Beyond early infant diagnosis: case finding strategies for identification of HIV-infected infants and children

Strategic HIV Case Findings among Infants at Different Entry Points of Health Facilities in Cameroon: Optimizing the Elimination of Mother-To-Child Transmission in Low- and- Middle-Income Countries

BACKGROUND

HIV case finding is an essential component for ending AIDS, but there is limited evidence on the effectiveness of such a strategy in the pediatric population. We sought to determine HIV positivity rates among children according to entry points in Cameroon.

METHODS

A facility-based survey was conducted from January 2015 to December 2019 among mother-child couples at various entry points of health facilities in six regions of Cameroon. A questionnaire was administered to parents/guardians. Children were tested by polymerase chain reaction (PCR). Positivity rates were compared between entry points. Associations were quantified using the unadjusted positivity ratio (PR) for univariate analyses and the adjusted positivity ratio (aPR) for multiple Poisson regression analyses with 95% confidence intervals (CIs). p-values < 0.05 were considered significant.

RESULTS

Overall, 24,097 children were enrolled. Among them, 75.91% were tested through the HIV prevention of mother-to-child transmission (PMTCT) program, followed by outpatient (13.27%) and immunization (6.27%) services. In total, PMTCT, immunization, and outpatient services accounted for 95.39% of children. The overall positivity was 5.71%, with significant differences (p < 0.001) between entry points. Univariate analysis showed that inpatient service (PR = 1.45; 95% CI: [1.08, 1.94]; p = 0.014), infant welfare (PR = 0.43; 95% CI: [0.28, 0.66]; p < 0.001), immunization (PR = 0.56; 95% CI: [0.45, 0.70]; p < 0.001), and PMTCT (PR = 0.41; 95% CI: [0.37, 0.46]; p < 0.001) were associated with HIV transmission. After adjusting for other covariates, only PMTCT was associated with transmission (aPR = 0.66; 95% CI: [0.51, 0.86]; p = 0.002).

CONCLUSIONS

While PMTCT accounts for most tested children, high HIV positivity rates were found among children presenting at inpatient, nutrition, and outpatient services and HIV care units. Thus, systematic HIV testing should be proposed for all sick children presenting at the hospital who have escaped the PMTCT cascade.

Using adult care visits to diagnose HIV infection in children, Burkina Faso

Objective

To estimate the feasibility, positivity rate and cost of offering child testing for human immunodeficiency virus (HIV) to mothers living with HIV attending outpatient clinics in Burkina Faso.

Methods

We conducted this implementation study in nine outpatient clinics between October 2021 and June 2022. We identified all women ≤ 45 years who were attending these clinics for their routine HIV care and who had at least one living child aged between 18 months and 5 years whose HIV status was not known. We offered these mothers an HIV test for their child at their next outpatient visit. We calculated intervention uptake, HIV positivity rate and costs.

Findings

Of 799 eligible children, we tested 663 (83.0%) and identified 16 new HIV infections: 2.5% (95% confidence interval, CI: 1.5-4.1). Compared with HIV-negative children, significantly more HIV-infected children were breastfed beyond 12 months (P-value: 0.003) and they had not been tested before (P-value: 0.003). A significantly greater proportion of mothers of HIV-infected children were unaware of the availability of child testing at 18 months (P-value: < 0.001) and had more recently learnt their HIV status (P-value: 0.01) than mothers of HIV-negative children. The intervention cost 98.1 United States dollars for one child testing HIV-positive. Barriers to implementing this strategy included shortages of HIV tests, increased workload for health-care workers and difficulty accessing children not living with their mothers.

Conclusion

Testing HIV-exposed children through their mothers in outpatient clinics is feasible and effective in a low HIV-prevalence setting such as Burkina Faso. Implementation of this strategy to detect undiagnosed HIV-infected children is recommended.

Pediatric Antiretroviral Therapy Coverage and AIDS Deaths in the "Treat All" Era

OBJECTIVES

In 2015, CD4-based clinical staging criteria for antiretroviral therapy (ART) initiation were removed, expanding ART eligibility ("Treat All") for children, who shoulder an outsized burden of HIV-related deaths. To quantify the impact of "Treat All" on pediatric HIV outcomes, we examined shifts in pediatric ART coverage and AIDS mortality before and after "Treat All" implementation.

METHODS

We abstracted country-level ART coverage (proportion of children <15 years on ART) and AIDS mortality (deaths per 100 000 population) estimates over 11 years. For 91 countries, we also abstracted the year "Treat All" was incorporated into national guidelines. We used multivariable 2-way fixed effects negative binomial regression to estimate changes in pediatric ART coverage and AIDS mortality potentially attributable to "Treat All" expansion, reported as adjusted incidence rate ratios (adj.IRR) with 95% confidence intervals (95% CI).

RESULTS

From 2010 to 2020, pediatric ART coverage tripled (16% to 54%), and AIDS-related deaths were halved (240 000 to 99 000). Compared with the pre-implementation period, observed ART coverage continued increasing after "Treat All" adoption, but this rate of increase declined by 6% (adj.IRR = 0.94, 95% CI: 0.91-0.98). AIDS mortality continued declining after "Treat All" adoption, but this rate of decline decreased by 8% (adj.IRR = 1.08, 95% CI: 1.05-1.11) in the post-implementation period.

CONCLUSIONS

Although "Treat All" called for increased HIV treatment equity, ART coverage continues lagging in children and comprehensive approaches that address structural issues, including family-based services and intensified case-finding, are needed to close pediatric HIV treatment gaps.

Pediatric HIV Pre-test Informational Video is Associated with Higher Knowledge Scores Compared to Counselor-Delivered Information

Video-based pre-test information is used in high resource settings to increase HIV testing coverage but remains untested in resource-limited settings. We conducted formative and evaluative focus group discussions with healthcare workers (HCWs) and caregivers of children in Kenya to develop and refine a pediatric HIV pre-test informational video. We then assessed HIV knowledge among caregivers sequentially enrolled in one of three pre-test information groups: (1) individual HCW-led (N = 50), (2) individual video-based (N = 50), and (3) group video-based (N = 50) sessions. A brief video incorporating information on national pediatric testing, modes of HIV transmission, and dramatized testimonials of caregivers who tested children was produced in three languages. Compared to individual HCW-led sessions (mean: 7.2/9; standard deviation [SD]: 1.3), both the group video-based (mean: 7.7; SD: 0.9) and individual video-based (mean: 7.6; SD: 0.9) sessions had higher mean knowledge scores. Video-based pre-test information could enhance existing pediatric HIV testing services.

Cytomegalovirus Viremia and Clinical Outcomes in Kenyan Children Diagnosed With Human Immunodeficiency Virus (HIV) in Hospital

BACKGROUND

Cytomegalovirus (CMV) viremia is common in human immunodeficiency virus (HIV) infection and is associated with worse long-term outcomes. To date, no studies have assessed CMV viremia in children diagnosed with HIV in hospital.

METHODS

We studied CMV viremia and clinical outcomes in 163 Kenyan children aged 2 months to 12 years, diagnosed with HIV in hospital. CMV DNA levels in plasma were measured using quantitative polymerase chain reaction (PCR). Regression models were used to assess associations between CMV viremia ≥1000 IU/mL and the risk of continued hospitalization or death at 15 days, duration of hospitalization, and 6-month mortality.

RESULTS

At enrollment, 62/114 (54%) children had CMV viremia, and 20 (32%) were ≥1000 IU/mL. Eleven CMV reactivations were observed after admission. The prevalence and level of CMV viremia were highest in children <2 years and lowest in children ≥5 years old. CMV viremia ≥1000 IU/mL was independently associated with age <2 years (P = .03), higher log10 HIV RNA level (P = .01), and height-for-age z score >-2 (P = .02). Adjusting for age and log10 HIV RNA, the relative risk of death or continued hospitalization at 15 days was 1.74 (95% confidence interval [CI] = 1.04, 2.90), and the hazard ratio of 6-month mortality was 1.97 (95% CI = .57, 5.07) for children with CMV DNA ≥1000 IU/mL compared to lower-level or undetectable CMV DNA. Children with CMV DNA ≥1000 IU/mL were hospitalized a median ~5 days longer than children with lower-level or undetectable CMV DNA (P = .002).

CONCLUSIONS

In this nested observational study, CMV viremia was common in hospitalized children with HIV, and levels ≥1000 IU/mL were associated with increased risk of mortality and longer hospitalization.

Motivational interviewing retention counseling and adherence to early infant diagnostic HIV testing schedule in South Africa: The PAEDLINK randomized trial

INTRODUCTION

We report the PAEDLINK randomized trial results on the effect of motivational interviewing (MI) retention counseling on the adherence of postpartum women to the early infant diagnostic human immunodeficiency virus (HIV) testing schedule.

METHODS

HIV positive women and their babies were enrolled 3 to 6 days after delivery at 4 midwife obstetric units in the Gauteng province of South Africa and randomized into (A) MI retention counseling and telephonic tracing, (B) biannual telephonic tracing, and (C) standard care. Mother-baby pairs were followed up for 18 months via medical records. The uptake of child HIV tests and maternal retention in the 0 to 6 and 7 to 18 month periods were modeled using Log-binomial regression.

RESULTS

Overall, 501/711 enrolled mother-baby pairs received a second HIV polymerase chain reaction test by 6 months (70.0%, 70.5%, and 70.0% in groups A, B, and C, respectively). A higher proportion of intervention children (60.9%) were tested at 7 to 90 days than group B (48.1%, adjusted risk ratio [aRR] 0.8 for B vs A, 95% confidence interval [CI]: 0.7-0.9) and group C children (52.7%, aRR 0.9 for C vs A, 95% CI: 0.9-1.0). Child testing between 7 and 18-months was also higher in group A than C (10.7% A, vs 5.5% C, RR 2.0, 95% CI: 1.0-3.7). However, maternal retention was similar across groups, with 41.6% and 16.3% retained during the 0 to 6 and the 7 to 18-months periods, respectively.

CONCLUSION

MI retention counseling can reduce delays in the early infant diagnosis testing schedule for HIV-exposed infants. However, further support is necessary to maximize later HIV tests and maternal retention.

Point-of-care tests detecting HIV nucleic acids for diagnosis of HIV-1 or HIV-2 infection in infants and children aged 18 months or less

BACKGROUND

The standard method of diagnosing HIV in infants and children less than 18 months is with a nucleic acid amplification test reverse transcriptase polymerase chain reaction test (NAT RT-PCR) detecting viral ribonucleic acid (RNA). Laboratory testing using the RT-PCR platform for HIV infection is limited by poor access, logistical support, and delays in relaying test results and initiating therapy in low-resource settings. The use of rapid diagnostic tests at or near the point-of-care (POC) can increase access to early diagnosis of HIV infection in infants and children less than 18 months of age and timely initiation of antiretroviral therapy (ART).

