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

Policies and Practices Facilitating Access to and Uptake of HIV Testing Services among Adolescents in Sub-Sahara Africa: A Narrative Review

PURPOSE OF REVIEW

Expanding access to HIV testing services and linking newly diagnosed positive adolescents to antiretroviral therapy is critical to epidemic control. However, testing coverage and treatment initiation rates continue to lag behind adult counterparts. This article synthesizes evidence on facilitative policies and service delivery practices focused on adolescents to inform programming.

RECENT FINDINGS

Our narrative review found that national policies are growing more adolescent-inclusive but barriers around the age of consent, waiver frameworks and dissemination constrain translate into practice. Facility-based provider-initiated testing through integrated sexual health services and dedicated youth centres demonstrates uptake effectiveness if confidentiality and youth-friendly adaptations are assured. Supportive policies, youth-responsive adaptations across testing models and strengthening age-disaggregated monitoring are vital to improving adolescents' engagement across the HIV testing and treatment cascade. Further implementation research is imperative to expand the reach of adolescent HIV testing in sub-Saharan Africa.

The Positive Impact of Foods Support on Loss to Follow Up Among Children and Adolescents on HIV Antiretroviral Therapy in a District Hospital in East Cameroon

Introduction

The pediatric HIV treatment coverage in Cameroon remains low at 35%. The high loss to follow up (LTFU) remains a major factor to this dismal performance which is related to the lack of implementation of effective interventions to improve retention in care. This study assessed the impact of foods support (FS) on LTFU among children and adolescents in a rural district hospital in eastern Cameroon.

Methods

This was a retro-prospective study conducted in Abong Mbang District Hospital (ADH) in the East Region of Cameroon. We provided foods kits to children and adolescents initiated on antiretroviral therapy (ART) in this facility during the study and followed them up prospectively (prospective phase). On the other hand, using medical records, we collected retrospectively data for children and adolescents who enrolled on ART in the hospital prior to the study (retrospective phase). We then compared the proportions of children and adolescents LTFU before (no FS) and after (with FS) the study, using the Fisher's exact test, logistic regression, Kaplan-Meier survival curves and Cox proportional-hazards model at 5% significant level.

Results

We found that with FS, the proportion of children and adolescents LTFU was 11 times lower (2.4% vs 26.7%, p=0.014), the mean time of retention in care was 30% higher (17 months vs 12 months, p<0.001) and children and adolescents who did not receive FS were 10 times more likely to be LTFU [aHR=10.3 (4.0-26.2), p<0.001)].

Conclusion

Foods support is an effective intervention in reducing LTFU among children and adolescents on ART. This intervention should be adequately funded to enable a large-scale implementation in the field. This could help to improve the outcome of pediatric ART coverage in resource-limited settings.

Delivery of index-linked HIV testing for children: learnings from a qualitative process evaluation of the B-GAP study in Zimbabwe

BACKGROUND

Index-linked HIV testing for children, whereby HIV testing is offered to children of individuals living with HIV, has the potential to identify children living with undiagnosed HIV. The "Bridging the Gap in HIV Testing and Care for Children in Zimbabwe" (B-GAP) study implemented and evaluated the provision of index-linked HIV testing for children aged 2-18 years in Zimbabwe. We conducted a process evaluation to understand the considerations for programmatic delivery and scale-up of this strategy.

METHODS

We used implementation documentation to explore experiences of the field teams and project manager who delivered the index-linked testing program, and to describe barriers and facilitators to index-linked testing from their perspectives. Qualitative data were drawn from weekly logs maintained by the field teams, monthly project meeting minutes, the project coordinator's incident reports and WhatsApp group chats between the study team and the coordinator. Data from each of the sources was analysed thematically and synthesised to inform the scale-up of this intervention.

