Superior uptake and outcomes of early infant diagnosis of HIV services at an immunization clinic versus an "under-five" general pediatric clinic in Malawi

Costs and cost-effectiveness of HIV early infant diagnosis in low- and middle-income countries: a scoping review

Background

Continuing progress in the global pediatric human immunodeficiency virus (HIV) response depends on timely identification and care of infants with HIV. As countries scale-out improvements to HIV early infant diagnosis (EID), economic evaluations are needed to inform program design and implementation. This scoping review aimed to summarize the available evidence and discuss practical implications of cost and cost-effectiveness analyses of HIV EID.

Methods

We systematically searched bibliographic databases (Embase, MEDLINE and EconLit) and grey literature for economic analyses of HIV EID in low- and middle-income countries published between January 2008 and June 2021. We extracted data on unit costs, cost savings, and incremental cost-effectiveness ratios as well as outcomes related to health and the HIV EID care process and summarized results in narrative and tabular formats. We converted unit costs to 2021 USD for easier comparison of costs across studies.

Results

After title and abstract screening of 1278 records and full-text review of 99 records, we included 29 studies: 17 cost analyses and 12 model-based cost-effectiveness analyses. Unit costs were 21.46–51.80 USD for point-of-care EID tests and 16.21–42.73 USD for laboratory-based EID tests. All cost-effectiveness analyses stated at least one of the interventions evaluated to be cost-effective. Most studies reported costs of EID testing strategies; however, few studies assessed the same intervention or reported costs in the same way, making comparison of costs across studies challenging. Limited data availability of context-appropriate costs and outcomes of children with HIV as well as structural heterogeneity of cost-effectiveness modelling studies limits generalizability of economic analyses of HIV EID.

Conclusions

The available cost and cost-effectiveness evidence for EID of HIV, while not directly comparable across studies, covers a broad range of interventions and suggests most interventions designed to improve EID are cost-effective or cost-saving. Further studies capturing costs and benefits of EID services as they are delivered in real-world settings are needed.

Graphical Abstract

Supplementary Information

The online version contains supplementary material available at 10.1186/s40249-022-01006-7.

Optimizing infant HIV diagnosis with additional screening at immunization clinics in three sub-Saharan African settings: a cost-effectiveness analysis

INTRODUCTION

Uptake of early infant HIV diagnosis (EID) varies widely across sub-Saharan African settings. We evaluated the potential clinical impact and cost-effectiveness of universal maternal HIV screening at infant immunization visits, with referral to EID and maternal antiretroviral therapy (ART) initiation.

METHODS

Using the CEPAC-Pediatric model, we compared two strategies for infants born in 2017 in Côte d'Ivoire (CI), South Africa (SA), and Zimbabwe: (1) existing EID programmes offering six-week nucleic acid testing (NAT) for infants with known HIV exposure (EID), and (2) EID plus universal maternal HIV screening at six-week infant immunization visits, leading to referral for infant NAT and maternal ART initiation (screen-and-test). Model inputs included published Ivoirian/South African/Zimbabwean data: maternal HIV prevalence (4.8/30.8/16.1%), current uptake of EID (40/95/65%) and six-week immunization attendance (99/74/94%). Referral rates for infant NAT and maternal ART initiation after screen-and-test were 80%. Costs included NAT ($24/infant), maternal screening ($10/mother-infant pair), ART ($5 to 31/month) and HIV care ($15 to 190/month). Model outcomes included mother-to-child transmission of HIV (MTCT) among HIV-exposed infants, and life expectancy (LE) and mean lifetime per-person costs for children with HIV (CWH) and all children born in 2017. We calculated incremental cost-effectiveness ratios (ICERs) using discounted (3%/year) lifetime costs and LE for all children. We considered two cost-effectiveness thresholds in each country: (1) the per-capita GDP ($1720/6380/2150) per year-of-life saved (YLS), and (2) the CEPAC-generated ICER of offering 2 versus 1 lifetime ART regimens (e.g. offering second-line ART; $520/500/580/YLS).

RESULTS

With EID, projected six-week MTCT was 9.3% (CI), 4.2% (SA) and 5.2% (Zimbabwe). Screen-and-test decreased total MTCT by 0.2% to 0.5%, improved LE by 2.0 to 3.5 years for CWH and 0.03 to 0.07 years for all children, and increased discounted costs by $17 to 22/child (all children). The ICER of screen-and-test compared to EID was $1340/YLS (CI), $650/YLS (SA) and $670/YLS (Zimbabwe), below the per-capita GDP but above the ICER of 2 versus 1 lifetime ART regimens in all countries.

CONCLUSIONS

Universal maternal HIV screening at immunization visits with referral to EID and maternal ART initiation may reduce MTCT, improve paediatric LE, and be of comparable value to current HIV-related interventions in high maternal HIV prevalence settings like SA and Zimbabwe.

Where have all the children gone? High HIV prevalence in infants attending nutrition and inpatient entry points

Introduction

Despite notable progress towards PMTCT, only 50% of HIV‐exposed infants in sub‐Saharan Africa were tested within the first 2 months of life and only 30% of HIV‐infected infants are on antiretroviral treatment. This study assessed HIV prevalence in infants and children receiving care at various service entry points in primary healthcare facilities in Uganda.