OBJECTIVES

To summarize the diagnostic accuracy of point-of-care nucleic acid-based testing (POC NAT) to detect HIV-1/HIV-2 infection in infants and children aged 18 months or less exposed to HIV infection.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (until 2 February 2021), MEDLINE and Embase (until 1 February 2021), and LILACS and Web of Science (until 2 February 2021) with no language or publication status restriction. We also searched conference websites and clinical trial registries, tracked reference lists of included studies and relevant systematic reviews, and consulted experts for potentially eligible studies.

SELECTION CRITERIA

We defined POC tests as rapid diagnostic tests conducted at or near the patient site. We included any primary study that compared the results of a POC NAT to a reference standard of laboratory NAT RT-PCR or total nucleic acid testing to detect the presence or absence of HIV infection denoted by HIV viral nucleic acids in infants and children aged 18 months or less who were exposed to HIV-1/HIV-2 infection. We included cross-sectional, prospective, and retrospective study designs and those that provided sufficient data to create the 2 × 2 table to calculate sensitivity and specificity. We excluded diagnostic case control studies with healthy controls.

DATA COLLECTION AND ANALYSIS

We extracted information on study characteristics using a pretested standardized data extraction form. We used the QUADAS-2 (Quality Assessment of Diagnostic Accuracy Studies) tool to assess the risk of bias and applicability concerns of the included studies. Two review authors independently selected and assessed the included studies, resolving any disagreements by consensus. The unit of analysis was the participant. We first conducted preliminary exploratory analyses by plotting estimates of sensitivity and specificity from each study on forest plots and in receiver operating characteristic (ROC) space. For the overall meta-analyses, we pooled estimates of sensitivity and specificity using the bivariate meta-analysis model at a common threshold (presence or absence of infection).

MAIN RESULTS

We identified a total of 12 studies (15 evaluations, 15,120 participants). All studies were conducted in sub-Saharan Africa. The ages of included infants and children in the evaluations were as follows: at birth (n = 6), ≤ 12 months (n = 3), ≤ 18 months (n = 5), and ≤ 24 months (n = 1). Ten evaluations were field evaluations of the POC NAT test at the point of care, and five were laboratory evaluations of the POC NAT tests.The POC NAT tests evaluated included Alere q HIV-1/2 Detect qualitative test (recently renamed m-PIMA q HIV-1/2 Detect qualitative test) (n = 6), Xpert HIV-1 qualitative test (n = 6), and SAMBA HIV-1 qualitative test (n = 3). POC NAT pooled sensitivity and specificity (95% confidence interval (CI)) against laboratory reference standard tests were 98.6% (96.1 to 99.5) (15 evaluations, 1728 participants) and 99.9% (99.7 to 99.9) (15 evaluations, 13,392 participants) in infants and children ≤ 18 months. Risk of bias in the included studies was mostly low or unclear due to poor reporting. Five evaluations had some concerns for applicability for the index test, as they were POC tests evaluated in a laboratory setting, but there was no difference detected between settings in sensitivity (-1.3% (95% CI -4.1 to 1.5)); and specificity results were similar.

AUTHORS' CONCLUSIONS

For the diagnosis of HIV-1/HIV-2 infection, we found the sensitivity and specificity of POC NAT tests to be high in infants and children aged 18 months or less who were exposed to HIV infection.

Balancing HIV testing efficiency with HIV case-identification among children and adolescents (2-19 years) using an HIV risk screening approach in Tanzania

To optimize HIV testing resources, programs are moving away from universal testing strategies toward a risk-based screening approach to testing children/adolescents, but there is little consensus around what defines an optimal risk screening tool. This study aimed to validate a 12-item risk screening tool among children and adolescents and provide suggested fewer-item tool options for screening both facility out-patient and community populations by age strata (<10 and ≥10 years). Children/adolescents (2–19 years) with unknown HIV status were recruited from a community-based vulnerable children program and health facilities in 5 regions of Tanzania in 2019. Lay workers administered the screening questions to caregivers/adolescents; nurses enrolled those eligible for the study and tested all participants for HIV. For each screening item, we estimated sensitivity, specificity, positive predictive value and negative predictive value and associated 95% confidence intervals (CI). We generated a score based on the count of items with a positive risk response and fit a receiver operating characteristic curve to determine a cut-off score. Sensitivity, specificity, positive predictive value (PPV; yield) and number needed to test to detect an HIV-positive child (NNT) were estimated for various tool options by age group. We enrolled 21,008 children and adolescents. The proportion of undiagnosed HIV-positive children was low (n = 76; 0.36%; CI:0.29,0.45%). A screening algorithm based on reporting at least one or more items on the 10 to 12-item tool had sensitivity 89.2% (CI:79.1,95.6), specificity 37.5% (CI:36.8,38.2), positive predictive value 0.5% (CI:0.4,0.6) and NNT = 211. An algorithm based on at least two or more items resulted in lower sensitivity (64.6%), improved specificity (69.1%), PPV (0.7%) and NNT = 145. A shorter tool derived from the 10 to 12-item screening tool with a score of “1” or more on the following items: relative died, ever hospitalized, cough, family member with HIV, and sexually active if 10–19 years performed optimally with 85.3% (CI:74.6,92.7) sensitivity, 44.2% (CI:43.5,44.9) specificity, 0.5% (CI:0.4,0.7) PPV and NNT = 193. We propose that different short-tool options (3–5 items) can achieve an optimal balance between reduced HIV testing costs (lower NNT) with acceptable sensitivity. In low prevalence settings, changes in yield may be negligible and NNT may remain high even for an effective tool.

Human immunodeficiency virus case detection and antiretroviral therapy enrollment among children below and above 18 months old: A comparative analysis from Cameroon

ABSTRACT

While pediatric human immunodeficiency virus (HIV) testing has been more focused on children below 18 months through prevention of mother to child transmission of HIV (PMTCT), the yield of this approach remains unclear comparatively to testing children above 18 months through routine provider-initiated testing and counselling (PITC). This study aimed at assessing and comparing the HIV case detection and antiretroviral therapy (ART) enrolment among children below and above 18 months of age in Cameroon. This information is required to guide the investments in HIV testing among children and adolescents.We conducted a cross-sectional study where we invited parents visiting or receiving HIV care in 3 hospitals to have their children tested for HIV. HIV testing was done using polymerase chain reaction (PCR) and antibody rapid tests for children <18 months and those ≥18 months, respectively. We compared HIV case detection and ART initiation between the 2 subgroups of children and this using Chi-square test at 5% significant level.A total of 4079 children aged 6 weeks to 15 years were included in the analysis. Compared with children <18 months, children group ≥18 months was 4-fold higher among those who enrolled in the study (80.3% vs 19.7%, P < .001); 3.5-fold higher among those who tested for HIV (77.6% vs 22.4%, P < .001); 6-fold higher among those who tested HIV+ (85.7% vs 14.3%, P = .24), and 11-fold higher among those who enrolled on ART (91.7% vs 8.3%, P = .02).Our results show that 4 out of 5 children who tested HIV+ and over 90% of ART enrolled cases were children ≥18 months. Thus, while rolling out PCR HIV testing technology for neonates and infants, committing adequate and proportionate resources in antibody rapid testing for older children is a sine quo none condition to achieve an acquired immunodeficiency syndrome (AIDS)-free generation.

HIV risk screening and HIV testing among orphans and vulnerable children in community settings in Tanzania: Acceptability and fidelity to lay-cadre administration of the screening tool

INTRODUCTION

HIV risk screening tool validation studies have not typically included process evaluations to understand tool implementation. The study aim was to assess the fidelity to which an HIV risk screening tool was administered by lay workers and acceptability of delivering home-based screening coupled with HIV testing to beneficiaries in an orphans and vulnerable children (OVC) program.

METHODS

This cross-sectional study was conducted March-April 2019 in two regions of Tanzania. Community case workers (CCW) were observed conducting screenings with OVC 2-19 years and participated in focus group discussions. Research staff used structured observation checklists to capture if screening questions were asked or reworded by CCW. In-depth interviews were conducted with older adolescents and caregivers in their homes following screening and testing. A composite score was developed for the checklist. Qualitative data were thematically analyzed to address screening and testing perceptions and experiences.

RESULTS

CCW (n = 32) participated in 166 observations. Commonly skipped items were malnutrition (34% of all observed screenings) and sexual activity and pregnancy (20% and 45% of screenings for adolescents only). Items frequently re-worded included child abuse (22%) and malnutrition (15%). CCW had an average composite observation score of 42/50. CCW in focus groups (n = 34) found the screening process acceptable. However, they described rewording some questions viewed as harsh or socially inappropriate to ask. Overall, adolescent beneficiaries (n = 17) and caregivers (n = 25) were satisfied with home-based screening and testing and reported no negative consequences. Learning one's HIV negative status was seen as an opportunity to discuss or recommit to healthy behaviors. While respondents identified multiple benefits of home testing, they noted the potential for privacy breaches in household settings.

CONCLUSIONS

We found sub-optimal fidelity to the administration of the screening tool by CCW in home environments to children and adolescents enrolled in an OVC program. Improvements to questions and their delivery and ongoing mentorship could strengthen tool performance and HIV case finding using a targeted testing approach. Overall, home-based HIV risk screening and testing were acceptable to beneficiaries and CCW, could improve testing uptake, and serve as a platform to promote healthy behaviors for those with limited health system interactions.

Factors influencing the delivery and uptake of early infant diagnosis of HIV services in Greater Accra, Ghana: A qualitative study

BACKGROUND

Early Infant Diagnosis (EID) of HIV and timely initiation of Antiretroviral Therapy (ART) can significantly reduce morbidity and mortality of HIV infected infants. Despite the benefits of early infant testing, the coverage of EID of HIV services is still low in Sub-Saharan Africa, including Ghana.

OBJECTIVES

To ascertain the factors that facilitate or hinder the delivery and uptake of EID of HIV services.

METHODS

The study is a cross-sectional exploratory qualitative research conducted in two health facilities in the Greater Accra Region of Ghana. Respondents (n = 50) comprising health workers (n = 20) and HIV positive mothers (n = 30) were purposively sampled and engaged in in-depth interviews. The Nvivo 11 software and the Braun and Clarke's stages of thematic analysis were used in coding data and data analysis respectively.

