Field Validation of Limiting-Antigen Avidity Enzyme Immunoassay to Estimate HIV-1 Incidence in Cross-Sectional Survey in Swaziland

AIDS Res Hum Retroviruses. 2019 Oct;35(10):896-905. doi: 10.1089/AID.2018.0284. Epub 2019 Aug 15.


Reliable and accurate laboratory assays to detect recent HIV-1 infection have potential as simple and practical methods of estimating HIV-1 incidence in cross-sectional surveys. This study describes validation of the limiting-antigen (LAg) avidity enzyme immunoassay (EIA) in a cross-sectional national survey, conducted in Swaziland, comparing it to prospective follow-up incidence. As part of the Swaziland HIV-1 Incidence Measurement Survey (SHIMS), 18,172 individuals underwent counseling and HIV rapid testing in a household-based, population survey conducted from December 2010 to June 2011. Plasma samples from HIV-positive persons were classified as recent infections using an incidence testing algorithm with LAg-Avidity EIA (normalized optical density ≤1.5) followed by viral load (VL ≥1,000 copies/mL). All HIV-seronegative samples were tested for acute HIV-1 infection by nucleic acid amplification test (NAAT) pooling. HIV-seronegative individuals who consented to follow-up were retested ∼6 months later to detect observed HIV-1 seroconversion. HIV-1 incidence estimates based on LAg+VL and NAAT were calculated using assay-specific parameters and were compared with prospective incidence estimate. A total of 5,803 (31.9%) of 18,172 survey participants tested HIV seropositive; of these 5,683 (97.9%) were further tested with LAg+VL algorithm. The weighted annualized incidence from the longitudinal cohort study was 2.4% (95% confidence interval 2.0-2.7). Based on cross-sectional testing of HIV positives with LAg+VL algorithm, overall weighted annualized HIV-1 incidence was 2.5% (2.0-3.0), whereas NAAT-based incidence was of 2.6%. In addition, LAg-based incidence in men (1.8%; 1.2-2.5) and women (3.2%; 2.4-3.9) were similar to estimates based on observed incidence (men = 1.7%, women = 3.1%). Changes in HIV-1 incidence with age in men and women further validate plausibility of the algorithm. These results demonstrate that the LAg EIA, in a serial algorithm with VL, is a cost-effective tool to estimate HIV-1 incidence in cross-sectional surveys.

Keywords: HIV; LAg; SHIMS; Swaziland; incidence; viral load.

Publication types

  • Research Support, U.S. Gov't, Non-P.H.S.
  • Research Support, U.S. Gov't, P.H.S.

MeSH terms

  • Acute Disease
  • Adolescent
  • Adult
  • Algorithms
  • Anti-HIV Agents / therapeutic use
  • Antibody Affinity
  • Cost-Benefit Analysis
  • Cross-Sectional Studies
  • Eswatini / epidemiology
  • Female
  • Follow-Up Studies
  • Geography, Medical
  • HIV Antibodies / immunology
  • HIV Antigens / immunology*
  • HIV Infections / drug therapy
  • HIV Infections / epidemiology*
  • HIV Seropositivity / epidemiology
  • HIV-1 / immunology*
  • HIV-1 / isolation & purification
  • Health Surveys
  • Humans
  • Immunoenzyme Techniques / economics
  • Immunoenzyme Techniques / methods*
  • Incidence
  • Male
  • Middle Aged
  • Nucleic Acid Amplification Techniques
  • Prospective Studies
  • RNA, Viral / blood
  • Viral Load
  • Viremia / epidemiology*
  • Young Adult


  • Anti-HIV Agents
  • HIV Antibodies
  • HIV Antigens
  • RNA, Viral