Low rates of child testing for HIV persist in a high-risk area of East Africa

Family Testing: An Index Case Finding Strategy to Close the Gaps in Pediatric HIV Diagnosis

Despite significant advances in pediatric HIV treatment, too many children remain undiagnosed and thus without access to lifesaving antiretroviral therapy. It is critical to identify these children and initiate antiretroviral therapy as early as possible. Although the children of HIV-infected adults are at higher risk of infection, few access HIV testing services because of missed opportunities in existing case finding programs. Family testing is an index case finding strategy through which HIV-infected patients are systematically screened to identify family members with unknown HIV status. By specifically targeting a high-risk population, family testing is a pragmatic, high-yield, and efficient approach to identify previously undiagnosed HIV-infected children and link them to care before they become symptomatic. Despite this, incorporation of family testing into national guidelines and implementation of this case finding approach is variable. In this article, we review the evidence base for family testing, describe its challenges, and provide guidance and sample tools for program managers aiming to integrate family testing into existing health systems.

Acceptability of children's testing for HIV infection during routine care activities in the Pediatrics Department of Sourô Sanou Teaching Hospital in Bobo-Dioulasso (Burkina Faso)

BACKGROUND

In order to contribute to the fight against the pediatric HIV infection, we have assessed, through a study in which we have systematically proposed to carry out children's testing, the rate of acceptability and the feasibility of children's HIV testing during the routine activities of the department. We have also analyzed the reasons for the acceptability or the refusal of the child's HIV testing by the accompanying person.

METHODS

The study took place from May to September 2015 including all the parents/legal guardians of any child aged 0 to 14 years coming for a consultation or who was hospitalized in the Pediatric Department of Souro Sanou Teaching Hospital. Counseling sessions conducted by community health workers focused on informing and proposing the principle of child testing. After obtaining the verbal and informed consent of the accompanying person, the first test was performed with Determine® by a hospital health worker. A second SD Bioline®/ImmunoCombII® test was performed if the first test was positive. With children aged less than 18 months, after a positive antibody test, we resorted to PCR for confirmation.

RESULTS

A total of 848 accompanying persons, 568 of whom were female, underwent a pre-test interview during which the HIV test was offered to them. The mean age of accompanying persons was 30 (25.5 to 38) years; 747 accompanying persons (88.1%) accepted the testing of their child. We have found an influence of the accompanying person's religion (P=0.02) and the type of accompanying person on the acceptability of children's testing. Mothers were more willing to accept the test compared to other accompanying persons (P=0.002). The main reason for refusing the child's testing was the absence of one of the child's parents, mainly the father whose opinion was needed. The test was positive for HIV1 in 10 children.

CONCLUSION

In health centers, getting the informed consent from parents to test their children is a big challenge. However, our study shows that this is possible, through the high rate of acceptability obtained.

Modality of Primary HIV Disclosure and Association with Mental Health, Stigma, and Antiretroviral Therapy Adherence in Tanzanian Youth Living with HIV

Disclosing HIV status to children before adolescence is a major challenge facing families and healthcare providers. This study used a mixed methods approach to explore the youth perspective of how youth living with HIV (YLHIV) found out their status and to quantify the association of disclosure modality with mental health, stigma, adherence, and HIV outcomes in adolescence. Youth 11-24 years of age attending adolescent HIV clinic in Moshi, Tanzania were included. Adolescents answered questions, including when and how they found out they had HIV, mental health surveys (nine-item Patient Health Questionnaire, Strengths and Difficulties Questionnaire, and modified University of California Los Angeles trauma screen), modified Berger's stigma scale, and self-reported adherence. HIV-1 RNA and latest CD4 were obtained. In-depth interviews were conducted using a convenience sample. The majority of youth reported that they found out their HIV status on their own (80%). Youth attending the government site were less likely to be purposefully told their HIV status compared with those attending the referral site (p < 0.01). Depressive and emotional/behavioral symptoms, internal stigma, and incomplete adherence were significantly more likely among those who figured out their HIV status on their own as compared with those who were purposefully told. Youth discussed how they figured out their HIV status on their own during in-depth interviews. These findings demonstrated that youth who figured out their HIV status on their own had increased mental health symptoms and worse adherence to antiretroviral therapy (ART). It is imperative to implement disclosure protocols in early childhood to reduce mental health difficulties, internal stigma, and promote ART adherence in YLHIV.