Methods

A total of 3600 infants up to 24 months of age were systematically enrolled and tested at four regional hospitals across Uganda. Six hundred infants were included and tested from six facility entry points: PMTCT, immunization, inpatient, nutrition, outpatient and community outreach services.

Findings

The traditional EID entry point, PMTCT, had a prevalence of 3.8%, representing 19.6% of the total HIV‐positive infants identified in the study. Fifty percent of the 117 identified HIV‐positive infants were found in the nutrition wards, which had a prevalence of 9.8% (p < 0.001 compared to PMTCT). Inpatient wards had a prevalence of 3.5% and yielded 17.9% of the HIV‐positive infants identified. Infants tested at immunization wards and through outreach services identified 0.8% and 1.7% of the HIV‐positive infants respectively, and had a prevalence of less than 0.3%.

Conclusions

Expanding routine early infant diagnosis screening beyond the traditional PMTCT setting to nutrition and inpatient entry points will increase the identification of HIV‐infected infants. Careful reflection for appropriate testing strategies, such as maternal re‐testing to identify new HIV infections and HIV‐exposed infants in need of follow‐up testing and care, at immunization and outreach services should be considered given the expectedly low prevalence rates. These findings may help HIV care programmes significantly expand testing to improve access to early infant diagnosis and paediatric treatment.

Accessibility of Early Infant Diagnostic Services by Under-5 Years and HIV Exposed Children in Muheza District, North-East Tanzania

Introduction: Early infant diagnosis (EID) of Human Immunodeficiency Virus (HIV) provides an opportunity for follow up of HIV exposed children for early detection of infection and timely access to antiretroviral treatment. We assessed predictors for accessing HIV diagnostic services among under-five children exposed to HIV infection in Muheza district, Tanzania.

Methods: A cross sectional facility-based study among mother/guardian-child pairs of HIV exposed children was conducted from June 2015 to June 2016. Using a structured questionnaire, we collected information on HIV status, socio-demographic characteristics and other relevant data. Multiple regression analyses were used to investigate associations of potential predictors of accessing EID services.

Results: A total of 576 children with their respective mothers/guardians were recruited. Of the 576 mothers/guardians, 549 (95.3%) were the biological mothers with a median age of 34 years (inter-quartile range: 30–38 years). The median age of the 576 children was 15 months (inter- quartile range: 8.5–38.0 months). A total of 251 (43.6%) children were born to mothers with unknown HIV status at conception. Only 329 (57.1%) children accessed EID between 4 and 6 weeks of age. Children born to mothers with unknown HIV status at conception (AOR = 0.6, 95% CI 0.4–0.8) and those with ages 13–59 months (AOR = 0.4, 95% CI 0.2–0.6) were the significant predictors of missed opportunity to access EID. Children living with the head of household with at least a high education level had higher chances of accessing EID (AOR = 1.8, 95% CI 1.1–3.3). Their chances of accessing EID services was three-fold higher among mothers/guardians with good knowledge of HIV infection prevention of mother to child transmission (AOR = 3.2, 95% CI 2.0–5.2) than those with poor knowledge. Mothers/guardians living in rural areas had poorer knowledge of HIV infection prevention of mother to child transmission (AOR = 0.6, 95% CI 0.4–0.9) than those living in urban areas.

Conclusion: Accessibility of EID services among children below 5 years exposed to HIV infection in Muheza is low. These findings stress the need for continued HIV education and outreach services, particularly in rural areas in order to improve maternal and child health.

Integration of Neonatal and Child Health Interventions with Pediatric HIV Interventions in Global Health

BACKGROUND/OBJECTIVES

In the last decade, many strategies have called for integration of HIV and child survival platforms to reduce missed opportunities and improve child health outcomes. Countries with generalized HIV epidemics have been encouraged to optimize each clinical encounter to bend the HIV epidemic curve. This systematic review looks at integrated child health services and summarizes evidence on their health outcomes, service uptake, acceptability, and identified enablers and barriers.

METHODS

Databases were systematically searched for peer-reviewed studies. Interventions of interest were HIV services integrated with: neonatal/child services for children <5 years, hospital care of children <5 years, immunizations, and nutrition services. Outcomes of interest were: health outcomes of children <5 years, integrated services uptake, acceptability, and enablers and barriers. PROSPERO ID: CRD42017082444.

RESULTS

Twenty-eight articles were reviewed: 25 (89%) evaluated the integration of HIV services into child health platforms, while three articles (11%) investigated the integration of child health services into HIV platforms. Studies measured health outcomes of children (n=9); service uptake (n=18); acceptability of integrated services (n=8), and enablers and barriers to service integration (n=14). Service integration had positive effects on child health outcomes, HIV testing, and postnatal service uptake. Integrated services were generally acceptable, although confidentiality and stigma were concerns.

CONCLUSION AND GLOBAL HEALTH IMPLICATIONS

Each clinical "touch point" with infants and children is an opportunity to provide comprehensive health services. In the current era of flat funding levels, integration of HIV and child health services is an effective, acceptable way to achieve positive child health outcomes.

Implementation and Operational Research: Impact of a Systems Engineering Intervention on PMTCT Service Delivery in Côte d'Ivoire, Kenya, Mozambique: A Cluster Randomized Trial

BACKGROUND

Efficacious interventions to prevent mother-to-child HIV transmission (PMTCT) have not translated well into effective programs. Previous studies of systems engineering applications to PMTCT lacked comparison groups or randomization.

