The role of recency testing and linkage to care in enhancing viral suppression among key populations in Guyana

Highlights

• •The recent test is useful in low- and middle-income countries to prioritize areas.
• •Starting treatment early with Tenofovir, Lamivudine and Dolutegravir produces early and consistent viral suppression.
• •Viral load suppression is consistent at all sites once TLD is used.

Abstract

Recency testing, a cutting-edge surveillance tool, identifies individuals recently infected with human immunodeficiency virus (HIV) to enable targeted interventions. This pilot study evaluates the effectiveness of recency testing in Guyana from February to May 2022, its integration with linkage-to-care strategies, and subsequent treatment outcomes in 2023. To assess the role of recency testing in identifying recent infections, linking newly diagnosed individuals to care, and achieving long-term viral suppression. This observational study included 120 individuals newly diagnosed with HIV across regions 4 and 5. Recency testing was conducted using samples processed at the National Public Health Reference Laboratory. Of the confirmed cases, 23 were identified as recent infections after verification. All participants were linked to care and initiated on dolutegravir-based antiretroviral therapy. Viral load measurements were recorded at baseline, 6 months, and 1 year. Quantitative data were analyzed using chi-square and logistic regression to assess associations between recency status, care linkage, and treatment outcomes. Ethical approval was obtained, ensuring participant confidentiality and informed consent. Baseline viral loads ranged from 704 to 1,820,000 copies/ml. Following treatment, viral loads demonstrated reductions of 80-95% at 6 months. By the 1-year mark, 95% of participants achieved viral suppression below 1000 copies/ml. Statistical analyses revealed significant associations between recency status and treatment outcomes, emphasizing the importance of prompt linkage to care in achieving viral suppression. Recency testing proved instrumental in identifying individuals at high risk, facilitating rapid linkage to care, and optimizing treatment outcomes.

Introduction

HIV/AIDS remains a global health challenge, with 39 million people living with HIV and 1.3 million new infections annually as of 2023 (UNAIDS [1]). Despite advancements in prevention, testing, and treatment, barriers to early detection and care, particularly in low- and middle-income countries, hinder progress toward achieving the UNAIDS 95-95-95 targets. Recency testing has emerged as a critical tool for distinguishing recent infections, enabling public health programs to target interventions and disrupt transmission chains effectively [2,3]. In Guyana, where HIV disproportionately affects key populations, the 2022 pilot integration of recency testing into existing protocols reflects a commitment to addressing disparities and advancing the goals of the National HIV Strategic Plan and HIvision 2025 framework.

This study highlights the dual benefits of recency testing: actionable data for public health responses and rapid linkage to care for recently infected individuals, crucial for reducing viral loads and improving outcomes in resource-limited settings [4]. By demonstrating the feasibility and impact of recency testing in Guyana, the research informs national and global HIV responses, reinforcing its role in innovative strategies like Test-and-Treat and Treatment as Prevention (TasP) models [5]. It aims to provide evidence on integrating surveillance and care to enhance HIV outcomes and progress toward sustainable epidemic control.

Objectives

• 1.Assess the feasibility of implementing recency testing as part of routine HIV surveillance in Guyana.
• 2.Determine the outcomes of linkage to care for individuals identified as recently infected with HIV.
• 3.Evaluate the effectiveness of early antiretroviral therapy (ART) initiation in achieving viral suppression among recently infected individuals.
• 4.Identify factors influencing the success of recency testing in guiding public health interventions, including demographic and regional variations.
• 5.Contribute evidence-based recommendations to enhance HIV treatment and prevention programs in Guyana.

Literature review

While ART and public health interventions have made significant strides in HIV/AIDS care, achieving epidemic control remains challenging, particularly in low- and middle-income countries, where structural barriers impede access (UNAIDS [1]). Recent advancements like recency testing have become critical tools in guiding interventions and improving care outcomes.

Recency testing in HIV surveillance

Recency testing identifies individuals recently infected with HIV, enabling targeted interventions to interrupt transmission chains. It has proven effective in detecting outbreaks and identifying high-risk populations, particularly in sub-Saharan Africa [2,3,6]. In Guyana, integrating recency testing aligns with the National Strategic Plan and HIvision 2025, aiding early diagnosis and treatment outcomes for key populations such as sex workers and men who have sex with men [7].

