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Chaila MJ, Mcleod D, Vermund SH, Mbolongwe-Thornicroft M, Mbewe M, Mubekapi-Musadaidzwa C, Harper A, Schaap A, Floyd S, Hoddinott G, Hayes R, Fidler S, Ayles H, Shanaube K. Assessment of a screening tool to aid home-based identification of adolescents (aged 10-14) living with HIV in Zambia and South Africa: HPTN 071 (PopART) study. PLoS One 2024; 19:e0266573. [PMID: 38363733 PMCID: PMC10871489 DOI: 10.1371/journal.pone.0266573] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2022] [Accepted: 09/05/2023] [Indexed: 02/18/2024] Open
Abstract
INTRODUCTION The HPTN071 (PopART) for Youth (P-ART-Y) study evaluated the acceptability and uptake of a community-level combination HIV prevention package including universal testing and treatment (UTT) among young people in Zambia and South Africa. We determined whether a four-question primary care level screening tool, validated for use in clinical settings, could enhance community (door-to-door) identification of undiagnosed HIV-positive younger adolescents (aged 10-14) who are frequently left out of HIV interventions. METHOD Community HIV-care Providers (CHiPs) contacted and consented adolescents in their homes and offered them participation in the PopART intervention. CHiPs used a four question-screening tool, which included: history of hospital admission; recurring skin problems; poor health in last 3 months; and death of at least one parent. A "yes" response to one or more questions was classified as being "at risk" of being HIV-positive. Rapid HIV tests were offered to all children. Data were captured through an electronic data capture device from August 2016 to December 2017. The sensitivity, specificity, positive predictive value and negative predictive value were estimated for the screening tool, using the rapid HIV test result as the gold standard. RESULTS In our 14 study sites, 33,710 adolescents aged 10-14 in Zambia and 8,610 in South Africa participated in the study. About 1.3% (427/33,710) and 1.2% (106/8,610) self-reported to be HIV positive. Excluding the self-reported HIV-positive, we classified 11.3% (3,746/33,283) of adolescents in Zambia and 17.5% (1,491/8,504) in South Africa as "at risk". In Zambia the estimated sensitivity was 35.3% (95% CI 27.3%-44.2%) and estimated specificity was 88.9% (88.5%-89.2%). In South Africa the sensitivity was 72.3% (26.8%-94.9%) and specificity was 82.5% (81.6-83.4%). CONCLUSION The sensitivity of the screening tool in a community setting in Zambia was low, so this tool should not be considered a substitute for universal testing where that is possible. In South Africa the sensitivity was higher, but with a wide confidence interval. Where universal testing is not possible the tool may help direct resources to adolescents more likely to be living with undiagnosed HIV. TRIAL REGISTRATION Clinical Trial Number: NCT01900977.
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Affiliation(s)
- Mwate Joseph Chaila
- Zambart, University of Zambia School of Medicine, Ridgeway Campus, Lusaka, Zambia
| | - David Mcleod
- Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Sten H Vermund
- Yale School of Public Health, New Haven, Connecticut, United States of America
| | | | - Madalitso Mbewe
- Zambart, University of Zambia School of Medicine, Ridgeway Campus, Lusaka, Zambia
| | - Constance Mubekapi-Musadaidzwa
- Faculty of Medicine and Health Sciences, Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Stellenbosch University, Cape Town, South Africa
| | - Abigail Harper
- Faculty of Medicine and Health Sciences, Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Stellenbosch University, Cape Town, South Africa
| | - Albertus Schaap
- Zambart, University of Zambia School of Medicine, Ridgeway Campus, Lusaka, Zambia
- Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Sian Floyd
- Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Graeme Hoddinott
- Faculty of Medicine and Health Sciences, Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Stellenbosch University, Cape Town, South Africa
| | - Richard Hayes
- Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Sarah Fidler
- Department of Medicine, Imperial College London, London, United Kingdom
| | - Helen Ayles
- Zambart, University of Zambia School of Medicine, Ridgeway Campus, Lusaka, Zambia
- Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Kwame Shanaube
- Zambart, University of Zambia School of Medicine, Ridgeway Campus, Lusaka, Zambia
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Lubega M, Guerra K, Ginivan M, Kamuntu Y, Senyama G, Musoke A, Gambanga F, Khan S, Taasi G, Nalubega S, Matovu JBJ. Risk Screening Tools Could Potentially Miss HIV-Positive Individuals Who Seek Testing Services: A Secondary Program Data Analysis on the Performance Characteristics of an Adolescent and Adult HIV Risk Screening Tool in Uganda. Trop Med Infect Dis 2024; 9:37. [PMID: 38393126 PMCID: PMC10892028 DOI: 10.3390/tropicalmed9020037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2023] [Revised: 01/17/2024] [Accepted: 01/24/2024] [Indexed: 02/25/2024] Open
Abstract
Improving HIV testing efficiency saves financial and material resources for health. We conducted a secondary data analysis of routinely collected HIV risk-screening program data in Uganda, from October to November 2019, to determine the performance characteristics of the adolescent and adult HIV risk screening tools in public health facilities. A total of 19,854 clients had been screened for HIV testing eligibility and tested for HIV. The overall positivity rate (cluster-weighted prevalence of HIV) among those screened was 4.5% (95% CI: 4.1-4.8) versus 3.71% (95% CI: 3.06-4.50) among those not screened. The sensitivity and specificity of the risk screening tool were 91% (95% CI: 89-93) and 25% (24.2-26), respectively. With screening, the number needed to test to identify one PLHIV was reduced from 27 to 22. Although risk screening would have led to a 24.5% (4825/19,704) reduction in testing volume, 9.3% (68/732) of PLHIV would have been missed and be misclassified as not eligible for testing. The cost saving per PLHIV identified was minimally reduced by 3% from USD 69 without screening to USD 66.9 with screening. Since the treatment-adjusted prevalence of HIV is dropping globally, overzealous use of risk screening tools to determine who to test or not carries the potential of missing PLHIV due to their limited specificity. We recommend the use of scientifically validated HIV risk screening tools, and a need to explore the use of HIV self-testing as a test for tirage to minimize misclassification of people who seek HIV testing services.