METHODS

Thirty-six health facilities in Côte d'Ivoire, Kenya, and Mozambique were randomized to usual care or a systems engineering intervention, stratified by country and volume. The intervention guided facility staff to iteratively identify and then rectify barriers to PMTCT implementation. Registry data quantified coverage of HIV testing during first antenatal care visit, antiretrovirals (ARVs) for HIV-positive pregnant women, and screening HIV-exposed infants (HEI) for HIV by 6-8 weeks. We compared the change between baseline (January 2013-January 2014) and postintervention (January 2015-March 2015) periods using t-tests. All analyses were intent-to-treat.

RESULTS

ARV coverage increased 3-fold [+13.3% points (95% CI: 0.5 to 26.0) in intervention vs. +4.1 (-12.6 to 20.7) in control facilities] and HEI screening increased 17-fold [+11.6 (-2.6 to 25.7) in intervention vs. +0.7 (-12.9 to 14.4) in control facilities]. In prespecified subgroup analyses, ARV coverage increased significantly in Kenya [+20.9 (-3.1 to 44.9) in intervention vs. -21.2 (-52.7 to 10.4) in controls; P = 0.02]. HEI screening increased significantly in Mozambique [+23.1 (10.3 to 35.8) in intervention vs. +3.7 (-13.1 to 20.6) in controls; P = 0.04]. HIV testing did not differ significantly between arms.

CONCLUSIONS

In this first randomized trial of systems engineering to improve PMTCT, we saw substantially larger improvements in ARV coverage and HEI screening in intervention facilities compared with controls, which were significant in prespecified subgroups. Systems engineering could strengthen PMTCT service delivery and protect infants from HIV.

Overcoming Health System Challenges for Women and Children Living With HIV Through the Global Plan

To meet the ambitious targets set by the Global Plan Towards the Elimination of New HIV Infections Among Children by 2015 and Keeping Their Mothers Alive (Global Plan), the initial 22 priority countries quickly developed innovative approaches for overcoming long-standing health systems challenges and providing HIV testing and treatment to pregnant and breastfeeding women and their infants. The Global Plan spurred programs for prevention of mother-to-child HIV transmission to integrate HIV-related care and treatment into broader maternal, newborn, and child health services; expand the effectiveness of the health workforce through task sharing; extend health services into communities; strengthen supply chain and commodity management systems; reduce diagnostic and laboratory hurdles; and strengthen strategic supervision and mentorship. The article reviews the ongoing challenges for prevention of mother-to-child HIV transmission programs as they continue to strive for elimination of vertical transmission of HIV infection in the post-Global Plan era. Although progress has been rapid, health systems still face important challenges, particularly follow-up and diagnosis of HIV-exposed infants, continuity of care, and the promotion of services that are respectful and client centered.

A systematic review of strategies to increase access to health services among children in low and middle income countries

Background

Universal Health Coverage is widely endorsed as the pivotal goal in global health, however substantial barriers to accessing health services for children in low and middle-income countries (LMIC) exist. Failure to access healthcare is an important contributor to child mortality in these settings. Barriers to access have been widely studied, however effective interventions to overcome barriers and increase access to services for children are less well documented.

Methods

We conducted a systematic review of effectiveness of interventions aimed at increasing access to health services for children aged 5 years and below in LMIC. Four databases (EMBASE, Global Health, MEDLINE, and PSYCINFO) were searched in January 2016. Studies were included if they evaluated interventions that aimed to increase: health care utilisation; immunisation uptake; and compliance with medication or referral. Randomised controlled trials and non-randomised controlled study designs were included in the review. A narrative approach was used to synthesise results.

Results

Fifty seven studies were included in the review. Approximately half of studies (49%) were conducted in sub-Saharan Africa. Most studies were randomised controlled trials (n = 44; 77%) with the remaining studies employing non-randomised designs. Very few studies were judged as high quality. Studies evaluated a diverse range of interventions and various outcomes. Supply side interventions included: delivery of services at or closer to home and service level improvements (eg. integration of services). Demand side interventions included: educational programmes, text messages, and financial or other incentives. Interventions that delivered services at or closer to home and text messages were in general associated with a significant improvement in relevant outcomes. A consistent pattern was not noted for the remaining studies.

Conclusions

This review fills a gap in the literature by providing evidence of the range and effectiveness of interventions that can be used to increase access for children aged ≤5 years in LMIC. It highlights some intervention areas that seem to show encouraging trends including text message reminders and delivery of services at or close to home. However, given the methodological limitations found in existing studies, the results of this review must be interpreted with caution.

Systematic review registration

PROSPERO CRD420160334200

Electronic supplementary material

The online version of this article (doi:10.1186/s12913-017-2180-9) contains supplementary material, which is available to authorized users.

Integration of HIV infant testing into immunization programmes: a systematic review

BACKGROUND

Integration of HIV infant testing into immunization sessions is one of the strategies designed to increase coverage of early infant diagnosis.

OBJECTIVE

To determine the evidence on the outcomes of such integration.

METHODS

A systematic review of peer-reviewed and grey literature was undertaken from electronic sources such as MEDLINE, Google Scholar, websites of international agencies, past conferences and ministries of health reports published between year 2002 and 2013. Randomized controlled trials, observational and qualitative studies were searched and those meeting selection criteria were selected and relevant information extracted using structured tool. Statistical pooling was not possible owing to the heterogeneity of the study designs and outcome measures.