RESULTS

Five main themes were identified related to the implementation of the intervention: (1) there was reduced clinic attendance of potentially eligible indexes due to community-based differentiated HIV care delivery and collection of HIV treatment by proxy individuals; (2) some indexes reported that they did not live in the same household as their children, reflecting the high levels of community mobility; (3) there were also thought to be some instances of 'soft refusal'; (4) further, delivery of HIV testing was limited by difficulties faced by indexes in attending health facilities with their children for clinic-based testing, stigma around community-based testing, and the lack of familiarity of indexes with caregiver provided oral HIV testing; (5) and finally, test kit stockouts and inadequate staffing also constrained delivery of index-linked HIV testing.

CONCLUSIONS

There was attrition along the index-linked HIV testing cascade of children. While challenges remain at all levels of implementation, programmatic adaptations of index-linked HIV testing approaches to suit patterns of clinic attendance and household structures may strengthen implementation of this strategy. Our findings highlight the need to tailor index-linked HIV testing to subpopulations and contexts to maximise its effectiveness.

Rates of confirmatory HIV testing, linkage to HIV services, and rapid initiation of antiretroviral treatment among newly diagnosed children living with HIV in Ethiopia: perspectives from caregivers and healthcare workers

BACKGROUND

Successful linkage to HIV services and initiation of antiretroviral treatment (ART) for children living with HIV (CLHIV) is critical to improve pediatric ART coverage. We aimed to assess confirmatory testing, linkage, and rapid ART initiation among newly diagnosed CLHIV in Ethiopia from the perspectives of caregivers and healthcare workers (HCWs).

METHODS

We conducted standardized surveys with HCWs and caregivers of children 2-14 years who were diagnosed with HIV but not yet on ART who had been identified during a cross-sectional study in Ethiopia from May 2017-March 2018. Eight health facilities based on their HIV caseload and testing volume and 21 extension sites were included. Forty-one children, 34 care givers and 40 healthcare workers were included in this study. Three months after study enrollment, caregivers were surveyed about timing and experiences with HIV service enrollment, confirmatory testing, and ART initiation. Data collected from HCWs included perceptions of confirmatory testing in CLHIV before ART initiation. SPSS was used to conduct descriptive statistics.

RESULTS

The majority of the 41 CLHIV were enrolled to HIV services (n = 34, 83%) and initiated ART by three months (n = 32, 94%). Median time from diagnosis to ART initiation was 12 days (interquartile range 5-18). Five children died before the follow-up interview. Confirmatory HIV testing was conducted in 34 children and found no discordant results; the majority (n = 23, 68%) received it within one week of HIV diagnosis. Almost all HCWs (n = 39/40, 98%) and caregivers (n = 31/34, 91%) felt better/the same about test results after conducting confirmatory testing.

CONCLUSION

Opportunities remain to strengthen linkage for newly diagnosed CLHIV in Ethiopia through intensifying early follow-up to ensure prompt confirmatory testing and rapid ART initiation. Additional services could help caregivers with decision-making around treatment initiation for their children.

A Systematic Review of HIV Testing Implementation Strategies in Sub-Saharan African Countries

HIV/AIDS remains a looming presence in public health across the world, particularly in Sub-Saharan Africa. The HIV Care Cascade hinges on testing and knowledge of HIV status. Though significant advances have been made in diagnosing people living with HIV (PLHIV), limitations in understanding which strategies are best suited to certain regions or populations have contributed to the uneven distribution in the success of various HIV testing strategies. Here, we present a conceptual framework that outlines effective HIV testing strategies for four target groups. This framework is based on a systematic literature review of articles published from January 1st, 2008, to December 31st, 2019. The effectiveness of HIV testing strategies depends on various factors including the setting, type of test and service providers. Multiple strategies are needed to reach the UNAIDS target of 95% of individuals knowing their HIV status. Expansion of community-based approaches, self-testing and HIV testing services in antenatal care will further improve the state of HIV testing in Sub-Saharan Africa.

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.