RESULTS

The study found that health system factors such as inadequate Staff with sample collection skills, unavailability of vehicles to convey samples to the reference laboratory for analysis, the long turnaround time for receipt of Polymerase Chain Reaction (PCR) results, inadequate and frequent breakdown of PCR machine hindered EID service delivery. On the other hand, adequate knowledge of health workers on EID, availability of Dried Blood Spot (DBS) cards and the adoption of task shifting strategies facilitated EID service delivery. Factors such as the denial of HIV status, non-completion of the EID process due to frustrations encountered whiles accessing service and delay in receipt of PCR results served as barriers to mother's utilisation of EID services for their exposed infants. The study also identified that adequate knowledge of EID, perceived importance of EID, financial stability as well as financial support from others and the positive attitudes of health workers facilitated HIV positive mother's uptake of EID services for their exposed infants.

CONCLUSION

The factors attributing to the low coverage of EID of HIV services must be promptly addressed to improve service delivery and uptake.

Integrated TB and HIV care for Mozambican children: temporal trends, site-level determinants of performance, and recommendations for improved TB preventive treatment

BACKGROUND

Pediatric tuberculosis (TB), human immunodeficiency virus (HIV), and TB-HIV co-infection are health problems with evidence-based diagnostic and treatment algorithms that can reduce morbidity and mortality. Implementation and operational barriers affect adherence to guidelines in many resource-constrained settings, negatively affecting patient outcomes. This study aimed to assess performance in the pediatric HIV and TB care cascades in Mozambique.

METHODS

A retrospective analysis of routine PEPFAR site-level HIV and TB data from 2012 to 2016 was performed. Patients 0-14 years of age were included. Descriptive statistics were used to report trends in TB and HIV indicators. Linear regression was done to assess associations of site-level variables with performance in the pediatric TB and HIV care cascades using 2016 data.

RESULTS

Routine HIV testing and cotrimoxazole initiation for co-infected children in the TB program were nearly optimal at 99% and 96% in 2016, respectively. Antiretroviral therapy (ART) initiation was lower at 87%, but steadily improved from 2012 to 2016. From the HIV program, TB screening at the last consultation rose steadily over the study period, reaching 82% in 2016. The percentage of newly enrolled children who received either TB treatment or isoniazid preventive treatment (IPT) also steadily improved in all provinces, but in 2016 was only at 42% nationally. Larger volume sites were significantly more likely to complete the pediatric HIV and TB care cascades in 2016 (p value range 0.05 to < 0.001).

CONCLUSIONS

Mozambique has made significant strides in improving the pediatric care cascades for children with TB and HIV, but there were missed opportunities for TB diagnosis and prevention, with IPT utilization being particularly problematic. Strengthened TB/HIV programming that continues to focus on pediatric ART scale-up while improving delivery of TB preventive therapy, either with IPT or newer rifapentine-based regimens for age-eligible children, is needed.

Implementation of blanket provider-initiated testing and counselling: Predictors of HIV seropositivity among infants, children and adolescents in Cameroon

Objectives

Study design

Methods

Results

Conclusions

•

Methods to increase the yield of PITC remain unclear.

•

HIV seropositivity predictors could improve PITC yield.

•

Identifying HIV seropositivity predictors among children and adolescents.

•

Targeted HIV testing to improve PITC yield in HIV high burden countries.

•

HIV seropositivity predictors could reduce gap in pediatric and adolescent ART.

Unsatisfactory long-term virological suppression in human immunodeficiency virus-infected children in the Amazonas State, Brazil

INTRODUCTION:

Achieving viral suppression (VS) in children is challenging despite the exponential increase in access to antiretroviral therapy (ART). We evaluated VS in children >1 year of age and adolescents 5 years after they had begun ART, in Manaus, Amazonas state, Brazil.

METHODS:

HIV-infected, ART-naive children >1 year of age between 1999 and 2016 were eligible. Analysis was stratified by age at ART initiation: 1-5 y, >5-10 y, and >10-19 y. CD4⁺ T-cell count and viral load were assessed on arrival at the clinic, on ART initiation, and at 6 months, 1 year, 2 years, and 5 years after ART initiation. The primary outcome was a viral load <50 copies/mL 5 years after ART initiation.

RESULTS:

Ultimately, 121 patients were included. The mean age at diagnosis was 4.8 years (SD 3.5), mean CD4% was 17.9 (SD 9.8), and mean viral load was 4.6 log10 copies/ml (SD 0.8). Five years after ART initiation, the overall VS rate was 46.9%. VS by patient age group was as follows: 36.6% for 1-5 y, 53.3% for >5-10 y, and 30% for >10-19 y. Almost all children (90,4%) showed an increase in CD4%+ T cell count. There were no statistically significant predictors for detecting children who do not achieve VS with treatment. VS remained below 65% in all the evaluated periods.

CONCLUSIONS:

Considerable immunological improvement is seen in children after ART initiation. Further efforts are needed to maintain adequate long-term VS levels and improve the survival of this vulnerable population.

Discordant retention of HIV-infected mothers and children: Evidence for a family-based approach from Southern Mozambique

It is often assumed that children and their caregivers either stay in care together or discontinue together, but data is lacking on caregiver-child retention concordance. We sought to describe the pattern of care among a cohort of human immunodeficiency virus (HIV) infected children and mothers enrolled in care at the Manhiça District Hospital (MDH).This was a retrospective review of routine HIV clinical data collected under a larger prospective HIV cohort study at MDH. Children enrolling HIV care from January 2013 to November 2016 were identified and matched to their mother's HIV clinical data. Retention in care for mothers and children was assessed at 24 months after the child's enrolment. Multinomial logistic regression was performed to evaluate variables associated with retention discordance.For the 351 mother-child pairs included in the study, only 39% of mothers had concordant care status at baseline (23% already active in care, 16% initiated care concurrently with their children). At 24-months follow up, a total of 108 (31%) mother-child pairs were concordantly retained in care, 88 (26%) pairs were concordantly lost to follow up (LTFU), and 149 (43%) had discordant retention. Pairs with concurrent registration had a higher probability of being concordantly retained in care. Children who presented with advanced clinical or immunological stage had increased probability of being concordantly LTFU.High rates of LTFU as well as high proportions of discordant retention among mother-child pairs were found. Prioritization of a family-based care model that has the potential to improve retention for children and caregivers is recommended.

They are likely to be there: using a family-centered index testing approach to identify children living with HIV in Kenya

In Kenya, only half of children with a parent living with HIV have been tested for HIV. The effectiveness of family-centered index testing to identify children (0-14 years) living with HIV was examined. A retrospective record review was conducted among adult index patients newly enrolled in HIV care between May and July 2015; family testing, results, and linkage to treatment outcomes were followed through May 2016 at 60 high-volume clinics in Kenya. Chi square test compared yield (percentage of HIV tests positive) among children tested through family-centered index testing, outpatient and inpatient testing. Review of 1937 index client charts led to 3005 eligible children identified for testing. Of 2848 (94.8%) children tested through family-centered index testing, 127 (4.5%) had HIV diagnosed, 100 (78.7%) were linked to care, and 85 of those eligible (91.4%) initiated antiretroviral therapy (ART).Family testing resulted in higher yield compared to inpatient (1.8%, p < 0.001) or outpatient testing (1.6%, p < 0.001). The absolute number of children living with HIV identified was highest with outpatient testing. The relative contribution of testing approach to total children identified with HIV was outpatient testing (69%), family testing (26%), and inpatient testing (5%). The family testing approach demonstrated promise in achieving the first two "90s" (identification and ART initiation) of the 90-90-90 targets for children, with additional effort required to improve linkage from testing to treatment.

Increasing pediatric HIV testing positivity rates through focused testing in high-yield points of service in health facilities-Nigeria, 2016-2017

Background

In 2017, UNAIDS estimated that 140,000 children aged 0–14 years are living with HIV in Nigeria, but only 35% have been diagnosed and are receiving antiretroviral therapy. Children are tested primarily in outpatient clinics, which show low HIV-positive rates. To demonstrate efficient facility-based HIV testing among children aged 0–14 years, we evaluated pediatric HIV-positivity rates in points of service in select health facilities in Nigeria.

Methods

We conducted a retrospective analysis of HIV testing and case identification among children aged 0–14 years at all points of service at nine purposively sampled hospitals (November 2016–March 2017). Points of service included family index testing, pediatric outpatient department (POPD), tuberculosis (TB) clinics, immunization clinics, and pediatric inpatient ward. Eligibility for testing at POPD was done using a screening tool while all children with unknown status were eligible for HIV test at other points of service. The main outcome was HIV positivity rates stratified by the testing point of service and by age group. Predictors of an HIV-positive result were assessed using logistic regression. All analyses were done using Stata 15 statistical software.

Results

Of 2,180 children seen at all facility points of service with unknown HIV status, 1,822 (83.6%) were tested for HIV, of whom 43 (2.4%) tested HIV positive. The numbers of children tested by age group were <1 years = 230 (12.6%); 1–4 years = 752 (41.3%); 5–9 years = 520 (28.5%); and 10–14 years = 320 (17.6%). The number of children tested by point of service were POPD = 906 (49.7%); family index testing = 693 (38.0%); pediatric inpatient ward = 192 (10.5%); immunization clinic = 16 (0.9%); and TB clinic = 15 (0.8%). HIV positivity rates by point of service were TB clinic = 6.7% (95% Confidence Interval (CI): 0.9–35.2%); pediatric inpatient ward = 4.7% (95%CI: 2.5–8.8%); family index testing = 3.5% (95%CI: 2.3–5.1%); POPD = 1.0% (95%CI: 0.5–1.9%); and immunization clinic = 0%. The percentage contribution to total HIV positive children found by point of services was: family index testing = 55.8% (95%CI: 40.9–69.8%); POPD = 20.9% (95%CI: 11.3–35.6%); inpatient ward = 20.9 (95%CI: 11.3–35.6%) and TB Clinic = 2.3% (95%CI: 0.3–14.8%). Compared with the POPD, the adjusted odds ratio (95% CI) for finding an HIV positive child by point of service were TB clinic = 7.2 (95% CI: 0.9–60.9); pediatric inpatient ward = 4.9 (95% CI: 1.9–12.8); and family index testing = 3.7 (95% CI: 1.5–8.8). HIV-positivity rates did not significantly differ by age group.

Conclusion

In Nigeria, to improve facility-based HIV positivity rates among children aged 0–14 years, an increased focus on HIV testing among children seeking care in pediatric inpatient wards, through family index testing, and perhaps TB clinics is appropriate.

Active pediatric HIV case finding in Kenya and Uganda: A look at missed opportunities along the prevention of mother-to-child transmission of HIV (PMTCT) cascade

Background

Children living with HIV remain undiagnosed due to missed opportunities along the prevention of mother-to-child HIV transmission cascade. This study addresses programmatic gaps in the cascade by describing pregnancy and HIV-related services received by mothers of children newly identified as HIV-positive through active case finding.