RESULTS

Of the nine articles which met the selection criteria, none used a randomized controlled design. Of these, five articles measured mother's acceptability of their infants being tested for HIV during its first pentavalent or DPT vaccination visit, and 89·5-100% accepted. Four articles reported the proportion of mothers who returned for HIV test results, ranging from 56·8% to 86·0%. Increased uptake of HIV testing following integration was confirmed by two articles. Only one study in Tanzania determined the uptake of vaccinations following integration, with urban facilities showing stable or slight increase of monthly vaccine uptake while decreases were observed across the rural sites. In two articles, stigma was perceived by service-providers and mothers as the potential risk following integration, particularly in rural settings.

DISCUSSION

Despite the limited number of articles, the findings in this systematic review suggest that HIV testing during immunization clinic visits is acceptable and feasible as a possible model for service delivery. However, the impact on vaccination uptake needs further study.

Scoping review: strategies of providing care for children with chronic health conditions in low- and middle-income countries

OBJECTIVES

To identify and review strategies of providing care for children living with chronic health conditions in low- and middle-income countries.

METHODS

We searched MEDLINE and Cochrane EPOC databases for papers evaluating strategies of providing care for children with chronic health conditions in low- or middle-income countries. Data were systematically extracted using a standardised data charting form, and analysed according to Arksey and O'Malley's 'descriptive analytical method' for scoping reviews.

RESULTS

Our search identified 71 papers addressing eight chronic conditions; two chronic communicable diseases (HIV and TB) accounted for the majority of papers (n = 37, 52%). Nine (13%) papers reported the use of a package of care provision strategies (mostly related to HIV and/or TB in sub-Saharan Africa). Most papers addressed a narrow aspect of clinical care provision, such as patient education (n = 23) or task-shifting (n = 15). Few papers addressed the strategies for providing care at the community (n = 10, 15%) or policy (n = 6, 9%) level. Low-income countries were under-represented (n = 24, 34%), almost exclusively involving HIV interventions in sub-Saharan Africa (n = 21). Strategies and summary findings are described and components of future models of care proposed.

CONCLUSIONS

Strategies that have been effective in reducing child mortality globally are unlikely to adequately address the needs of children with chronic health conditions in low- and middle-income settings. Current evidence mostly relates to disease-specific, narrow strategies, and more research is required to develop and evaluate the integrated models of care, which may be effective in improving the outcomes for these children.

Predictors of Infant Age at Enrollment in Early Infant Diagnosis Services in Kenya

Despite the importance of early detection to signal lifesaving treatment initiation for HIV+ infants, early infant diagnosis (EID) services have received considerably less attention than other aspects of prevention of mother to child transmission care. This study draws on baseline data from an on-going cluster randomized study of an intervention to improve EID services at six government hospitals across Kenya. Two logistic regressions examined potential predictors of “on time” (infant ≤6 weeks of age) vs. “late” (≥7 weeks) and “on time” versus “very late” (≥12 weeks) EID engagement among 756 mother-infant pairs. A quarter of the infants failed to get “on time” testing. Predictors of “on time” testing included being informed about EID by providers when pregnant, perceiving less HIV stigma, and mother’s level of education. Predictors of “very late” testing (≥12 weeks of age) included not being informed about EID by providers when pregnant and living farther from services. Findings highlight the importance of ensuring that health care providers actively and repeatedly inform HIV+ mothers of the availability of EID services, reduce stigma by frequently communicating judgment free support, and assisting mothers in early planning for accessing EID services. Extra care should be focused on engaging mothers with less formal education who are at increased risk for seeking “late” EID testing. This study offers clear targets for improving services so that all HIV-exposed infants can be properly engaged in EID services, thus increasing the potential for the best possible outcomes for this vulnerable population.

Paediatric HIV testing beyond the context of prevention of mother-to-child transmission: a systematic review and meta-analysis

BACKGROUND

Many HIV-positive children in low-income and middle-income countries remain undiagnosed. Although HIV testing in children at health facilities is recommended by WHO, it is not well implemented. This systematic review and meta-analysis examines the case-finding benefit of HIV screening in children aged 0-5 years in low-income and middle-income countries.

METHODS

We did this systematic review and meta-analysis in accordance with an a-priori protocol. We searched PubMed, MEDLINE, WHO Global Index Medicus, Web of Science, Médecins Sans Frontières, Cochrane, Embase, CABS Abstracts, and LILACS databases for articles published between Jan 1, 2004, and April 30, 2016, that reported the quantitative prevalence of HIV detected through screening in four key contexts (paediatric inpatient settings, paediatric outpatient settings, nutrition centres, and expanded programme on immunisation centres) in paediatric populations in low-income and middle-income countries. Articles were identified and data were extracted in duplicate. The primary outcome was HIV prevalence, for which we used a DerSimonian-Laird random-effects meta-analysis to pool prevalence data and 95% CIs. We did stratified analyses according to geographical context and testing strategy. This study is registered with PROSPERO, number CRD42014014372.