Comparison of index-linked HIV testing for children and adolescents in health facility and community settings in Zimbabwe: findings from the interventional B-GAP study

BACKGROUND

Index-linked HIV testing, whereby children of individuals with HIV are targeted for testing, increases HIV yield but relies on uptake. Community-based testing might address barriers to testing access. In the Bridging the Gap in HIV testing and care for children in Zimbabwe (B-GAP) study, we investigated the uptake and yield of index-linked testing in children and the uptake of community-based vs facility-based HIV testing in Zimbabwe.

METHODS

B-GAP was an interventional study done in the city of Bulawayo and the province of Matabeleland South between Jan 29 and Dec 12, 2018. All HIV-positive attendees (index patients) at six urban and three rural primary health-care clinics were offered facility-based or community-based HIV testing for children (age 2-18 years) living in their households who had never been tested or had tested as HIV-negative more than 6 months ago. Community-based options involved testing in the home by either a trained lay worker with a blood-based rapid diagnostic test (used in facility-based testing), or by the child's caregiver with an oral HIV test. Among consenting individuals, the primary outcome was testing uptake in terms of the proportion of eligible children tested. Secondary outcomes were uptake of the different HIV testing methods, HIV yield (proportion of eligible children who tested positive), and HIV prevalence (proportion of HIV-positive children among those tested). Logistic regression adjusting for within-index clustering was used to investigate index patient and child characteristics associated with testing uptake, and the uptake of community-based versus facility-based testing.

FINDINGS

Overall, 2870 index patients were linked with 6062 eligible children (3115 [51·4%] girls [sex unknown in seven], median age 8 years [IQR 5-13]). Testing was accepted by index patients for 5326 (87·9%) children, and 3638 were tested with a known test outcome, giving an overall testing uptake among 6062 eligible children of 60·0%. 39 children tested positive for HIV, giving an HIV prevalence among the 3638 children of 1·1% and an HIV yield among 6062 eligible children of 0·6%. Uptake was positively associated with female sex in the index patient (adjusted odds ratio [aOR] 1·56 [95% CI 1·38-1·77], p<0·0001) and child (aOR 1·10 [1·03-1·19], p=0·0080), and negatively associated with any financial cost of travel to a clinic (aOR 0·86 [0·83-0·88], p<0·0001), increased child age (6-9 years: aOR 0·99 (0·89-1·09); 10-15 years: aOR 0·91 [0·83-1·00]; and 16-18 years: aOR 0·75 [0·66-0·85]; p=0·0001 vs 2-5 years), and unknown HIV status of the mother (aOR 0·81 [0·68-0·98], p=0·027 vs HIV-positive status). Additionally, children had increased odds of being tested if community-based testing was chosen over facility-based testing at screening (1320 [73·9%] children tested of 1787 vs 2318 [65·5%] of 3539; aOR 1·49 [1·22-1·81], p=0·0001).

INTERPRETATION

The HIV yield of index-linked testing was low compared with blanket testing approaches in similar settings. Index-linked HIV testing can improve testing uptake among children, although strategies that improve testing uptake in older children are needed. Community based testing by lay workers is a feasible strategy that can be used to improve uptake of HTS among children and adolescents.

FUNDING

UK Medical Research Council, UK Department for International Development, Wellcome Trust.

Use of Trained Non-Medical Staff to Improve Access to HIV Testing Services in Africa: Implementation of the World Health Organization Opt-out Approach in Cameroon

BACKGROUND

The Joint United Nations Programme on HIV/AIDS (UNAIDS) in 2019 estimated that 450,000 to 50,000 people in Cameroon were living with HIV, yet only 79% knew their HIV status which is far from the 90% target for 2020. To address this situation, Cameroon adopted the "Opt-out" strategy of the World Health Organization (WHO) and use of trained non-medical cadre (psychosocial agents) to reach out to more people with HIV testing services (HTS). This describes the implementation and outcomes of this strategy by reviewing the activity of a typical day in the Yaoundé Central Hospital (YCH) in Cameroon.