Index case finding facilitates identification and linkage to care of children and young persons living with HIV/AIDS in Malawi

OBJECTIVES

Evaluation of a novel index case finding and linkage-to-care programme to identify and link HIV-infected children (1-15 years) and young persons (>15-24 years) to care.

METHODS

HIV-infected patients enrolled in HIV services were screened and those who reported untested household members (index cases) were offered home- or facility-based HIV testing and counselling (HTC) of their household by a community health worker (CHW). HIV-infected household members identified were enrolled in a follow-up programme offering home and facility-based follow-up by CHWs.

RESULTS

Of the 1567 patients enrolled in HIV services, 1030 (65.7%) were screened and 461 (44.8%) identified as index cases; 93.5% consented to HIV testing of their households and of those, 279 (64.7%) reported an untested child or young person. CHWs tested 711 children and young persons, newly diagnosed 28 HIV-infected persons (yield 4.0%; 95% CI: 2.7-5.6), and identified an additional two HIV-infected persons not enrolled in care. Of the 30 HIV-infected persons identified, 23 (76.6%) were linked to HIV services; 18 of the 20 eligible for ART (90.0%) were initiated. Median time (IQR) from identification to enrolment into HIV services was 4 days (1-8) and from identification to ART start was 6 days (1-8).

CONCLUSIONS

Almost half of HIV-infected patients enrolled in treatment services had untested household members, many of whom were children and young persons. Index case finding, coupled with home-based testing and tracked follow-up, is acceptable, feasible and facilitates the identification and timely linkage to care of HIV-infected children and young persons.

Vertical HIV transmission in perinatally-exposed infants in South-Rift region of Kenya: a retrospective cross sectional study

BACKGROUND

Despite proven efficacy of the prevention mother-to-child transmission of HIV strategy, its adoption in Africa has remained slow. In Kenya, its effectiveness remain unknown. The aim of this study was to assess the effectiveness of a prevention of mother-to-child transmission program in Kenya.

METHODS

This retrospective cross-sectional study analyzed 2,642 records of HIV-exposed infants who had a deoxyribonucleic acid polymerase chain reaction test done. The main outcome measure was HIV vertical transmission rates, stratified by i) infant age at diagnosis, ii) maternal prophylaxis and iii) infant mode of feeding. The characteristics of the infants who tested positive were compared to those who tested negative using Chi-square and Wilcoxon-Ranksum test. Bivariate and multivariate logistic regression analyses were conducted to establish associations and explore relationship between covariates and HIV transmission.

RESULTS

One thousand and one hundred nineteen (42.4%) infants had dried blood spot samples taken for HIV deoxyribonucleic acid polymerase chain reaction test within the first 6 weeks of age. Median age at diagnosis for HIV-positive infants was 4 months (IQR 1.5-9) while that of HIV-negative infants was 2 months (IQR 1.5-6). In total, 1,906 (72.1%) infants received prophylactic antiretrovirals. Infants whose mothers received prophylaxis had significantly lower vertical transmission rate (6.7%) compared to those whose mothers did not receive prophylaxis (24.0%), (OR 0.23, p < 0.001). When adjusted for feeding option and infant's age at diagnosis, the odds of transmission among women who received prophylaxis was 76% lower than that of women who did not receive any prophylaxis (OR 0.2 p < 0.001). 1,368 infants less than 6 months of age, 67.3%) were exclusively breastfed, 214 (10.5%) were replacement fed, and 164 (8.1%) mixed fed. Mixed feeding was associated with increased risk of HIV transmission (OR 2.7, p = 0.007). 67% of children older than 6 months were breastfed and had higher HIV transmission rate compared to those who were not breastfed (OR 2.3, p = 0.006).