FINDINGS

Our search found 2996 studies, of which 26 met the inclusion criteria. Paediatric HIV prevalence across all settings was 15·6% (95% CI 11·8-19·5). HIV prevalence by setting was highest in paediatric inpatient settings (21·1%, 95% CI 14·9-27·3), followed by nutrition centres (13·1%, 95% CI 3·4-22·7), expanded programme on immunisation centres (3·3%, 95% CI 0-6·9), and paediatric outpatient settings (2·7%, 95% CI 0·3-5·2). Universal testing and testing triggered by symptoms had similar diagnostic yield in the inpatient setting (21·3%, 95% CI 11·6-31·0 in triggered testing vs 20·9%, 95% CI 13·5-28·3 in universal testing).

INTERPRETATION

HIV testing in paediatric populations in low-income and middle-income countries outside the context of prevention of mother-to-child transmission programmes provides an important opportunity to identify HIV-positive children. For countries wishing to prioritise interventions, the highest diagnostic yields were obtained from inpatient wards and nutrition centres. Universal testing might be the preferred approach since it did not have a substantially lower diagnostic yield than triggered testing

FUNDING

None.

Implementation Research for the Prevention of Mother-to-Child HIV Transmission in Sub-Saharan Africa: Existing Evidence, Current Gaps, and New Opportunities

Tremendous gains have been made in the prevention of mother-to-child HIV transmission (PMTCT) in sub-Saharan Africa. Ambitious goals for the "virtual elimination" of pediatric HIV appear increasingly feasible, driven by new scientific advances, forward-thinking health policy, and substantial donor investment. To fulfill this promise, however, rapid and effective implementation of evidence-based practices must be brought to scale across a diversity of settings. The discipline of implementation research can facilitate this translation from policy into practice; however, to date, its core principles and frameworks have been inconsistently applied in the field. We reviewed the recent developments in implementation research across each of the four "prongs" of a comprehensive PMTCT approach. While significant progress continues to be made, a greater emphasis on context, fidelity, and scalability-in the design and dissemination of study results-would greatly enhance current efforts and provide the necessary foundation for future evidence-based programs.

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.

A Cluster Randomised Trial on the Impact of Integrating Early Infant HIV Diagnosis with the Expanded Programme on Immunization on Immunization and HIV Testing Rates in Rural Health Facilities in Southern Zambia

Background

We assessed the integration of early infant HIV diagnosis with the expanded programme for immunization in a rural Zambian setting with the aim of determining whether infant and postpartum maternal HIV testing rates would increase without harming immunization uptake.

Methods

In an unblinded, location stratified, cluster randomised controlled trial, 60 facilities in Zambia’s Southern Province were equally allocated to a control group, Simple Intervention group that received a sensitization meeting and the resupply of HIV testing commodities in the event of a stock-out, and a Comprehensive Intervention group that received the Simple Intervention as well as on-site operational support to facilitate the integration of HIV testing services with EPI.

Findings

The average change in number of first dose diphtheria, pertussis, and tetanus vaccine (DPT1) provided per month, per facility was approximately 0.86 doses higher [90% confidence interval (CI) -1.40, 3.12] in Comprehensive Intervention facilities compared to the combined average change in the Simple Intervention and control facilities. The interventions resulted in a 16.6% [90% CI: -7%, 46%, P-value = 0.26] and 10% [90% CI: -10%, 36%, P-value = 0.43] greater change in average monthly infant DBS testing compared to control for the Simple and Comprehensive facilities respectively. We also found 15.76 (90% CI: 7.12, 24.41, P-value < 0.01) and 10.93 (90% CI: 1.52, 20.33, P-value = 0.06) additional total maternal re-tests over baseline for the Simple and Comprehensive Facilities respectively.

Conclusions

This study provides strong evidence to support Zambia’s policy of integration of HIV testing and EPI services. Actions in line with the interventions, including HIV testing material supply reinforcement, can increase HIV testing rates without harming immunization uptake. In response, Zambia’s Ministry of Health issued a memo to remind health facilities to provide HIV testing at under-five clinics and to include under-five HIV testing as part of district performance assessments.

Trial Registration

ClinicalTrials.gov Registration Number: NCT02479659

Supporting Option B+ scale up and strengthening the prevention of mother-to-child transmission cascade in central Malawi: results from a serial cross-sectional study

BACKGROUND

We established Safeguard the Family (STF) to support Ministry of Health (MoH) scale-up of universal antiretroviral therapy (ART) for HIV-infected pregnant and breastfeeding women (Option B+) and to strengthen the prevention of mother-to-child transmission (PMTCT) cascade from HIV testing and counseling (HTC) through maternal ART provision and post-delivery early infant HIV diagnosis (EID). To these ends, we implemented the following interventions in 5 districts: 1) health worker training and mentorship; 2) couples' HTC and male partner involvement; 3) women's psychosocial support groups; and 4) health and laboratory system strengthening for EID.

METHODS

We conducted a serial cross-sectional study using facility-level quarterly (Q) program data and individual-level infant HIV-1 DNA PCR data to evaluate STF performance on PMTCT indicators for project years (Y) 1 (April-December 2011) through 3 (January-December 2013), and compared these results to national averages.