Methods

This was a prospective observational cohort (2017–2018) of HIV-positive children <15 years of age newly diagnosed at study facilities and/or surrounding communities in Kenya and Uganda. At enrollment, caregivers were interviewed about maternal and child health and HIV history. Child medical and laboratory information was abstracted at two months post-diagnosis. Descriptive summary statistics were calculated; associations between selected factors and child age at HIV diagnosis were evaluated using generalized estimating equations.

Results

174 HIV-positive children (median age 2.4 years) were enrolled. Among maternal caregivers, 110/132 (83.3%) attended antenatal care and 60 (45.5%) reported testing HIV-negative in antenatal care. Of 41 and 56 women known to be HIV-positive during pregnancy and breastfeeding respectively, 17 (41.5%) and 15 (26.8%) did not receive antiretroviral drugs. Despite known maternal HIV-positive status during pregnancy, 39% of these children were not diagnosed until after two years of age; children were diagnosed at younger ages in Uganda (p = 0.0074) and if mother was the caregiver (p<0.0001). The most common HIV testing points identifying children were outpatient (44.3%) and maternal/child health departments (29.9%). Nearly all children initiated antiretroviral therapy within two weeks of diagnosis.

Conclusions

Multiple missed opportunities for HIV prevention and delays in HIV testing of HIV-exposed children were identified in newly diagnosed children. Findings support critical prevention messaging and retesting of HIV-negative women during pregnancy and breastfeeding, strengthening HIV treatment initiation and follow-up systems and interventions to ensure HIV-positive women receive lifelong antiretroviral therapy throughout the cascade, and broader implementation of community case finding so children not engaged in care receive testing services.

Understanding the association between caregiver sex and HIV infection among orphans and vulnerable children in Tanzania: learning from the USAID Kizazi Kipya project

Background

Tanzania has met only 50.1% of the 90% target for diagnosing HIV in children. The country’s pediatric case finding strategy uses global best practices of index testing, provider-initiated counselling and testing, and targeted community testing of at-risk populations to find about 50,000 children living with HIV (CLHIV) who are undiagnosed. However, context-specific strategies are necessary to find the hidden children to meet the full 90% target. This study assesses whether sex of the caregiver is associated with HIV status of orphans and vulnerable children (OVC) as a valuable strategy for enhanced pediatric case findings.

Methods

Data originate from the community-based, United States Agency for International Development (USAID)-funded Kizazi Kipya Project, which works towards increasing OVC’s and their caregivers’ uptake of HIV/AIDS and other health and social services in Tanzania. Included in this study are 39,578 OVC ages 0–19 years who the project enrolled during January through March 2017 in 18 regions of Tanzania and who voluntarily reported their HIV status. Data analysis involved multi-level logistic regression, with OVC HIV status as the outcome of interest and caregiver’s sex as the main independent variable.

Results

Three-quarters (74.3%) of the OVC included in the study had female caregivers, and their overall HIV prevalence was 7.1%. The prevalence was significantly higher (p < 0.001) among OVC with male caregivers (7.8%) than among OVC with female caregivers (6.8%), and indeed, multivariate analysis showed that OVC with male caregivers were significantly 40% more likely to be HIV-positive than those with female caregivers (OR = 1.40, 95% CI 1.08–1.83). This effect was the strongest among 0–4 year-olds (OR = 4.02, 95% CI 1.61–10.03), declined to 1.72 among 5–9 year-olds (OR = 1.72, 95% CI 1.02–2.93), and lost significance for children over age 9 years. Other significant factors included OVC age and nutritional status; caregiver HIV status and marital status; household health insurance status, and family size; and rural versus urban residence.

Conclusions

OVC in Tanzania with male caregivers have a 40% higher likelihood of being HIV-positive than those with female caregivers. HIV risk assessment activities should target OVC with male caregivers, as well as OVC who have malnutrition, HIV-positive caregivers, or caregivers who do not disclose their HIV status to community volunteers. Further, younger HIV-positive OVC are more likely to live in rural areas, while older HIV-positive OVC are more likely to live in urban areas. These factors should be integrated in HIV risk assessment algorithms to enhance HIV testing yields and pediatric case-finding in the OVC population in Tanzania.

Clinical and operational factors associated with low pediatric inpatient HIV testing coverage in Mozambique

Setting

Eleven pediatric wards in Maputo Province, Mozambique.

Objective

1) To determine provider-initiated testing and counseling (PITC) coverage, the rate of human immunodeficiency virus (HIV) positivity, and the clinical and facility-level variables associated with PITC; and 2) to assess the care cascade for HIV-exposed and -infected children.

Design

This was a cross-sectional, retrospective review of inpatient charts, selected via systematic randomization, of patients aged 0-4 years, admitted between July and December 2015.

Results

Among the 800 patients included, the median age was 23 months and median duration of hospitalization was 3 days. HIV testing was ordered in 46.0% of eligible patients (known HIV-infected at admission excluded), with results documented for 35.7%, of whom 8.3% were positive. The patient hospitalization diagnoses with the highest PITC rates were malnutrition (73.8%), sepsis (71.4%) and tuberculosis (58.3%), with positivity rates of respectively 16.1%, 20.0%, and 28.6%. Longer hospitalization, weekday admission, and PITC training for staff were significantly associated with better PITC performance. Antiretroviral treatment was initiated during hospitalization for 29.6% of eligible patients.

Conclusion

PITC coverage was low, with high HIV positivity rates, highlighting missed opportunities for diagnosis and linkage to treatment. Strengthened routine testing on wards with consideration of inpatient ART initiation are needed to help achieve pediatric 90-90-90 goals.

Effectiveness of symptom-based diagnostic HIV testing versus targeted and blanket provider-initiated testing and counseling among children and adolescents in Cameroon

Objectives

The concurrent implementation of targeted (tPITC) and blanket provider-initiated testing and counselling (bPITC) is recommended by the World Health Organization (WHO) for HIV case-finding in generalized HIV epidemics. This study assessed the effectiveness of this intervention compared to symptom-based diagnostic HIV testing (DHT) in terms of HIV testing uptake, case detection and antiretroviral therapy (ART) enrollment among children and adolescents in Cameroon, where estimated HIV prevalence is relatively low at 3.7%.

Methods

In three hospitals where DHT was the standard practice before, tPITC and bPITC were implemented by inviting HIV-positive parents in care at the ART clinics to have their biological children (6 weeks-19 years) tested for HIV (tPITC). Concurrently, at the outpatient departments, similarly-age children/adolescents were systematically offered HIV testing via accompanying parents/guardians. The mean monthly number of children tested for HIV, identified HIV-positive and ART-enrolled were used to compare the outcomes of different HIV testing strategies before and after the intervention.

Results

In comparing DHT to bPITC, there was a significant increase in the mean monthly number of children/adolescents tested for HIV (223.0 vs 348.3, p = 0.0073), but with no significant increase in the mean monthly number of children/adolescents: testing HIV-positive (10.5 vs 9.7, p = 0.7574) and ART- enrolled (7.3 vs 6.3, p = 0.5819). In comparing DHT to tPITC, there was no significant difference in the mean monthly number of children/adolescents: tested for HIV (223 vs 193.8, p = 0.4648); tested HIV-positive (10.5 vs 10.6, p = 0.9544), and ART-enrolled (7.3 vs 5.8, p = 0.4672). When comparing DHT versus bPITC+tPITC, there was a significant increase in the mean monthly number of children/adolescents: tested for HIV (223.0 to 542.2, p<0.0001), testing HIV-positive (10.5 vs 20.3, p = 0.0256), and ART-enrolled (7.3 vs 12.2, p = 0.0388).

Conclusions

These findings suggest that concurrent implementation of bPITC+tPITC was more effective compared to DHT in terms of HIV testing uptake, case detection and ART enrolment. However, considering that DHT and bPITC had comparable outcomes with regards to case detection and ART enrolment, bPITC+tPITC may not be efficient. Thus, this finding does not support concurrent bPITC+tPITC implementation as recommended by WHO. Rather, continued DHT+tPITC could effectively and efficiently accelerate HIV case detection and ART coverage among children and adolescents in Cameroon and similar low-prevalence context.

Prevalence of HIV infection among siblings of HIV positive children in Calabar, Nigeria

INTRODUCTION

Early diagnosis and treatment of paediatric HIV is key as mortality of untreated patients is very high in the first two years of life, and reaches 80% by four years. Case finding efforts for children especially outside Prevention of mother-to-child transmission (PMTCT) is inadequate. Targeting siblings of index HIV-exposed and infected children is an important way of improving identification and enrolment into care thereby reducing paediatric mortality. The study therefore aimed to determine the prevalence of HIV infection among siblings of HIV positive children in care in Calabar.

METHODS

This descriptive cross-sectional study was conducted among children aged six weeks to 15 years who are siblings of HIV positive children receiving care. Parental consent and child assent were obtained, the children were tested for HIV at their homes irrespective of their prior test results. Ethical clearance certificates were obtained from the health institutions.

RESULTS

Siblings of 401 index patients were tested for HIV, four were positive giving a prevalence rate of 1%. Three hundred and sixty-seven 367(91.5%) had been tested previously while 34(8.5%) never had HIV test. Among the siblings who were HIV positive, 1(0.3%) was a male while 3(0.7%) were females. There were more HIV positive siblings in the 11-15 years age group.

CONCLUSION

All the four HIV positive siblings were from the lower socioeconomic class (p=0.022). The routine screening of siblings of HIV positive children should be sustained with focus on adolescents from the lower socioeconomic class. This will improve early identification and enrolment into care thereby reducing paediatric mortality.

Healthcare Workers' Perspectives on the Barriers to Providing HIV Services to Children in Sub-Saharan Africa

Background

In order to accelerate the HIV response to meet the UNAIDS 90-90-90 indicators for children, healthcare workers need to lead a scale-up of HIV services in primary healthcare settings. Such a scale-up will require investigation into existing barriers that prevent healthcare workers from effectively providing those services to children. Furthermore, if the identified barriers are not well understood, designing context-specific and effective public health response programmes may prove difficult.

Objective

This study reviews the current literature pertaining to healthcare workers' perspectives on the barriers to providing HIV services to children in the primary care setting in Sub-Saharan Africa.