CONCLUSIONS

The recorded rate of 9.3%, suggest the interventions implemented at the study sites were moderately effective, more so when provided early. Program performance will improve should the 12.8% of pregnant women who did not receive antiretroviral prophylaxis are reached.

An update on the HIV treatment cascade in children and adolescents

PURPOSE OF REVIEW

To provide an update on the HIV treatment cascade in children and adolescents. We reviewed the literature on the steps in the cascade, for the period 2014-2015.

RECENT FINDINGS

There remains high attrition of children with regards to early testing and linking those patients who are positive to early treatment. Barriers to screening and testing in children and adolescents are multifactorial. Linkage to pre-antiretroviral therapy care and retention in care are the main steps at which attrition occurs. There are a number of new formulations available for use in adolescents and children which offer more options for antiretroviral therapy treatment. Adherence levels appear to be reasonable in Africa and Asia; however, achieving viral load suppression remains a challenge.

SUMMARY

We have a long way to go to achieve decreased attrition at each step of the cascade and retain patients in care. Recent improvements in each step of the cascade are bringing us closer to achieving treatment success.

Acceptance of provider-initiated testing and counseling for HIV infection by caregivers in a tertiary health institution in Abuja, Nigeria: a cross sectional study

INTRODUCTION

Less than 10% of HIV positive children are enrolled into antiretroviral treatment program in the country. Provider-initiated testing and counseling was introduced to increasing uptake of HIV testing. The aim of this study is to determine the acceptability and factors undermining the acceptance of this laudable initiative by parents/caregivers of children attending paediatric out patient clinical services in our health institution.

METHODS

A cross sectional study of children aged 18 months to 18 years and their parents/caregivers attending paediatric outpatient clinic of the hospital was undertaken for the above objectives.

RESULTS

There were statistically more female parents/caregivers (82.5%, p=0.00), more male patients (52.9 %, p= 0.02), and 11.9% adolescents in this study. While 91.7% of parents/caregivers admitted not having knowledge of provider-initiated testing and counseling, 95.6% knew what HIV was. Acceptance of the program was high (98.7%), majority (89.7%) wanting to know the HIV status of their children/wards. Non-acceptance was small (1.2%), there main reason being prior knowledge of their HIV status. Prevalence of HIV among tested children was 1.7%. There was a strong relationship between having willingness to test for HIV and many of the study variables with religion of the parents/caregivers having the strongest relationship [OR: 13.94, (CI 1.82, 55.34)], and tribe having list association, [OR: 3.60, (CI 1.85, 17.14)].

CONCLUSION

There was general wiliness to accept HIV test for children by their parents/caregiver in this study, and HIV prevalence in children is on a downward trend; its sustenance to be continued and adolescent clinics need to be created.

One size does not fit all: HIV testing preferences differ among high-risk groups in Northern Tanzania

In order to maximize the effectiveness of "Seek, Test, and Treat" strategies for curbing the HIV epidemic, new approaches are needed to increase the uptake of HIV testing services, particularly among high-risk groups. Low HIV testing rates among such groups suggest that current testing services may not align well with the testing preferences of these populations. Female bar workers and male mountain porters have been identified as two important high-risk groups in the Kilimanjaro Region of Tanzania. We used conventional survey methods and a discrete choice experiment (DCE), a preference elicitation method increasingly applied by economists and policy-makers to inform health policy and services, to analyze trade-offs made by individuals and quantify preferences for HIV testing services. Bivariate descriptive statistics were used to analyze differences in survey responses across groups. Compared to 486 randomly selected community members, 162 female bar workers and 194 male Kilimanjaro porters reported 2-3 times as many lifetime sexual partners (p < 0.001), but similar numbers of lifetime HIV tests (median 1-2 across all groups). For the DCE, participants' stated choices across 12,978 hypothetical HIV testing scenarios (422 female and 299 male participants × 9 choice tasks × 2 alternatives) were analyzed using gender-specific mixed logit models. Direct assessments and the DCE data demonstrated that barworkers were less likely to prefer home testing and were more concerned about disclosure issues compared with their community counterparts. Male porters preferred testing in venues where antiretroviral therapy was readily available. Both high-risk groups were less averse to traveling longer distances to test compared to their community counterparts. These results expose systematic differences in HIV testing preferences across high-risk populations compared to their community peers. Tailoring testing options to the preferences of high-risk populations should be evaluated as a means of improving uptake of testing in these populations.