RESULTS

Facility-level uptake of HTC, ART, infant nevirapine prophylaxis, and infant DNA PCR testing increased significantly from quarterly baselines of 66 % (n/N = 32,433/48,804), 23 % (n/N = 442/1,958), 1 % (n/N = 10/1,958), and 52 % (n/N = 1,385/2,644) to 87 % (n/N = 39,458/45,324), 96 % (n/N = 2,046/2,121), 100 % (n/N = 2,121/2,121), and 62 % (n/N = 1,462/2,340), respectively, by project end (all p < 0.001). Quarterly HTC, ART, and infant nevirapine prophylaxis uptake outperformed national averages over years 2-3. While transitioning EID laboratory services to MoH, STF provided first-time HIV-1 DNA PCR testing for 2,226 of 11,261 HIV-exposed infants (20 %) tested in the MoH EID program in STF districts from program inception (Y2) through Y3. Of these, 78 (3.5 %) tested HIV-positive. Among infants with complete documentation (n = 608), median age at first testing decreased from 112 days (interquartile range, IQR: 57-198) in Y2 to 76 days (IQR: 46-152) in Y3 (p < 0.001). During Y3 (only year with national data for comparison), non-significantly fewer exposed infants tested HIV-positive (3.6 %) at first testing in STF districts than nationally (4.1 %) (p = 0.4).

CONCLUSIONS

STF interventions, integrated within the MoH Option B+ program, achieved favorable HTC, maternal ART, infant prophylaxis, and EID services uptake, and a low proportion of infants found HIV-infected at first DNA PCR testing. Continued investments are needed to strengthen the PMTCT cascade, particularly around EID.

Clinical, nutritional and immunological characteristics of HIV-infected children in an area of high HIV prevalence

OBJECTIVES

To evaluate the clinical, nutritional and neurodevelopment status of HIV-infected children in a high HIV prevalence area.

METHODS

All HIV-infected children under 15 years of age attending an outpatient clinic of Mozambique between April and May 2010 were recruited. Clinical data were collected and physical examination was performed.

RESULTS

In all, 140 children were recruited. The median age at HIV diagnosis was 2.1 years. Fifty-one percent of the children were classified in WHO clinical Stages 3 or 4. Median age of antiretroviral treatment commencement was 3.9 years. Overall, 68% were undernourished, mainly stunted. Forty-four percent failed to pass the national psychomotor developmental test.

CONCLUSIONS

The pathways for early HIV diagnosis and start of antiretrovirals in children should be improved in Mozambique. Malnutrition, especially stunting, and developmental delay were highly prevalent. Further research focused on early diagnosis of neurocognitive disorders and on the indications of antiretroviral treatment commencement based on chronic malnutrition is required.

Consolidating HIV testing in a public health laboratory for efficient and sustainable early infant diagnosis (EID) in Uganda

Uganda introduced an HIV Early Infant Diagnosis (EID) program in 2006, and then worked to improve the laboratory, transportation, and clinical elements. Reported here are the activities involved in setting up a prospective analysis in which the Ministry of Health, with its NGO partners, determined it would be more effective and efficient to consolidate the initial eight-laboratory system for EID testing of HIV dried blood samples offered by two nongovernmental partners operating research facilities into a single well-equipped and staffed laboratory within the Ministry. A retrospective analysis confirmed that redesign reduced overhead cost per PCR test of HIV dried blood samples from US$22.20 to an average of $5. Along with the revamped system of sample collection, transportation, and result communication, Uganda has been able to vastly increase the HIV diagnosis of babies and engagement of them and their mothers in clinical care, including antiretroviral therapy. Uganda reduced turnaround times for results reporting to clinicians from more than a month in 2006 to just 2 weeks by 2014, even as samples tested increased dramatically. The next challenge is overcoming loss of babies and mothers to follow up.

Correlates of suboptimal entry into early infant diagnosis in rural north central Nigeria

BACKGROUND

Despite an estimated 59,000 incident pediatric HIV infections in 2012 in Nigeria, rates of early infant diagnosis (EID) of HIV service uptake remain low. We evaluated maternal factors independently associated with EID uptake in rural North Central Nigeria.

METHODS

We performed a cohort study using HIV/AIDS program data of HIV-infected pregnant women enrolled into HIV care/treatment on or before December 31, 2012 (n = 712). We modeled the probability of initiation of EID using multivariable logistic regression.

RESULTS

Three hundred fifty-seven HIV-infected pregnant women enrolled their infants in EID across the 4 study sites. Women who enrolled their infants in EID vs. those who did not were similar across age, occupation, referral source, and select laboratory variables. Clinic of enrollment and date of enrollment were strong predictors for EID entry (P < 0.001). Women enrolled more recently were less likely to have their infants undergo EID than those enrolled at the beginning of the project (January 2011 vs. January 2010, adjusted odds ratio = 0.35, 95% confidence interval: 0.22 to 0.56; January 2012 vs. January 2010, adjusted odds ratio = 0.30, 95% confidence interval: 0.14 to 0.61). Women who received care in the more urban setting of Umaru Yar Adua Hospital were more likely to have their infants enrolled in EID than those who received care in the other 3 clinics.

CONCLUSIONS

HIV-infected women in our prevention of mother-to-child HIV transmission program were more likely to bring in their infants for EID if they were enrolled in a more urbanized clinic location, and if they presented during an earlier phase of the program. The need for more intensive family engagement and program quality improvement is apparent, especially in rural settings.

Qualitative assessment of the integration of HIV services with infant routine immunization visits in Tanzania

BACKGROUND

In 2009, a project was implemented in 8 primary health clinics throughout Tanzania to explore the feasibility of integrating pediatric HIV prevention services with routine infant immunization visits.

METHODS

We conducted interviews with 64 conveniently sampled mothers of infants who had received integrated HIV and immunization services and 16 providers who delivered the integrated services to qualitatively identify benefits and challenges of the intervention midway through project implementation.