Methods

English articles published between 2010 and April 2018 were searched in electronic databases including Sabinet, MEDLINE, PubMed, and Google Scholar. Key search words used during the search were “healthcare workers' perspectives” and “barriers to providing HIV testing to children” OR “barriers to ART adherence AND children” and “barriers to HIV disclosure AND children.” Results. There are various barriers to provider-initiated counselling and testing (PICT) of children and disclosure of HIV status to children, including the following: lack of child-friendly infrastructure at clinics; lack of consensus on legal age of consent for both HIV testing and disclosure; healthcare worker unfamiliarity with HIV testing and disclosure guidelines; lack of training in child psychology; and confusion around the healthcare worker's role, which most believed was only to provide health education and clinical services and to correct false information, but not to participate in disclosure. Additionally, primary caregivers were reported to be a barrier to care and treatment of children as they continue to refuse HIV testing for their children and delay disclosure.

Conclusion

Training, mentoring, and providing healthcare workers with guidelines on how to provide child-focused HIV care have the potential to address the majority of the barriers to the provision of child-friendly HIV services to children. However, the need to educate primary caregivers on the importance of testing children and disclosing to them is equally important.

Brief Report: Disclosure, Consent, Opportunity Costs, and Inaccurate Risk Assessment Deter Pediatric HIV Testing: A Mixed-Methods Study

BACKGROUND

Prompt child HIV testing and treatment is critical; however, children are often not diagnosed until symptomatic. Understanding factors that influence pediatric HIV testing can inform strategies to increase testing.

METHODS

A mixed-methods study was conducted at a tertiary hospital in Nairobi, Kenya. Three focus group discussions with health care workers (HCWs) and 18 in-depth interviews with HIV-infected adults with children of unknown status were analyzed using thematic analysis. A structured questionnaire was administered to 116 HIV-infected caregivers of children of unknown status to triangulate qualitative findings.

RESULTS

Analysis revealed 3 key periods of the pediatric HIV testing process: decision to test, test visit, and posttest. Key issues included: decision to test: inaccurate HIV risk perception for children, challenges with paternal consent, lack of caregiver HIV status disclosure to partners or older children; test experience: poor understanding of child consent/assent and disclosure guidelines, perceived costs of testing and care, school schedules, HCW discomfort with pediatric HIV testing; and posttest: pessimism regarding HIV-infected children's prognosis, caregiver concerns about their own emotional health if their child is positive, and challenges communicating about HIV with children. Concerns about all 3 periods influenced child testing decisions. In addition, 3 challenges were unique to pediatric HIV: inaccurate HIV risk perception for children; disclosure, consent, and permission; and costs and scheduling.

CONCLUSIONS

Pediatric HIV testing barriers are distinct from adult barriers. Uptake of pediatric HIV testing may be enhanced by interventions to address misconceptions, disclosure services, psychosocial support addressing concerns unique to pediatric testing, child-focused HCW training, and alternative clinic hours.

Financial Incentives for Pediatric HIV Testing in Kenya

The acceptability of financial incentives for pediatric HIV testing was evaluated in Kenya. Sixty HIV-positive women with children of unknown status were randomized to receive $5, $10 or $15 conditional upon HIV testing. Forty-four (73%) completed child testing, with similar rates across arms. Uptake was significantly higher than a cohort with similar procedures but no incentives (73% vs. 14%, P < 0.001).

Active case finding: comparison of the acceptability, feasibility and effectiveness of targeted versus blanket provider-initiated-testing and counseling of HIV among children and adolescents in Cameroon

Background

Children and adolescents still lag behind adults in accessing antiretroviral therapy (ART), which is largely due to their limited access to HIV testing services. This study compares the acceptability, feasibility and effectiveness of targeted versus blanket provider-initiated testing and counseling (PITC) among children and adolescents in Cameroon.

Methods

During a 6-month period in three hospitals in Cameroon, we invited HIV-positive parents to have their biological children (6 weeks-19 years) tested for HIV (targeted PITC). During that same period and in the same hospitals, we also systematically offered HIV testing to all children evaluated at the outpatient department (blanket PITC). Children of consenting parents were tested for HIV, and positive cases were enrolled on ART. We compared the acceptability, feasibility and effectiveness of targeted and blanket PITC using Chi-square test at 5% significant level.

Results

We enrolled 1240 and 2459 eligible parents in the targeted PITC (tPITC) and blanket PITC (bPITC) group, and 99.7% and 98.8% of these parents accepted the offer to have their children tested for HIV, respectively. Out of the 1990 and 2729 children enrolled in the tPITC and bPITC group, 56.7% and 90.3% were tested for HIV (p < 0.0001), respectively. The HIV positivity rate was 3.5% (CI:2.4–4.5) and 1.6% (CI:1.1–2.1) in the tPITC and bPITC (p = 0.0008), respectively. This finding suggests that the case detection was two times higher in tPITC compared to bPITC, or alternatively, 29 and 63 children have to be tested to identify one HIV case with the implementation of tPITC and bPITC, respectively. The majority (84.8%) of HIV-positive children in the tPITC group were diagnosed earlier at WHO stage 1, and cases were mostly diagnosed at WHO stage 3 (39.1%) (p < 0.0001) in the bPITC group. Among the children who tested HIV-positive, 85.0% and 52.5% from the tPITC and bPITC group respectively, were enrolled on ART (p = 0.0018).

Conclusions

The tPITC and bPITC strategies demonstrated notable high HIV testing acceptance. tPITC was superior to bPITC in terms of case detection, case detection earliness and linkage to care. These findings indicate that tPITC is effective in case detection and linkage of children and adolescents to ART.

Trial registration

Trial registration Number: NCT03024762. Name of Registry: ClinicalTrial.gov. Date registration: January 19, 2017 (‘retrospectively registered’). Date of enrolment first patient: 15/07/2015.

Electronic supplementary material

The online version of this article (10.1186/s12887-018-1276-7) contains supplementary material, which is available to authorized users.

Strategies for Identifying and Linking HIV-Infected Infants, Children, and Adolescents to HIV Treatment Services in Resource Limited Settings

Many children living with HIV in resource-limited settings remain undiagnosed and at risk for HIV-related mortality and morbidity. This article describes 5 key strategies for strengthening HIV case finding and linkage to treatment for infants, children, and adolescents. These strategies result from lessons learned during the Accelerating Children's HIV/AIDS Treatment Initiative, a public-private partnership between the President's Emergency Plan for AIDS Relief (PEPFAR) and the Children's Investment Fund Foundation (CIFF). The 5 strategies include (1) implementing a targeted mix of HIV case finding approaches (eg, provider-initiated testing and counseling within health facilities, optimization of early infant diagnosis, index family testing, and integration of HIV testing within key population and orphan and vulnerable children programs); (2) addressing the unique needs of adolescents; (3) collecting and using data for program improvement; (4) fostering a supportive political and community environment; and (5) investing in health system-strengthening activities. Continued advocacy and global investments are required to eliminate AIDS-related deaths among children and adolescents.

HIV viral suppression and longevity among a cohort of children initiating antiretroviral therapy in Eastern Cape, South Africa

INTRODUCTION

There are limited data on viral suppression (VS) in children with HIV receiving antiretroviral therapy (ART) in routine care in low-resource settings. We examined VS in a cohort of children initiating ART in routine HIV care in Eastern Cape Province, South Africa.

METHODS

The Pediatric Enhanced Surveillance Study enrolled HIV-infected ART eligibility children zero to twelve years at five health facilities from 2012 to 2014. All children received routine HIV care and treatment services and attended quarterly study visits for up to 24 months. Time to VS among those starting treatment was measured from ART start date to first viral load (VL) result <1000 and VL <50 copies/mL using competing risk estimators (death as competing risk). Multivariable sub-distributional hazards models examined characteristics associated with VS and VL rebound following suppression among those with a VL >30 days after the VS date.

RESULTS

Of 397 children enrolled, 349 (87.9%) started ART: 118 (33.8%) children age <12 months, 122 (35.0%) one to five years and 109 (31.2%) six to twelve years. At study enrolment, median weight-for-age z-score (WAZ) was -1.7 (interquartile range (IQR):-3.1 to -0.4) and median log VL was 5.6 (IQR: 5.0 to 6.2). Cumulative incidence of VS <1000 copies/mL at six, twelve and twenty-four months was 57.6% (95% CI 52.1 to 62.7), 78.7% (95% CI 73.7 to 82.9) and 84.0% (95% CI 78.9 to 87.9); for VS <50 copies/mL: 40.3% (95% CI 35.0 to 45.5), 63.9% (95% CI 58.2 to 69.0) and 72.9% (95% CI 66.9 to 78.0). At 12 months only 46.6% (95% CI 36.6 to 56.0) of children <12 months had achieved VS <50 copies/mL compared to 76.9% (95% CI 67.9 to 83.7) of children six to twelve years (p < 0.001). In multivariable models, children with VL >1 million copies/mL at ART initiation were half as likely to achieve VS <50 copies/mL (adjusted sub-distributional hazards 0.50; 95% CI 0.36 to 0.71). Among children achieving VS <50 copies/mL, 37 (19.7%) had VL 50 to 1000 copies/mL and 31 (16.5%) had a VL >1000 copies/mL. Children <12 months had twofold increased risk of VL rebound to VL >1000 copies/mL (adjusted relative risk 2.03, 95% CI: 1.10 to 3.74) compared with six to twelve year olds.

CONCLUSIONS

We found suboptimal VS among South African children initiating treatment and high proportions experiencing VL rebound, particularly among younger children. Greater efforts are needed to ensure that all children achieve optimal outcomes.

High loss to follow-up of children on antiretroviral treatment in a primary care HIV clinic in Johannesburg, South Africa

Outcomes of HIV-infected children have improved dramatically over the past decade, but are undermined by patient loss to follow-up (LTFU). We assessed patterns of LTFU among HIV-infected children receiving antiretroviral treatment (ART) at a large inner-city HIV clinic in Johannesburg, South Africa between 2005 and 2014.Demographic and clinical data were extracted from clinic records of children under 12 years. Differences between characteristics of children retained in care and LTFU were assessed using Wilcoxon rank sum tests or Pearson χ tests. Cox proportional hazard models then identified characteristics associated with LTFU.Of 135 children, the median age at ART initiation was 21.5 months (IQR: 6.3-47.7) with a median follow-up time of 3.3 years (IQR: 1.4-5.0). The incidence rate of LTFU was 10.8 per 100 person-years (95% CI: 8.2-14.4); cumulatively 36% of children were LTFU. Almost a third (n = 39) of children missed a clinic visit, but then returned to care; 77% of these were eventually LTFU. In total, 18% of children had elevated viral loads after 6 or more months of ART. Older age at ART initiation (18-59 months: aHR 1.6, 95% CI: 3.9-14.2) and ever missing a clinic visit (aHR 7.4 95% CI: 3.9-14.2) were independent predictors of LTFU.High rates of LTFU were observed in this primary care clinic. Risks for LTFU included older age (>18 months old) and missed clinic visits. Identifying children who miss scheduled visits and developing strategies directed at retaining them in care is critical to improving long-term pediatric HIV outcomes.

