHI were fever, sore throat, headache, genital discharge and lower abdominal pain. 16 (62%) patients initiated ART. After two weeks, eight of 11 patients who were followed up had a suppressed viral load below 1000 copies/ml, and by three months, all patients who were on treatment achieved virological suppression. CD4 count was scheduled at every visit and among those with available test results, the median CD4 count was 476 cells/mm3 (IQR 305-768, n=16) at ART initiation, 522 cells/mm3 (IQR 426-713, n=eight) at one month, and 406 cells/mm3 (IQR 400-452, n=five) at three months. Only 11 partners were notified through the index patient; nine of them were HIV-negative and offered prevention methods, and two were HIV-positive.

CONCLUSION
Identifying and treating AHI in a routine outpatient setting can contribute to linkage with prompt HIV diagnosis and treatment. Conceivably, this could help contribute towards epidemic control in high HIV incidence settings. However, contact tracing and rapid linkage to care are vital challenges that need to be addressed.

CONFLICTS OF INTEREST
None declared.

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Diagnosing and treating cases of acute HIV infection within a high HIV incidence setting: feasibility study, Eswatini