FINDINGS

Mothers' perceived benefits of the integrated services included time savings, opportunity to learn their child's HIV status and receive HIV treatment, if necessary. Providers' perceived benefits included reaching mothers who usually would not come for only HIV testing. Mothers and providers reported similar challenges, including mothers' fear of HIV testing, poor spousal support, perceived mandatory HIV testing, poor patient flow affecting confidentiality of service delivery, heavier provider workloads, and community stigma against HIV-infected persons; the latter a more frequent theme in rural compared with urban locations.

INTERPRETATION

Future scale-up should ensure privacy of these integrated services received at clinics and community outreach to address stigma and perceived mandatory testing. Increasing human resources for health to address higher workloads and longer waiting times for proper patient flow is necessary in the long term.

Prevention of mother-to-child HIV transmission within the continuum of maternal, newborn, and child health services

PURPOSE OF REVIEW

To reach virtual elimination of pediatric HIV, programs for the prevention of mother-to-child HIV transmission (PMTCT) must expand coverage and achieve long-term retention of mothers and infants. Although PMTCT have been traditionally aligned with maternal, newborn, and child health (MNCH) services, novel approaches are needed to address the increasing demands of evolving global PMTCT policies.

RECENT FINDINGS

PMTCT-MNCH integration has improved the uptake and timely initiation of antiretroviral therapy (ART) among treatment-eligible pregnant women in public health settings. Postpartum engagement of HIV-infected mothers and HIV-exposed infants has been insufficient, although alignment of visits to the childhood immunization schedule and establishment of integrated mother-infant clinics may increase retention. Evidence also suggests that the integration of maternal HIV testing into childhood immunization clinics can significantly increase the identification of at-risk HIV-exposed infants previously missed by traditional PMTCT models.

SUMMARY

Targeted service integration models can improve PMTCT uptake. However, as global PMTCT policy shifts to universal provision of maternal ART during pregnancy (i.e., Option B/B+), these findings must be reexamined in the context of increased service demand and systems burden. Intensive evaluation is needed to ensure quality clinical care is maintained both for PMTCT and for underpinning MNCH services.

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

There are 3.4 million children infected with HIV worldwide, with up to 2.6 million eligible for treatment under current guidelines. However, roughly 70% of infected children are not receiving live-saving HIV care and treatment. Strengthening case finding through improved diagnosis strategies, and actively linking identified HIV-infected children to care and treatment is essential to ensuring that these children benefit from the care and treatment available to them. Without attention or advocacy, the majority of these children will remain undiagnosed and die from complications of HIV. In this article, we summarize the challenges of identifying HIV-infected infants and children, review currently available evidence and guidance, describe promising new strategies for case finding, and make recommendations for future research and interventions to improve identification of HIV-infected infants and children.

HIV-exposed infants: rethinking care for a lifelong condition

Each year over a million infants are born to HIV-infected mothers. With scale up of prevention of mother-to-child transmission (PMTCT) interventions, only 210 000 of the 1.3 million infants born to mothers with HIV/AIDS in 2012 became infected. Current programmatic efforts directed at infants born to HIV-infected mothers are primarily focused on decreasing their risk of infection, but an emphasis on maternal interventions has meant follow-up of exposed infants has been poor. Programs are struggling to retain this population in care until the end of exposure, typically at the cessation of breastfeeding, between 12 and 24 months of age. But HIV exposure is a life-long condition that continues to impact the health and well being of a child long after exposure has ended. A better understanding of the impact of HIV on exposed infants is needed and new programs and interventions must take into consideration the long-term health needs of this growing population. The introduction of lifelong treatment for all HIV-infected pregnant women is an opportunity to rethink how we provide services adapted for the long-term retention of mother-infant pairs.

Do diagnosis delays impact receipt of test results? Evidence from the HIV early infant diagnosis program in Uganda

Background

There is scant evidence on the association between diagnosis delays and the receipt of test results in HIV Early Infant Diagnosis (EID) programs. We determine the association between diagnosis delays and other health care system and patient factors on result receipt.

Methods

We reviewed 703 infant HIV test records for tests performed between January 2008 and February 2009 at a regional referral hospital and level four health center in Uganda. The main outcome was caregiver receipt of the test result. The primary study variable was turnaround time (time between sample collection and result availability at the health facility). Additional variables included clinic entry point, infant age at sample collection, reported HIV status and receipt of antiretroviral prophylaxis for prevention of mother-to-child transmission. We conducted a pooled analysis in addition to separate analyses for each facility. We estimated the relative risk of result receipt using modified Poisson regression with robust standard errors.

Results

Overall, the median result turnaround time, was 38 days. 59% of caregivers received infant test results. Caregivers were less likely to receive results at turnaround times greater than 49 days compared to 28 days or fewer (ARR = 0.83; 95% CI = 0.70–0.98). Caregivers were more likely to receive results at the PMTCT clinic (ARR = 1.81; 95% CI = 1.40–2.33) and less likely at the pediatric ward (ARR = 0.54; 95% CI = 0.37–0.81) compared to the immunization clinic. At the level four health center, result receipt was half as likely among infants older than 9 months compared to 3 months and younger (ARR= 0.47; 95% CI = 0.25–0.93).