An assessment of HIV treatment outcomes among utilizers of semi-mobile clinics in rural Kenya

HIV/AIDS is a major cause of morbidity and mortality in Africa, and rates of retention in treatment are low. Some research has shown that mobile clinics are effective in connecting people in rural areas with health care. We compared HIV outcomes between HIV-positive patients who chose to access treatment from a regional hospital to those who chose care in one of four semi-mobile clinics closer to where they live. The subjects for this analysis were HIV-positive residents in West Pokot accessing care at one of four semi-mobile sites (Kabichbich, Chepareria, Kacheliba, and Sigor) or at the regional hospital in Kapenguria. We examined four outcome variables between the two groups: (1) retention in HIV treatment, (2) change in CD4 count, (3) adherence to ARVs, and (4) deaths. The patients who chose semi-mobile clinic care were less well educated, poorer, and sicker than those who chose to continue care in the regional hospital. There were no statistically significant differences between the groups in any of the four outcome measures. Although the population of patients attending semi-mobile clinics was on average poorer and sicker than those attending the hospital, their outcomes were similar. Care at the semi-mobile clinics did not result in significantly different outcomes from care in the district hospital. This program showed that semi-mobile clinics are a viable alternative to hospital care for very ill, isolated populations, but further measures must be taken to improve retention and adherence in these settings.

The Lablite project: a cross-sectional mapping survey of decentralized HIV service provision in Malawi, Uganda and Zimbabwe

Background

In sub-Saharan Africa antiretroviral therapy (ART) is being decentralized from tertiary/secondary care facilities to primary care. The Lablite project supports effective decentralization in 3 countries. It began with a cross-sectional survey to describe HIV and ART services.

Methods

81 purposively sampled health facilities in Malawi, Uganda and Zimbabwe were surveyed.

Results

The lowest level primary health centres comprised 16/20, 21/39 and 16/22 facilities included in Malawi, Uganda and Zimbabwe respectively. In Malawi and Uganda most primary health facilities had at least 1 medical assistant/clinical officer, with average 2.5 and 4 nurses/midwives for median catchment populations of 29,275 and 9,000 respectively. Primary health facilities in Zimbabwe were run by nurses/midwives, with average 6 for a median catchment population of 8,616. All primary health facilities provided HIV testing and counselling, 50/53 (94%) cotrimoxazole preventive therapy (CPT), 52/53 (98%) prevention of mother-to-child transmission of HIV (PMTCT) and 30/53 (57%) ART management (1/30 post ART-initiation follow-up only). All secondary and tertiary-level facilities provided HIV and ART services. In total, 58/81 had ART provision. Stock-outs during the 3 months prior to survey occurred across facility levels for HIV test-kits in 55%, 26% and 9% facilities in Malawi, Uganda and Zimbabwe respectively; for CPT in 58%, 32% and 9% and for PMTCT drugs in 26%, 10% and 0% of facilities (excluding facilities where patients were referred out for either drug). Across all countries, in facilities with ART stored on-site, adult ART stock-outs were reported in 3/44 (7%) facilities compared with 10/43 (23%) facility stock-outs of paediatric ART. Laboratory services at primary health facilities were limited: CD4 was used for ART initiation in 4/9, 5/6 and 13/14 in Malawi, Uganda and Zimbabwe respectively, but frequently only in selected patients. Routine viral load monitoring was not used; 6/58 (10%) facilities with ART provision accessed centralised viral loads for selected patients.