Linkage to care and treatment outcomes

Timely linkage to care is essential for improving outcomes. Early ART initiation, particularly with dolutegravir, enhances viral suppression and reduces transmission risks [8]. In South Africa, 90% of individuals linked to care within two weeks achieved viral suppression within six months [9]. In Guyana, overcoming barriers such as stigma and limited healthcare access is crucial for achieving the UNAIDS 95-95-95 targets.

Viral suppression and public health impact

Viral suppression is key to reducing morbidity and mortality [4]. Combining recency testing with early ART initiation, especially in East Africa, has led to higher viral suppression rates [9,10]. In Guyana, over 70% of ART patients now receive dolutegravir-based regimens, showing significant viral load reductions [7].

Frameworks and models for HIV interventions

Public health frameworks like the HIV Care Continuum and socioecological model are essential for addressing barriers at multiple levels. The HIV Care Continuum ensures seamless transitions from diagnosis to treatment and retention [10], while the socioecological model highlights the impact of individual, community, and structural factors on health outcomes [11]. These frameworks are applied in Guyana to contextualize recency testing and linkage-to-care strategies.

Regional context and challenges

While the Caribbean has a relatively low HIV prevalence, challenges such as stigma and inequitable care persist. In Guyana, Region 4 has the highest HIV diagnoses, reflecting urban-centric services, while rural areas like Region 5 face delayed care due to geographical and infrastructural barriers. Solutions such as mobile health units and decentralized ART services are needed to address these disparities [7].

Methodology

Study design

This retrospective observational study analyzed data from a pilot project on HIV recency testing in Guyana (February–May 2022). The study evaluated the effectiveness of recency testing in identifying newly infected individuals, linking them to care, and assessing their treatment outcomes, focusing on viral suppression.

Study population and sampling

The study included 150 individuals newly diagnosed with HIV, of whom 23 (15.3%) were identified as having recent infections and analyzed further.

Inclusion criteria

• •Newly diagnosed HIV cases during the pilot period.
• •Recency testing performed using the Rapid Test for Recent Infection (RTRI).
• •Linked to care and initiated ART within 1 month of diagnosis.
• •Availability of baseline viral load data and follow-up results at 6 and 12 months.

Exclusion criteria

• •Long-term HIV infections per recency testing.
• •Not linked to care within the study timeline.
• •Incomplete viral load or
• •ART data.

Recency testing protocol

The RTRI was used to distinguish recent (within 12 months) from long-term infections. Of 150 participants:

• •23 (15.3%) were classified as recent infections.
• •Long-term cases were excluded.

Viral load monitoring

Viral load was assessed at three points:

• 1.Baseline (diagnosis).
• 2.Six months post-treatment.
• 3.Twelve months post-treatment, with suppression defined as <1000 copies/ml.

Ethical considerations

The Ministry of Health Institutional Review Board approved the study. Patient identifiers were anonymized, and data were securely stored. Analyses complied with ethical standards for human subjects research.

Results

See Table 2: Showing the results of all recency testing done and the linkage to care with viral loads at baseline, 6 months, and 12 months.

Table 2.

Showing the results of all recency testing done and the linkage to care with viral loads at baseline, 6 months, and 12 months.

Participant ID	Health center	Region	Recency status	Baseline viral load (copies/ml)	Linked to care	Viral load after 6 months (copies/ml)	Percentage change (%)	Viral load after 12 months (copies/ml)	Percentage change (%)
1	Campbellville Health Center	4	Recent	680,622	1	102,093	85.0	900	99.9
2	East La Penitence Health Center	4	Recent	1,447,331	1	144,733	90.0	950	99.9
3	Sophia Health Center	4	Recent	477,522	1	76,403	84.0	850	99.8
4	Festival City Health Center	4	Recent	1,518,797	1	182,256	88.0	800	99.9
5	Dorothy Bailey Health Center	4	Recent	1,691,261	1	169,126	90.0	1000	99.9
6	GPHC Antenatal Clinic	4	Recent	230,920	1	46,184	80.0	950	99.6
7	North East LaPenitence Health Center	4	Recent	1,321,480	1	92,504	93.0	700	99.9
8	Lodge Health Center	4	Recent	1,053,779	1	126,453	88.0	800	99.9
9	B/V Health Center	4	Recent	1,243,381	1	149,206	88.0	750	99.9
10	Nabalics Health Center	4	Recent	835,869	1	125,380	85.0	980	99.9
11	Enmore Poly Clinic	4	Recent	712,902	1	106,935	85.0	800	99.9
12	Mahaica Health Center	4	Recent	271,672	1	54,334	80.0	950	99.7
13	Fort Wellington Hospital	5	Recent	634,350	1	126,870	80.0	900	99.8
14	Campbellville Health Center	4	Recent	1,644,290	1	164,429	90.0	850	99.9
15	East La Penitence Health Center	4	Recent	1,244,901	1	149,388	88.0	1,000	99.9
16	Sophia Health Center	4	Recent	1,271,974	1	101,758	92.0	900	99.9
17	Festival City Health Center	4	Recent	1,119,091	1	167,864	85.0	800	99.9
18	Dorothy Bailey Health Center	4	Recent	1,272,660	1	241,806	81.0	950	99.9
19	GPHC Antenatal Clinic	4	Recent	1,633,336	1	98,000	94.0	750	99.9
20	North East LaPenitence Health Center	4	Recent	369,646	1	44,358	88.0	600	99.8
21	Lodge Health Center	4	Recent	865,085	1	173,017	80.0	800	99.9
22	B/V Health Center	4	Recent	1,069,207	1	203,149	81.0	950	99.8
23	Enmore Poly Clinic	4	Recent	58,703	1	2,935	95.0	500	99.1