Conclusion

In this study setting, we find evidence that longer turnaround times, clinic entry point and age at sample collection may be associated with receipt of infant HIV test results.

Universal HIV screening at postnatal points of care: which public health approach for early infant diagnosis in Côte d'Ivoire?

BACKGROUND

Universal HIV pediatric screening offered at postnatal points of care (PPOC) is an entry point for early infant diagnosis (EID). We assessed the parents' acceptability of this approach in Abidjan, Côte d'Ivoire.

METHODS

In this cross-sectional study, trained counselors offered systematic HIV screening to all children aged 6-26 weeks attending PPOC in three community health centers with existing access to HAART during 2008, as well as their parents/caregivers. HIV-testing acceptability was measured for parents and children; rapid HIV tests were used for parents. Both parents' consent was required according to the Ivorian Ethical Committee to perform a HIV test on HIV-exposed children. Free HIV care was offered to those who were diagnosed HIV-infected.

FINDINGS

We provided 3,013 HIV tests for infants and their 2,986 mothers. While 1,731 mothers (58%) accepted the principle of EID, only 447 infants had formal parental consent 15%; 95% confidence interval (CI): [14%-16%]. Overall, 1,817 mothers (61%) accepted to test for HIV, of whom 81 were HIV-infected (4.5%; 95% CI: [3.5%-5.4%]). Among the 81 HIV-exposed children, 42 (52%) had provided parental consent and were tested: five were HIV-infected (11.9%; 95% CI: [2.1%-21.7%]). Only 46 fathers (2%) came to diagnose their child. Parental acceptance of EID was strongly correlated with prenatal self-reported HIV status: HIV-infected mothers were six times more likely to provide EID parental acceptance than mothers reporting unknown or negative prenatal HIV status (aOR: 5.9; 95% CI: [3.3-10.6], p = 0.0001).

CONCLUSIONS

Although the principle of EID was moderately accepted by mothers, fathers' acceptance rate remained very low. Routine HIV screening of all infants was inefficient for EID at a community level in Abidjan in 2008. Our results suggest the need of focusing on increasing the PMTCT coverage, involving fathers and tracing children issued from PMTCT programs in low HIV prevalence countries.

Routine inpatient provider-initiated HIV testing in Malawi, compared with client-initiated community-based testing, identifies younger children at higher risk of early mortality

OBJECTIVE

To determine how routine inpatient provider-initiated HIV testing differs from traditional community-based client-initiated testing with respect to clinical characteristics of children identified and outcomes of outpatient HIV care.

DESIGN

Prospective observational cohort.

METHODS

Routine clinical data were collected from children identified as HIV-infected by either testing modality in Lilongwe, Malawi, in 2008. After 1 year of outpatient HIV care at the Baylor College of Medicine Clinical Center of Excellence, outcomes were assessed.

RESULTS

Of 742 newly identified HIV-infected children enrolling into outpatient HIV care, 20.9% were identified by routine inpatient HIV testing. Compared with community-identified children, hospital-identified patients were younger (median 25.0 vs 53.5 months), with more severe disease (22.2% vs 7.8% WHO stage IV). Of 466 children with known outcomes, 15.0% died within the first year of HIV care; median time to death was 15.0 weeks for community-identified children vs 6.0 weeks for hospital-identified children. The strongest predictors of early mortality were severe malnutrition (hazard ratio, 4.3; 95% confidence interval, 2.2-8.3), moderate malnutrition (hazard ratio, 3.2; confidence interval, 1.6-6.6), age < 12 months (hazard ratio, 3.2; 95% confidence interval, 1.4-7.2), age 12 to 24 months (hazard ratio, 2.5; 95% confidence interval, 1.1-5.7), and WHO stage IV (hazard ratio, 2.2; 95% confidence interval, 1.1-4.6). After controlling for other variables, hospital identification did not independently predict mortality.

CONCLUSIONS

Routine inpatient HIV testing identifies a subset of younger HIV-infected children with more severe, rapidly progressing disease that traditional community-based testing modalities are currently missing.

Linkage of HIV-infected infants from diagnosis to antiretroviral therapy services across the Western Cape, South Africa

Introduction

Early infant diagnosis (EID) of HIV infection is an important service to reduce paediatric morbidity and mortality related to HIV/AIDS. Although South Africa has a national EID programme based on PCR testing, there are no population-wide data on the linkage of infants testing HIV PCR-positive to HIV care and treatment services.

Methods

We conducted a retrospective analysis of all public sector laboratory data from across the Western Cape province between 2005 and 2011. We linked positive HIV PCR results to subsequent HIV viral load testing to determine the proportion of infants who were successfully linked to HIV care.

Results

A total of 83 698 unique infant HIV PCR tests were documented, of which 6322 (8%) were PCR positive. The proportion of PCR-positive children declined from 12% in 2005 to 3% in 2011. Of the children testing PCR-positive, 4105 (65%) had subsequent viral load testing indicating successful linkage to care. The proportion of successfully linked infants increased from 54% in 2005 to 71% in 2010, while the median delay in days to successful linkage decreased from 146 days in 2005 to 33 days in 2010.

Discussion

From 2005 to 2011 there has been a reduction in the proportion of children testing HIV PCR-positive, and an increase in the proportion of infected infants successfully linked to HIV care and treatment, in this setting. However a large proportion of infected infants remain unlinked to antiretroviral therapy services and there is a clear need for interventions to further strengthen EID programmes.