Conclusions

Although coverage of HIV testing, PMTCT and cotrimoxazole prophylaxis was high in all countries, decentralization of ART services was variable and incomplete. Challenges of staffing and stock management were evident. Laboratory testing for toxicity and treatment effectiveness monitoring was not available in most primary level facilities.

Electronic supplementary material

The online version of this article (doi:10.1186/1472-6963-14-352) contains supplementary material, which is available to authorized users.

HIV testing preferences in Tanzania: a qualitative exploration of the importance of confidentiality, accessibility, and quality of service

Background

HIV counseling and testing (HCT), an effective preventive strategy and an entry point for care, remains under-utilized in Tanzania. Limited uptake of HCT, despite the widespread availability of varied testing options, suggests that existing options may not align well with population preferences for testing.

Methods

Between October and December 2011, we conducted an exploratory study in the Kilimanjaro Region to develop a conceptual framework for understanding which characteristics of HIV testing are associated with preferences for testing. Forty individuals (55% women, 53% never having tested) participated in in-depth interviews and focus groups to identify factors that influence whether and where people test for HIV.

Results

A variety of discrete characteristics of testing venues, test providers, and testing procedures (e.g. distance to testing, counselor experience, type of HIV test, and availability of antiretroviral therapy) mapped conceptually to three domains: confidentiality of testing and test results, quality of HCT, and accessibility and availability of ancillary services. We noted heterogeneous preferences and demonstrate that while some test characteristics overlap and reinforce across multiple domains, others demand clients to make trade-offs between domains.

Conclusion

Testing decisions appear to be influenced by an array of often inter-linked factors across multiple domains, including quality, confidentiality, and accessibility; perceptions of these factors varied greatly across participants and across available testing options. HCT interventions that jointly target barriers spanning the three domains have the potential to increase uptake of HIV testing and deserve further exploration.

Barriers to provider-initiated testing and counselling for children in a high HIV prevalence setting: a mixed methods study

BACKGROUND

There is a substantial burden of HIV infection among older children in sub-Saharan Africa, the majority of whom are diagnosed after presentation with advanced disease. We investigated the provision and uptake of provider-initiated HIV testing and counselling (PITC) among children in primary health care facilities, and explored health care worker (HCW) perspectives on providing HIV testing to children.

METHODS AND FINDINGS

Children aged 6 to 15 y attending six primary care clinics in Harare, Zimbabwe, were offered PITC, with guardian consent and child assent. The reasons why testing did not occur in eligible children were recorded, and factors associated with HCWs offering and children/guardians refusing HIV testing were investigated using multivariable logistic regression. Semi-structured interviews were conducted with clinic nurses and counsellors to explore these factors. Among 2,831 eligible children, 2,151 (76%) were offered PITC, of whom 1,534 (54.2%) consented to HIV testing. The main reasons HCWs gave for not offering PITC were the perceived unsuitability of the accompanying guardian to provide consent for HIV testing on behalf of the child and lack of availability of staff or HIV testing kits. Children who were asymptomatic, older, or attending with a male or a younger guardian had significantly lower odds of being offered HIV testing. Male guardians were less likely to consent to their child being tested. 82 (5.3%) children tested HIV-positive, with 95% linking to care. Of the 940 guardians who tested with the child, 186 (19.8%) were HIV-positive.

CONCLUSIONS

The HIV prevalence among children tested was high, highlighting the need for PITC. For PITC to be successfully implemented, clear legislation about consent and guardianship needs to be developed, and structural issues addressed. HCWs require training on counselling children and guardians, particularly male guardians, who are less likely to engage with health care services. Increased awareness of the risk of HIV infection in asymptomatic older children is needed.

Provider-initiated HIV testing and counselling for children

Mary-Ann Davies and Emma Kalk reflect on recent research by Rashida Ferrand and colleagues into barriers to provider-initiated HIV testing for older children in Zimbabwe. Please see later in the article for the Editors' Summary