Survival of HIV-1 vertically infected children

PURPOSE OF REVIEW

It is 20 years since the start of the combination antiretroviral therapy (cART) era and more than 10 years since cART scale-up began in resource-limited settings. We examined survival of vertically HIV-infected infants and children in the cART era.

RECENT FINDINGS

Good survival has been achieved on cART in all settings with up to 10-fold mortality reductions compared with before cART availability. Although mortality risk remains high in the first few months after cART initiation in young children with severe disease, it drops rapidly thereafter even for those who started with advanced disease, and longer term mortality risk is low. However, suboptimal retention on cART in routine programs threatens good survival outcomes and even on treatment children continue to experience high comorbidity risk; infections remain the major cause of death. Interventions to address infection risk include a cotrimoxazole prophylaxis, isoniazid preventive therapy, routine childhood and influenza immunization, and improving maternal survival.

SUMMARY

Pediatric survival has improved substantially with cART and HIV-infected children are aging into adulthood. It is important to ensure access to diagnosis and early cART, good program retention as well as optimal comorbidity prophylaxis and treatment to achieve the best possible long-term survival and health outcomes for vertically infected children.

Prevention of mother-to-child transmission of HIV Option B+ cascade in rural Tanzania: The One Stop Clinic model

Background

Strategies to improve the uptake of Prevention of Mother-To-Child Transmission of HIV (PMTCT) are needed. We integrated HIV and maternal, newborn and child health services in a One Stop Clinic to improve the PMTCT cascade in a rural Tanzanian setting.

Methods

The One Stop Clinic of Ifakara offers integral care to HIV-infected pregnant women and their families at one single place and time. All pregnant women and HIV-exposed infants attended during the first year of Option B+ implementation (04/2014-03/2015) were included. PMTCT was assessed at the antenatal clinic (ANC), HIV care and labour ward, and compared with the pre-B+ period. We also characterised HIV-infected pregnant women and evaluated the MTCT rate.

Results

1,579 women attended the ANC. Seven (0.4%) were known to be HIV-infected. Of the remainder, 98.5% (1,548/1,572) were offered an HIV test, 94% (1,456/1,548) accepted and 38 (2.6%) tested HIV-positive. 51 were re-screened for HIV during late pregnancy and one had seroconverted. The HIV prevalence at the ANC was 3.1% (46/1,463). Of the 39 newly diagnosed women, 35 (90%) were linked to care. HIV test was offered to >98% of ANC clients during both the pre- and post-B+ periods. During the post-B+ period, test acceptance (94% versus 90.5%, p<0.0001) and linkage to care (90% versus 26%, p<0.0001) increased. Ten additional women diagnosed outside the ANC were linked to care. 82% (37/45) of these newly-enrolled women started antiretroviral treatment (ART). After a median time of 17 months, 27% (12/45) were lost to follow-up. 79 women under HIV care became pregnant and all received ART. After a median follow-up time of 19 months, 6% (5/79) had been lost. 5,727 women delivered at the hospital, 20% (1,155/5,727) had unknown HIV serostatus. Of these, 30% (345/1,155) were tested for HIV, and 18/345 (5.2%) were HIV-positive. Compared to the pre-B+ period more women were tested during labour (30% versus 2.4%, p<0.0001). During the study, the MTCT rate was 2.2%.

Conclusions

The implementation of Option B+ through an integrated service delivery model resulted in universal HIV testing in the ANC, high rates of linkage to care, and MTCT below the elimination threshold. However, HIV testing in late pregnancy and labour, and retention during early ART need to be improved.

Implementation and Operational Research: Active Referral of Children of HIV-Positive Adults Reveals High Prevalence of Undiagnosed HIV

OBJECTIVES

Few routine systems exist to test older, asymptomatic children for HIV. Testing all children in the population has high uptake but is inefficient, whereas testing only symptomatic children increases efficiency but misses opportunities to optimize outcomes. Testing children of HIV-infected adults in care may efficiently identify previously undiagnosed HIV-infected children before symptomatic disease.

METHODS

HIV-infected parents in HIV care in Nairobi, Kenya were systematically asked about their children's HIV status and testing history. Adults with untested children ≤12 years old were actively referred and offered the choice of pediatric HIV testing at home or clinic. Testing uptake and HIV prevalence were determined, as were bottlenecks in pediatric HIV testing cascade.

RESULTS

Of 10,426 HIV-infected adults interviewed, 8,287 reported having children, of whom 3,477 (42%) had children of unknown HIV status, and 611 (7%) had children ≤12 years of unknown HIV status. After implementation of active referral, the rate of pediatric HIV testing increased 3.8-fold from 3.5 to 13.6 children tested per month (Relative risk: 3.8, 95% confidence interval: 2.3 to 6.1). Of 611 eligible adults, 279 (48%) accepted referral and were screened, and 74 (14%) adults completed testing of 1 or more children. HIV prevalence among 108 tested children was 7.4% (95% confidence interval: 3.3 to 14.1%) and median age was 8 years (interquartile range: 2-11); 1 child was symptomatic at testing.

CONCLUSIONS

Referring HIV-infected parents in care to have their children tested revealed many untested children and significantly increased the rate of pediatric testing; prevalence of HIV was high. However, despite increases in pediatric testing, most adults did not complete testing of their children.

Implementation and Operational Research: An Integrated and Comprehensive Service Delivery Model to Improve Pediatric and Maternal HIV Care in Rural Africa

BACKGROUND

Strategies to improve HIV diagnosis and linkage into care, antiretroviral treatment coverage, and treatment outcomes of mothers and children are urgently needed in sub-Saharan Africa.

METHODS

From December 2012, we implemented an intervention package to improve prevention of mother-to-child transmission (PMTCT) and pediatric HIV care in our rural Tanzanian clinic, consisting of: (1) creation of a PMTCT and pediatric unit integrated within the reproductive and child health clinic; (2) implementation of electronic medical records; (3) provider-initiated HIV testing and counseling in the hospital wards; and (4) early infant diagnosis test performed locally. To assess the impact of this strategy, clinical characteristics and outcomes were compared between the period before (2008-2012) and during/after the implementation (2013-2014).

RESULTS

After the intervention, the number of mothers and children enrolled into care almost doubled. Compared with the pre-intervention period (2008-2012), in 2013-2014, children presented lower CD4% (16 vs. 16.8, P = 0.08) and more advanced disease (World Health Organization stage 3/4 72% vs. 35%, P < 0.001). The antiretroviral treatment coverage rose from 80% to 98% (P < 0.001), the lost-to-follow-up rate decreased from 20% to 11% (P = 0.002), and mortality ascertainment improved. During 2013-2014, 261 HIV-exposed infants were enrolled, and the early mother-to-child transmission rate among mother-infant pairs accessing PMTCT was 2%.

CONCLUSIONS

This strategy resulted in an increased number of mothers and children diagnosed and linked into care, a higher detection of children with AIDS, universal treatment coverage, lower loss to follow-up, and an early mother-to-child transmission rate below the threshold of elimination. This study documents a feasible and scalable model for family-centered HIV care in sub-Saharan Africa.

Non-Uptake of HIV Testing in Children at Risk in Two Urban and Rural Settings in Zambia: A Mixed-Methods Study

This article investigates reasons why children who were considered at risk of HIV were not taken for HIV testing by their caregivers. Qualitative and quantitative data collected in Zambia from 2010–11 revealed that twelve percent of caregivers who stated that they had been suspecting an HIV infection in a child in their custody had not had the child tested. Fears of negative reactions from the family were the most often stated reason for not testing a child. Experience of pre-existing conflicts between the couple or within the family (aOR 1.35, 95% CI 1.00–1.82) and observed stigmatisation of seropositive children in one’s own neighbourhood (aOR 1.69, 95% CI1.20–2.39) showed significant associations for not testing a child perceived at risk of HIV. Although services for HIV testing and treatment of children have been made available through national policies and programmes, some women and children were denied access leading to delayed diagnosis and treatment–not on the side of the health system, but on the household level. Social norms, such as assigning the male household head the power to decide over the use of healthcare services by his wife and children, jeopardize women’s bargaining power to claim their rights to healthcare, especially in a conflict-affected relationship. Social norms and customary and statutory regulations that disadvantage women and their children must be addressed at every level–including the community and household–in order to effectively decrease barriers to HIV related care.

Hospitalized Children Reveal Health Systems Gaps in the Mother-Child HIV Care Cascade in Kenya

To identify missed opportunities in HIV prevention, diagnosis, and linkage to care, we enrolled 183 hospitalized, HIV-infected, ART-naïve Kenyan children 0-12 years from four hospitals in Nairobi and Kisumu, and reviewed prevention of mother-to-child transmission of HIV (PMTCT), hospitalization, and HIV testing history. Median age was 1.8 years (IQR = 0.8, 4.5). Most mothers received HIV testing during pregnancy (77%). Among mothers tested, 60% and 40% reported HIV-negative and positive results, respectively; 33% of HIV-diagnosed mothers did not receive PMTCT antiretrovirals. First missed opportunities for pediatric diagnosis and linkage were due to failure to test mothers (23.1%), maternal HIV acquisition following initial negative test (45.7%), no early infant diagnosis (EID) or provider-initiated testing (PITC) (12.7%), late breastfeeding transmission (8.7%), failure to collect child HIV test results (1.2%), and no linkage to care following HIV diagnosis (8.7%). Among previously hospitalized children, 38% never received an HIV test. Strengthening initial and repeat maternal HIV testing and PITC are key interventions to prevent, detect, and treat pediatric HIV infections.

Integration of HIV in child survival platforms: a novel programmatic pathway towards the 90-90-90 targets

Introduction

Integration of HIV into child survival platforms is an evolving territory with multiple connotations. Most literature on integration of HIV into other health services focuses on adults; however promising practices for children are emerging. These include the Double Dividend (DD) framework, a new programming approach with dual goal of improving paediatric HIV care and child survival. In this commentary, the authors discuss why integrating HIV testing, treatment and care into child survival platforms is important, as well as its potential to advance progress towards global targets that call for, by 2020, 90% of children living with HIV to know their status, 90% of those diagnosed to be on treatment and 90% of those on treatment to be virally suppressed (90–90–90).

