Statistical Considerations for Cross-Sectional HIV Incidence Estimation Based on Recency Test

Abstract: Longitudinal cohorts to determine the incidence of HIV infection are logistically challenging, so researchers have sought alternative strategies. Recency test methods use biomarker profiles of HIV-infected subjects in a cross-sectional sample to infer whether they are "recently" infected and to estimate incidence in the population. Two main estimators have been used in practice: one that assumes a recency test is perfectly specific, and another that allows for false-recent results. To date, these commonly used estimators have not been rigorously studied with respect to their assumptions and statistical properties. In this paper, we present a theoretical framework with which to understand these estimators and interrogate their assumptions, and perform a simulation study to assess the performance of these estimators under realistic HIV epidemiological dynamics. We conclude with recommendations for the use of these estimators in practice and a discussion of future methodological developments to improve HIV incidence estimation via recency test.