METHODS

HTS were offered to hospitalized and ambulatory patients (including their companions) in different departments of the YCH. Following screening for recent HIV testing, those with unknown HIV status that gave consent or did not explicitly refuse testing (as per the "Opt-out Strategy"), were counseled and tested for HIV. Testing followed the "National HIV Rapid Testing Algorithm" using rapid diagnostic test kits. Results were either positive, negative or indeterminate. Patients with positive HIV results were linked to the Care and Treatment Center for treatment initiation.

RESULTS

Of the 350 patients screened and offered HTS using non-medical cadre (psychosocial agents), 193 (55.1%) were hospitalized and 157 (44.9%) came for outpatient visits. The age of participants ranged from 14 to 92 years and the yield of HIV testing in the sample population was 5.1% (6.2% for hospitalized patients and 3.8% for outpatient clinics). Statistics revealed that five HIV-positive patients had never been offered HTS before the study. The study revealed that HTS acceptance rate among hospitalized patients was 69.6% and that all new positive patients started antiretroviral treatment on the same day.

CONCLUSION AND GLOBAL HEALTH IMPLICATIONS

It is feasible to use trained non-medical staff for HIV testing services (HTS). Task-shifting by using trained psychosocial agents can help in case identification and linkage to HIV treatment services.

Home- and Clinic-Based Pediatric HIV Index Case Testing in Kenya: Uptake, HIV Prevalence, Linkage to Care, and Missed Opportunities

INTRODUCTION

Gaps in HIV testing of children persist, particularly among older children born before the expansion of the prevention of mother-to-child transmission of HIV programs.

METHODS

The Counseling and Testing for Children at Home study evaluated an index-case pediatric HIV testing approach. Caregivers receiving HIV care at 7 health facilities in Kenya (index cases), who had children of unknown HIV status aged 0-12 years, were offered the choice of clinic-based testing (CBT) or home-based testing (HBT). Testing uptake and HIV prevalence were compared between groups choosing HBT and CBT; linkage to care, missed opportunities, and predictors of HIV-positive diagnosis were identified.

RESULTS

Among 493 caregivers, 70% completed HIV testing for ≥1 child. Most caregivers who tested children chose CBT (266/347, 77%), with 103 (30%) agreeing to same-day testing of an untested accompanying child. Overall HIV prevalence among 521 tested children was 5.8% (CBT 6.8% vs HBT 2.4%; P = 0.07). Within 1 month of diagnosis, 88% of 30 HIV-positive children had linked to care, and 54% had started antiretroviral treatment. For 851 children eligible for testing, the most common reason for having an unknown HIV status was that the child's mother was not tested for HIV or had tested HIV negative during pregnancy (82%).

CONCLUSION

Testing uptake and HIV prevalence were moderate with nonsignificant differences between HBT and CBT. Standardized offer to test children accompanying caregivers is feasible to scale-up with little additional investment. Linkage to care for HIV-positive children was suboptimal. Lack of peripartum maternal testing contributed to gaps in pediatric testing.

Addressing the challenges and relational aspects of index-linked HIV testing for children and adolescents: insights from the B-GAP study in Zimbabwe

INTRODUCTION

Index-linked HIV testing, targeted at sexual contacts or children of individuals with HIV, may improve yield and efficiency. The B-GAP study evaluated index-linked testing approaches in health facility and community-based settings. This paper reports on a qualitative study to understand factors that affect uptake of index-linked HIV testing for children and adolescents.

METHODS

We conducted four focus group discussions (FGDs) with caregivers who had their children tested through B-GAP and one FGD with providers who offered index-linked HIV testing to indexes. We aimed to understand enabling and inhibiting factors in the decision-making process. Translated and transcribed transcripts were read for familiarisation. Following initial coding, analytical memos were written to identify emerging key themes across the data.