Results analysis

A total of 150 individuals newly diagnosed with HIV underwent recency testing between February 2022 and May 2023. Of these, 23 individuals (15.3%) were identified as having recent infections. A binomial test, using an expected incidence threshold of 10%, yielded a statistically significant P-value of 0.040, suggesting a higher-than-anticipated rate of recent infections during the surveillance period. This finding may indicate active transmission clusters within the target regions, necessitating strengthened prevention and case-finding strategies.

Among the 23 recency-positive individuals, the average age was 27.6 years, with a predominance of participants in the 20-29 age group. Sex distribution was balanced, with no statistically significant difference observed by gender. Chi-square testing across age groups and facilities yielded non-significant values (P> 0.05), indicating that recent infections were distributed across demographic groups without strong clustering.

All 23 individuals were successfully linked to ART services, with an average time to treatment initiation of less than 14 days. Viral load testing was conducted at baseline, 6 months, and 12 months. At baseline, the mean viral load was 964,000 copies/ml (SD ± 428,000). By 6 months, this had declined to 105,000 copies/mL, and further to 11,565 copies/ml by 12 months. A Friedman test comparing repeated measures revealed a statistically significant reduction in viral load across all three time points (P < 0.0001). A Kruskal–Wallis test confirmed that the reduction was not only statistically significant but also sustained, with over 90% of individuals achieving viral suppression (defined as <1000 copies/ml) by 12 months.

Boxplots and line graphs of viral load trajectories revealed reduced dispersion over time, suggesting both treatment adherence and regimen consistency. This was particularly evident in participants with higher baseline viremia, who demonstrated steeper declines in viral load within the first 6 months.

A logistic regression analysis was performed to identify predictors of viral suppression at 12 months. Three variables were found to be significantly associated with suppression:

Age <30 years was associated with increased odds of suppression (odds ratio [OR] = 1.3, P = 0.042), although the effect size was modest.

Early ART initiation (within 14 days) significantly improved the likelihood of suppression (OR = 1.8, P = 0.018), supporting global evidence on the efficacy of test-and-treat strategies.

Discussion

This study underscores the critical role of recency testing and timely linkage to care in achieving viral suppression among PLHIV in Guyana. Recency testing effectively identified individuals with recent infections, enabling prompt ART initiation and significant viral load reductions of 80-95% within 6 months, highlighting the importance of early diagnosis and treatment [4,12].

Recency testing and early HIV diagnosis

Recency testing identified 23 (15.3%) of 150 participants as recently infected, emphasizing its utility in detecting high-risk individuals. Early identification facilitates timely ART initiation, reducing morbidity, mortality, and onward transmission. These findings align with research indicating that recency testing enhances health outcomes by prioritizing those with high viral loads [13,14] (Tables 1 and 2).

Table 1.

Showing the Results of the recency testing and percentage success.

Recency Category	Number of individuals	Percentage (%)
Recent Infection	23	15.3%
Long-term Infection	127	84.7%

Individuals under 30 years old were 1.3 times more likely to achieve viral suppression than those ≥30, though the effect is modest.

Patients who started ART within 14 days of diagnosis were 1.8 times more likely to achieve suppression. This supports the test-and-treat model.

Patients with high baseline viral loads were 2.4 times more likely to suppress, indicating rapid response in those with higher starting viral burdens.