Discussion

Integration is critical in improving health outcomes and efficiency gains. In children, integration of HIV in programmes such as immunization and nutrition has been associated with an increased uptake of HIV infant testing. Integration is increasingly recognized as a case-finding strategy for children missed from prevention of mother-to-child transmission programmes and as a platform for diffusing emerging technologies such as point-of-care diagnostics. These support progress towards the 90–90–90 targets by providing a pathway for early identification of HIV-infected children with co-morbidities, prompt initiation of treatment and improved survival. There are various promising practices that have demonstrated HIV outcomes; however, few have documented the benefits of integration on child survival interventions. The DD framework is well positioned to address the bidirectional impacts for both programmes.

Conclusions

Integration provides an important programmatic pathway for accelerated progress towards the 90–90–90 targets. Despite this encouraging information, there are still challenges to be addressed in order to maximize the benefits of integration.

90-90-90--Charting a steady course to end the paediatric HIV epidemic

INTRODUCTION

The new "90-90-90" UNAIDS agenda proposes that 90% of all people living with HIV will know their HIV status, 90% of all people with diagnosed HIV infection will receive sustained antiretroviral therapy and 90% of all people receiving antiretroviral therapy will have viral suppression by 2020. By focusing on children, the global community is in the unique position of realizing an end to the paediatric HIV epidemic.

DISCUSSION

Despite vast scientific advances in the prevention and treatment of paediatric HIV infection over the last two decades, in 2014 there were an estimated 220,000 new paediatric infections attributed to mother-to-child HIV transmission (MTCT) and 150,000 HIV-related paediatric deaths. Furthermore, adolescents remain at particularly high risk for acquisition of new HIV infections, and HIV/AIDS remains the second leading cause of death in this age group. Among the estimated 2.6 million children less than 15 years of age living with HIV infection, only 32% were receiving life-saving antiretroviral treatment. After decades of languishing, good progress is now being made to prevent MTCT. Unfortunately, efforts to scale up HIV treatment services have been less robust for children and adolescents compared with adult populations. These discrepancies reflect substantial gaps in essential services and numerous missed opportunities to prevent HIV transmission and provide effective life-saving antiretroviral treatment to children, adolescents and families. The road to an AIDS-free generation will require bridging the gaps in HIV services and addressing the particular needs of children across the developmental spectrum from infancy through adolescence. To reach the ambitious new targets, innovations and service improvements will need to be rapidly escalated at each step along the prevention-treatment cascade.

CONCLUSIONS

Charting a successful course to reach the 90-90-90 targets will require sustained political and financial commitment as well as the rapid implementation of a broad set of systematic improvements in service delivery. The prospect of a world where HIV no longer threatens the lives of infants, children and adolescents may finally be within reach.

Brief Report: Impact of Option B+ on the Infant PMTCT Cascade in Lilongwe, Malawi

This observational study compared uptake of infant prevention of mother-to-child transmission of HIV services pre/post implementation of Option B+ in Lilongwe, Malawi. There were 845 (pre) and 998 (post) births. Post-B+, infants had longer median predelivery maternal antiretroviral therapy {62 days [interquartile range (IQR): 38-94] pre-B+ vs. 95 days [IQR: 61-131] post-B+; P < 0.0001} and improved polymerase chain reaction testing (82.0% vs. 86.5%; P = 0.01) at younger median age [7.6 weeks (IQR: 6.6-10.9) vs. 6.9 (IQR: 6.4-8.1); P < 0.0001]. Proportion testing polymerase chain reaction positive decreased (4.6% vs. 2.6%; P = 0.03). Proportion of HIV-infected infants starting antiretroviral therapy (75% vs. 77.3%) and age at initiation [19.7 weeks (IQR: 15.4-31.1) vs. 16 (IQR: 13.3-17.9)] remained unchanged. These findings suggest modest improvements in infant care with Option B+.

Paediatric HIV: Progress on Prevention, Treatment and Cure

PURPOSE OF REVIEW

This review provides an update on current developments with prevention, treatment and cure strategies in the field of pediatric HIV.

RECENT FINDINGS/SUMMARY

There has been tremendous progress in the prevention and treatment of pediatric HIV infection. With new strategies for prevention of mother-to-child transmission, we are growing ever closer towards elimination of pediatric HIV, though challenges with retention of pregnant woman and their HIV-exposed infants remain. Ongoing vigilance regarding the potential hazards of in utero ART exposure to infants continues with no significant alarms yet identified. Though cure has not been achieved, evidence of the impact of early treatment on reducing HIV-1 reservoir size with subsequent prolonged remission has enlivened efforts to rapidly identify and treat HIV-infected newborns. There is an increasing array of treatment options for pediatric patients and reassuring evidence regarding long-term complications of ART. Unfortunately, despite evidence suggesting the benefit of early treatment, timely identification and treatment of children remains a challenge. Better strategies for effective case-finding and engagement in care are urgently needed in addition to an improved understanding of how to retain HIV-positive children and adolescents on treatment. However, further emboldened by recent international commitments and robust global support, the future is hopeful.

Early diagnosis is critical to ensure good outcomes in HIV-infected children: outlining barriers to care

HIV-infected children require early initiation of antiretroviral therapy (ART) to ensure good outcomes. The aim was to investigate missed opportunities in childhood HIV diagnosis leading to delayed ART initiation. Baseline data were reviewed of all children aged <15 years referred over a 1-year period for ART initiation to the Kalafong Hospital HIV services in Gauteng, South Africa. Of the 250 children, one-quarter (24.5%) was of school-going age, 34.5% in the preschool group, 18% between 6 and 12 months old and 23% below 6 months of age (median age = 1.5 years [interquartile range 0.5-4.8]). Most children (82%) presented with advanced/severe HIV disease, particularly those aged 6-12 months (95%). Malnutrition was prominent and referrals were mostly from hospital inpatient services (61%). A structured caregiver interview was conducted in a subgroup, with detailed review of medical records and HIV results. The majority (≥89%) of the 65 interviewed caregivers reported good access to routine healthcare, except for postnatal care (26%). Maternal HIV-testing was mostly done during the second and third pregnancy trimesters (69%). Maternal non-disclosure of HIV status was common (63%) and 83% of mothers reported a lack of psychosocial support. Routine infant HIV-testing was not done in 66%, and inadequate reporting on patient-held records (Road-to-Health Cards/Booklets) occurred frequently (74%). Children with symptomatic HIV disease were not investigated at primary healthcare in 53%, and in 68% of families the siblings were not tested. One-third of children (35%) had a previous HIV diagnosis, with 77% of caregivers aware of these prior results, while 50% acknowledged failing to attend ART services despite referral. In conclusion, a clear strategy on paediatric HIV case finding, especially at primary healthcare, is vital. Multiple barriers need to be overcome in the HIV care pathway to reach high uptake of services, of which especially maternal reasons for not attending paediatric ART services need further exploration.

The burden of disease on HIV-infected orphaned and non-orphaned children accessing primary health facilities in a rural district with poor resources in South Africa: a cross-sectional survey of primary caregivers of HIV-infected children aged 5-18 years

Background

Provider-initiated HIV testing and counseling (PITC) is offered as part of the normal standard of care to increase access to treatment for HIV-infected children. In practice, HIV diagnosis occurs in late childhood following recurrent and chronic infections. We investigated primary caregivers’ reported reasons for seeking HIV testing for children aged 5–18 years, determined the orphan status of the children, and compared the clinical profile and disease burden of orphans and non-orphans.

Methods

This was a cross-sectional survey of primary caregivers of HIV-infected children accessing antiretroviral treatment (ART) from two community hospitals and 34 primary healthcare facilities in a rural district in Mpumalanga province, South Africa.

Results

The sample consisted of 406 primary caregivers: 319 (78.6%) brought the child to the health facility for HIV testing because of chronic and recurrent infections. Almost half (n = 183, 45.1%) of the children were maternal orphans, 128 (31.5%) were paternal orphans, and 73 (39.9%) were double orphans. A univariate analysis showed that maternal orphans were significantly more likely to be older (OR = 2.57, p = 0.000, CI: 1.71–3.84), diagnosed late (OR = 2.48, p = 0.009, CI: 1.26–4.88), and to start ART later (OR = 2.5, p = 0.007, CI: 1.28–4.89) than non-orphans. There was a high burden of infection among the children prior to HIV diagnosis; 274 (69.4%) presented with multiple infections. Multiple logistic regression showed that ART start age (aOR = 1.19, p = 0.000, CI: 1.10–1.29) and time on ART (aOR = 2.30, p = 0.000, CI: 1.45–3.64) were significantly associated with orphanhood status. Half (n = 203, (50.2%) of the children were admitted to hospital prior to start of ART, and hospitalization was associated with multiple infections (OR = 1.27, p = 0.004, CI: 1.07–1.51).

Conclusions

The study found late presentation with undiagnosed perinatal HIV infection and high prevalence of orphanhood among the children. The health of maternal orphans was more compromised than non-orphans. Routine PICT should be strengthened to increase community awareness about undiagnosed HIV among older children and to encourage primary caregivers to accept HIV testing for children.

Electronic supplementary material

The online version of this article (doi:10.1186/s40249-015-0049-x) contains supplementary material, which is available to authorized users.

Feasibility and effectiveness of two community-based HIV testing models in rural Swaziland

Objectives

To evaluate the feasibility (population reached, costs) and effectiveness (positivity rates, linkage to care) of two strategies of community-based HIV testing and counselling (HTC) in rural Swaziland.

Methods

Strategies used were mobile HTC (MHTC) and home-based HTC (HBHTC). Information on age, sex, previous testing and HIV results was obtained from routine HTC records. A consecutive series of individuals testing HIV-positive were followed up for 6 months from the test date to assess linkage to care.

Results

A total of 9 060 people were tested: 2 034 through MHTC and 7 026 through HBHTC. A higher proportion of children and adolescents (<20 years) were tested through HBHTC than MHTC (57% vs. 17%; P < 0.001). MHTC reached a higher proportion of adult men than HBHTC (42% vs. 39%; P = 0.015). Of 398 HIV-positive individuals, only 135 (34%) were enrolled in HIV care within 6 months. Of 42 individuals eligible for antiretroviral therapy, 22 (52%) started treatment within 6 months. Linkage to care was lowest among people who had tested previously and those aged 20–40 years. HBHTC was 50% cheaper (US$11 per person tested; $797 per individual enrolled in HIV care) than MHTC ($24 and $1698, respectively).

Conclusion

In this high HIV prevalence setting, a community-based testing programme achieved high uptake of testing and appears to be an effective and affordable way to encourage large numbers of people to learn their HIV status (particularly underserved populations such as men and young people). However, for community HTC to impact mortality and incidence, strategies need to be implemented to ensure people testing HIV-positive in the community are linked to HIV care.