RESULTS

Our findings showed there was inadequate emphasis on paediatric HIV in routine care which had a negative impact on subsequent uptake of testing for children. Once the decision to test had been made, access to facilities was sometimes challenging and alleviated by community-based testing. A key finding was that HIV testing is not a discrete event but a process that was influenced by relationships with other family members and children themselves. These relationships raised complex issues that could prevent or delay the testing process.

CONCLUSION

There is a need to improve messaging on the importance of HIV testing for children and adolescents and to provide support to caregivers and their families in order to improve testing uptake. Addressing access barriers through the provision of community-based testing and implementing a family-centred approach can optimise index-linked testing.

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.

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.

Brief Report: Diagnostic Accuracy of Oral Mucosal Transudate Tests Compared with Blood-Based Rapid Tests for HIV Among Children Aged 18 Months to 18 Years in Kenya and Zimbabwe

Gaps persist in HIV testing for children who were not tested in prevention of mother-to-child HIV transmission programs. Oral mucosal transudate (OMT) rapid HIV tests have been shown to be highly sensitive in adults, but their performance has not been established in children.

Parental and child-level predictors of HIV testing uptake, seropositivity and treatment initiation among children and adolescents in Cameroon

Background

There is a growing body of evidence positioning targeted provider-initiated testing and counselling (tPITC, also known as index case testing) as a promising HIV case-finding and linkage strategy among children and adolescents. However, the effectiveness and efficiency of this strategy is limited by low HIV testing uptake and case detection rates. Despite this fact, there is very little literature on factors associated with HIV testing uptake, HIV seropositivity and ART-enrolment in tPITC implementation among African children. This study aims to bridge this information gap and contribute in improving the effectiveness and efficiency of tPITC among children and adolescents in Cameroon and beyond.

Methods

In three ART clinics where tPITC was previously inexistent, we introduced the routine implementation of this strategy by inviting parents living with HIV/AIDS in care to have their biological children (6 weeks-19 years) HIV-tested. Children of consenting parents were HIV-tested; those testing positive were enrolled on ART. Parental and child-level characteristics associated with HIV testing uptake, seropositivity and ART-enrollment were assessed using bivariate and multivariate regression analysis at 5% significance level.

Results

We enrolled 1,236 parents, through whom 1,990 children/adolescents were recruited for HIV testing. Among enrolled parents, 46.2% (571/1,236) had at least one child tested, and 6.8% (39/571) of these parents had at least one HIV-positive child. Among enrolled children/adolescents, 56.7% (1,129/1,990) tested for HIV and 3.5% (40/1129) tested HIV-positive. Parental predictors of HIV testing uptake among children/adolescents were sex, occupation and duration on ART: female [aOR = 1.6 (1.1–2.5)], office workers/students [aOR = 2.0 (1.2–3.3)], and parents with ART duration > 5 years [aOR = 2.0 (1.3–2.9)] had significantly higher odds to test a child than male, farmers/traders, and parents with ART duration < 5 years respectively. The only child-level predictor of testing uptake was age: children < 18 months [aOR = 5(2–10)] had significantly higher odds to test for HIV than adolescents > 15 years. Parents of children identified as HIV-positive were more likely to be female, aged 40–60 years, farmers/traders, widows/divorcees and not on ART. Children found HIV-positive and who were ART-enrolled were more likely to be female and aged 5–9 years. However, none of the above-mentioned associations was statistically significant.

Conclusions

Parents who were male, farmers/traders, and on ART for ≤ 5 years were less likely to test their children for HIV. Also, adolescents 10–19 years old were less likely to be tested. Therefore, these groups should be targeted with intensive counseling and follow-up to facilitate optimal testing uptake. No association was found between parental or child-level characteristics and HIV seropositivity among tested children. This finding prompts for further research to investigate approaches to better identify and target HIV testing to children/adolescents with the highest likelihood of HIV seropositivity.

Clinical trial registration

Reg: CinicalTrials.gov # NCT03024762.

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.