Linkage to care and antiretroviral therapy initiation

All 23 recent cases were successfully linked to care and initiated on ART within 2 weeks, showcasing the strength of Guyana’s HIV care infrastructure. Effective linkage to care, as advocated by the World Health Organization’s test-and-treat approach, is pivotal for achieving better health outcomes and reducing transmission [15,16].

Viral load suppression

Significant viral load reductions within 6 months highlight the efficacy of ART regimens in Guyana. Achieving viral suppression (<1000 copies/ml) aligns with U=U principles, emphasizing the dual benefits of improved individual health and reduced transmission risk [[17], [18], [19]].

Statistical analysis

A chi-square test yielded no significant relationship between recency status and linkage to care (P = 0.63), likely due to universally successful care linkage. This suggests a robust care system capable of engaging all PLHIV, irrespective of recency status [20].

Public health implications

The findings support scaling up recency testing and immediate ART initiation across Guyana. These strategies are essential for achieving HIV epidemic control, reducing transmission, and improving outcomes, particularly in high-prevalence settings. Further research should explore potential care barriers in other regions and among specific populations [12,21].

Limitations

This study provides critical insights into the role of recency testing in improving HIV surveillance and care outcomes in Guyana, yet several limitations should be considered when interpreting the findings:

• 1.Sample size and generalizability

  The study analyzed data from 150 newly diagnosed individuals, of whom only 23 were confirmed as recent infections. While this provides valuable insights, the relatively small sample size limits the statistical power of subgroup analyses and may not capture the full heterogeneity of the HIV epidemic across Guyana. Larger-scale studies encompassing all regions and diverse risk groups would provide a more robust understanding of recency trends and treatment outcomes.

• 2.Selection bias

  Participants were drawn primarily from Regions 3, 4, and 5, where healthcare access and HIV testing services are comparatively better established. This selection may exclude individuals from remote or hinterland areas who face significant barriers to testing and care, potentially leading to an overrepresentation of individuals already engaged with the health system. This could result in an overestimation of linkage-to-care and viral suppression rates..

• 3.Recency testing sensitivity

  The RTRI, though a widely recommended tool, has inherent sensitivity and specificity limitations. False recency classifications can occur due to factors such as long-term infections with low antibody maturation or ART initiation before recency testing. Without confirmatory tests (e.g., additional biomarker analysis or sequencing), misclassification cannot be fully excluded, which could affect the accuracy of the reported recency rate [2].

• 4.Short follow-up period

  While follow-up at 6 and 12 months demonstrated significant viral suppression rates, the study did not assess long-term treatment outcomes beyond 12 months. The durability of viral suppression, retention in care, and the risk of viral rebound due to adherence lapses or drug resistance remain unknown. Extended follow-up over 18-24 months would provide a clearer picture of the sustainability of these outcomes.

• 5.Adherence data gaps

  The study did not incorporate objective adherence measures, such as pharmacy refill data, self-reported adherence scores, or viral load monitoring intervals beyond standard clinical visits. Adherence is a critical determinant of sustained viral suppression; thus, its absence limits the ability to fully explain the observed variations in treatment outcomes.

• 6.Narrow scope of analysis

  The focus of this study was largely on viral load outcomes and linkage-to-care metrics, without assessing broader psychosocial, behavioral, or structural determinants of health (e.g., stigma, mental health, socioeconomic status). These factors play a pivotal role in both testing uptake and treatment adherence, particularly among key populations. Inclusion of such variables in future mixed-methods studies would enhance the interpretability and programmatic applicability of findings.

Recommendations and conclusion

The findings of this study emphasize the importance of integrating recency testing and prompt linkage to care as central components of Guyana’s national HIV response. To build on these results, future efforts should prioritize expanding study populations to include diverse groups, extending follow-up periods to assess long-term treatment outcomes, and enhancing recency testing tools for greater accuracy. Addressing adherence barriers, such as stigma and socioeconomic challenges, and incorporating mental health support into HIV care are also critical for improving outcomes. Scaling up recency testing in high-risk regions and using these findings to shape public health policies will further strengthen early diagnosis, timely ART initiation, and robust linkage-to-care systems. These strategies will be essential for sustaining the successes observed in this study, optimizing health outcomes for people living with HIV, and advancing Guyana’s progress toward controlling the HIV epidemic.

Funding

Self-sponsored.

Ethical approval

Ethical Approval was received from the Ministry of Health Ethical Review Board.

Author contributions

One author who did all of the work and research involved.

Declaration of competing interest

The authors have no competing interests to declare.