IntroductionAcute HIV infection (AHI) diagnosis is challenging due to complex diagnostics and low prevalence. We tested different targeting approaches for AHI testing using data from a cross-sectional study of STI burden in Eswatini.MethodsFrom June 2022 to April 2023, adults underwent routine HIV and viral load (VL) testing (Xpert) and completed a questionnaire on socio-demographics, behavioral characteristics and current symptoms. AHI was defined as negative/discordant serial HIV rapid diagnostic test and VL ≥10,000 copies/mL. We used lasso regression to determine risk factors for AHI and build study-specific predictor risk score (PRS). We evaluated the ability of the PRS and other targeting approaches to predict AHI.ResultsOf 1064 participants, ten (0.9%) had AHI. The 10-parameter PRS at cut-off ≥10.8 had the area under the curve (AUC) 0.87 (0.86-0.89), sensitivity 100% (69.2-100), and proportion needed to test (PNT) 26.1%. At the cut-off ≥14.1 the AUC was 0.85 (0.71-0.98), sensitivity 80% (44.4-97.5) and PNT 11.5%. A previously developed PRS and targeting young women reporting AHI symptoms also performed well, but not the WHO-recommended clinical screening criteria for AHI (sensitivity 40%).ConclusionsTargeted approaches that combine AHI symptoms and locally relevant characteristics may be an efficient way to support the scale-up of AHI testing.