Objectifs

Evaluer la faisabilité (population atteinte, coûts) et l'efficacité (taux de positivité, liaison aux soins) de deux stratégies de dépistage et conseil (DC) communautaire du VIH en zone rurale au Swaziland.

Méthodes

Les stratégies utilisées étaient des DC mobiles (DC-M) et le DC à domicile (DC-D). Les informations sur l’âge, le sexe, les tests précédents et les résultats VIH ont été obtenues à partir des dossiers de routine du DC. Une série d'individus séropositifs consécutifs a été suivie pendant six mois à partir de la date du test afin d’évaluer les liaisons aux soins.

Résultats

9.060 personnes ont été testées: 2.034 par le biais du DC-M et 7026 par le biais du DC-D. Une plus grande proportion d'enfants et d'adolescents (<20 ans) ont été testés par le biais du DC-D que par celui du DC-M (57% vs 17%; p <0,001). Le DC-M a atteint une proportion plus élevée d'hommes adultes que le DC-D (42% vs 39%; p = 0,015). Des 398 personnes séropositives, seules 135 (34%) ont été inscrites à des soins VIH dans les 6 mois. De 42 personnes admissibles à la thérapie antirétrovirale, 22 (52%) ont commencé le traitement dans les 6 mois. Les liaisons avec les soins étaient plus faibles chez les personnes qui ont effectué un dépistage auparavant et celles âgées de 20 à 40 ans. Le DC-D était 50% moins cher (11 $ US par personne testée, 797 $ par personne inscrite dans les soins VIH) que le DC-M (24 $ et 1.698 $, respectivement).

Conclusion

Dans ce contexte à haute prévalence du VIH, un programme de dépistage communautaire a atteint une couverture élevée et semble être un moyen efficace et abordable pour encourager un grand nombre de personnes à connaître leur statut VIH (en particulier les populations mal desservies, telles que les hommes et les jeunes personnes). Cependant, afin que le DC communautaire ait un impact sur la mortalité et l'incidence, des stratégies doivent être mises en œuvre pour assurer que les personnes testées séropositives dans la communauté soient reliées aux soins du VIH.

Objetivos

Evaluar la viabilidad (población alcanzada, costes) y efectividad (tasas de positividad, vinculación al tratamiento) de dos estrategias comunitarias de asesoramiento y prueba para el VIH (APV) en zonas rurales de Suazilandia.

Métodos

Las estrategias utilizadas fueron la de APV en instalaciones clínicas móviles (APVM) y el APV realizado en el hogar (APVBH). Se obtuvo información sobre la edad, el sexo, la realización de pruebas anteriores y resultados de VIH de los informes rutinarios de APV. A una serie consecutiva de individuos que habían dado positivo en la prueba de VIH se les siguió durante 6 meses a partir del día de la prueba, con el fin de evaluar la conexión posterior a los cuidados y tratamiento adecuados.

Resultados

Se evaluaron 9,060 personas: 2,034 mediante APVM y 7,026 mediante APVBH. A una mayor proporción de niños y adolescentes (<20 años) se les realizó la prueba mediante APVBH que mediante APVM (57% vs. 17%; p<0.001). El APVM llegó a una mayor proporción de hombres adultos que el APVBH (42% vs. 39%; p=0.015). De 398 individuos VIH positivos, solo 135 (34%) estaban recibiendo atención y cuidados para el VIH después de 6 meses. De 42 individuos elegibles para Terapia Antirretroviral, 22 (52%) comenzaron el tratamiento dentro de los 6 meses siguientes a la prueba. La vinculación a los cuidados y atención para VIH posterior a la prueba era menor entre aquellos que habían dado previamente positivo y aquellos con edades entre 20-40 años. El APVBH era un 50% más barato (US$11 por persona a la que se le realizó la prueba, $797 por individuo recibiendo cuidados para VIH) que el APVM ($24 y $1698, respectivamente).

Conclusión

En este emplazamiento con una alta prevalencia de VIH, un programa de prueba para el VIH basado en la comunidad alcanzó un alto nivel de aceptación de la prueba, y parece ser una manera efectiva y económicamente asumible de animar a un gran número de personas a conocer su estatus de VIH (en particular población actualmente poco alcanzada como los hombres y personas jóvenes). Sin embargo, para que el APV comunitario tenga un impacto sobre la mortalidad y la incidencia, es necesario implementar estrategias apoyen el tratamiento, asegurando que las personas que dan positivo en la prueba son remitidas y reciben los cuidados adecuados.

High mortality in HIV-infected children diagnosed in hospital underscores need for faster diagnostic turnaround time in prevention of mother-to-child transmission of HIV (PMTCT) programs

Background

Despite expanded programs for prevention of mother-to-child HIV transmission (PMTCT), HIV-infected infants may not be diagnosed until they are ill. Comparing HIV prevalence and outcomes in infants diagnosed in PMTCT programs to those in hospital settings may improve pediatric HIV diagnosis strategies.

Methods

HIV-exposed infants <12 months old were recruited from 9 PMTCT sites in public maternal child health (MCH) clinics or from an inpatient setting in Nairobi, Kenya and tested for HIV using HIV DNA assays. A subset of HIV-infected infants <4.5 months of age was enrolled in a research study and followed for 2 years. HIV prevalence, number needed to test, infant age at testing, and turnaround time for tests were compared between PMTCT programs and hospital sites. Among the enrolled cohort, baseline characteristics, survival, and timing of antiretroviral therapy (ART) initiation were compared between infants diagnosed in PMTCT programs versus hospital.

Results

Among 1,923 HIV-exposed infants, HIV prevalence was higher among infants tested in hospital than PMTCT early infant diagnosis (EID) sites (41% vs. 11%, p < 0.001); the number of HIV-exposed infants needed to test to diagnose one infection was 2.4 in the hospital vs. 9.1 in PMTCT. Receipt of HIV test results was faster among hospitalized infants (7 vs. 25 days, p < 0.001). Infants diagnosed in hospital were older at the time of testing than PMTCT diagnosed infants (5.0 vs. 1.6 months, respectively, p < 0.001).

In the subset of 99 HIV-infected infants <4.5 months old followed longitudinally, hospital-diagnosed infants did not differ from PMTCT-diagnosed infants in time to ART initiation; however, hospital-diagnosed infants were >3 times as likely to die (HR = 3.1, 95% CI = 1.3-7.6).

Conclusions

Among HIV-exposed infants, hospital-based testing was more likely to detect an HIV-infected infant than PMTCT testing. Because young symptomatic infants diagnosed with HIV during hospitalization have very high mortality, every effort should be made to diagnose HIV infections before symptom onset. Systems to expedite turnaround time at PMTCT EID sites and to routinize inpatient pediatric HIV testing are necessary to improve pediatric HIV outcomes.

Improved identification and enrolment into care of HIV-exposed and -infected infants and children following a community health worker intervention in Lilongwe, Malawi

BACKGROUND

Early identification and entry into care is critical to reducing morbidity and mortality in children with HIV. The objective of this report is to describe the impact of the Tingathe programme, which utilizes community health workers (CHWs) to improve identification and enrolment into care of HIV-exposed and -infected infants and children.

METHODS

Three programme phases are described. During the first phase, Mentorship Only (MO) (March 2007-February 2008) on-site clinical mentorship on paediatric HIV care was provided. In the second phase, Tingathe-Basic (March 2008-February 2009), CHWs provided HIV testing and counselling to improve case finding of HIV-exposed and -infected children. In the final phase, Tingathe-PMTCT (prevention of mother-to-child transmission) (March 2009-February 2011), CHWs were also assigned to HIV-positive pregnant women to improve mother-infant retention in care. We reviewed routinely collected programme data from HIV testing registers, patient mastercards and clinic attendance registers from March 2005 to March 2011.

RESULTS

During MO, 42 children (38 HIV-infected and 4 HIV-exposed) were active in care. During Tingathe-Basic, 238 HIV-infected children (HIC) were newly enrolled, a six-fold increase in rate of enrolment from 3.2 to 19.8 per month. The number of HIV-exposed infants (HEI) increased from 4 to 118. During Tingathe-PMTCT, 526 HIC were newly enrolled over 24 months, at a rate of 21.9 patients per month. There was also a seven-fold increase in the average number of exposed infants enrolled per month (9.5-70 patients per month), resulting in 1667 enrolled with a younger median age at enrolment (5.2 vs. 2.5 months; p < 0.001). During the Tingathe-Basic and Tingathe-PMTCT periods, CHWs conducted 44,388 rapid HIV tests, 7658 (17.3%) in children aged 18 months to 15 years; 351 (4.6%) tested HIV-positive. Over this time, 1781 HEI were enrolled, with 102 (5.7%) found HIV-infected by positive PCR. Additional HIC entered care through various mechanisms (including positive linkage by CHWs and transfer-ins) such that by February 2011, a total of 866 HIC were receiving care, a 23-fold increase from 2008.

CONCLUSIONS

A multipronged approach utilizing CHWs to conduct HIV testing, link HIC into care and provide support to PMTCT mothers can dramatically improve the identification and enrolment into care of HIV-exposed and -infected children.

A mathematical model evaluating the timing of early diagnostic testing in HIV-exposed infants in South Africa

BACKGROUND

Antiretroviral therapy is often initiated too late to impact early HIV-related infant mortality. Earlier treatment requires an earlier diagnosis, and the currently recommended 6-week HIV polymerase chain reaction (PCR) test needs reconsideration. This study aims to identify (1) optimal testing intervals to maximize the number of perinatal HIV infections diagnosed and (2) programmatic issues that impact diagnosis.

METHODS

A mathematical model was developed to simulate antiretroviral prophylaxis uptake and health outcomes in 240,000 HIV-exposed South African infants. The model considered routine early testing with 1 PCR (at birth, 6, 10, or 14 weeks of age) and with 2 PCR tests (at birth and at 6, 10, or 14 weeks of age).

RESULTS

A single 6-week test would diagnose the same number of perinatal HIV infections as birth testing (P = 0.92) but fewer infections than a 10-week test (P < 0.01). Ten-week testing identifies the highest number of perinatally infected infants (P < 0.01 compared with a single test at all other ages) but does not save additional life years compared with birth testing (P = 0.27). Performing 2 PCR tests (at birth and 10 weeks) would identify the highest number of perinatal infections (P < 0.01 versus a second 6- or 14-week test). However, 25% of perinatal HIV infections would remain undiagnosed, largely because of failure to return PCR test results to caregivers.

CONCLUSIONS

Six weeks may no longer be the optimal age to diagnose perinatal HIV infections. Two early PCR tests (at birth and 10 weeks) would likely be the ideal diagnostic algorithm, but must be coupled with improved program coverage.