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Affiliation(s)
- Marvin Lubega
- Clinton Health Access Initiative-Uganda, Moyo Close, Kampala P.O. Box 2191, Uganda; (M.L.); (K.G.); (M.G.); (Y.K.); (G.S.); (A.M.); (F.G.); (S.K.)
| | - Katherine Guerra
- Clinton Health Access Initiative-Uganda, Moyo Close, Kampala P.O. Box 2191, Uganda; (M.L.); (K.G.); (M.G.); (Y.K.); (G.S.); (A.M.); (F.G.); (S.K.)
| | - Megan Ginivan
- Clinton Health Access Initiative-Uganda, Moyo Close, Kampala P.O. Box 2191, Uganda; (M.L.); (K.G.); (M.G.); (Y.K.); (G.S.); (A.M.); (F.G.); (S.K.)
| | - Yewande Kamuntu
- Clinton Health Access Initiative-Uganda, Moyo Close, Kampala P.O. Box 2191, Uganda; (M.L.); (K.G.); (M.G.); (Y.K.); (G.S.); (A.M.); (F.G.); (S.K.)
| | - George Senyama
- Clinton Health Access Initiative-Uganda, Moyo Close, Kampala P.O. Box 2191, Uganda; (M.L.); (K.G.); (M.G.); (Y.K.); (G.S.); (A.M.); (F.G.); (S.K.)
| | - Andrew Musoke
- Clinton Health Access Initiative-Uganda, Moyo Close, Kampala P.O. Box 2191, Uganda; (M.L.); (K.G.); (M.G.); (Y.K.); (G.S.); (A.M.); (F.G.); (S.K.)
| | - Fiona Gambanga
- Clinton Health Access Initiative-Uganda, Moyo Close, Kampala P.O. Box 2191, Uganda; (M.L.); (K.G.); (M.G.); (Y.K.); (G.S.); (A.M.); (F.G.); (S.K.)
| | - Shaukat Khan
- Clinton Health Access Initiative-Uganda, Moyo Close, Kampala P.O. Box 2191, Uganda; (M.L.); (K.G.); (M.G.); (Y.K.); (G.S.); (A.M.); (F.G.); (S.K.)
| | - Geoffrey Taasi
- AIDS Control Program, Ministry of Health, Plot 6, Lourdel Road, Kampala P.O. Box 7272, Uganda;
| | - Sylivia Nalubega
- Institute of Applied Technology, Fatima College of Health Sciences, Ajman P.O. Box 3798, United Arab Emirates;
| | - John Bosco Junior Matovu
- AIDS Control Program, Ministry of Health, Plot 6, Lourdel Road, Kampala P.O. Box 7272, Uganda;
- ICAP at Columbia University, Nairobi P.O. Box 29840-00202, Kenya
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Katirayi L, Maphosa T, Kudiabor K, Kayira D, Gross J, Hrapcak S, Chamanga R, Nkhoma H, Puleni P, Maida A, Ahimbisibwe A, Woelk G. Acceptability and usability of a paediatric HIV screening tool in high-volume outpatient settings in Malawi, perspectives from caregivers and healthcare workers. BMJ Paediatr Open 2023; 7:10.1136/bmjpo-2022-001713. [PMID: 36882230 PMCID: PMC10008159 DOI: 10.1136/bmjpo-2022-001713] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/15/2022] [Accepted: 01/22/2023] [Indexed: 03/08/2023] Open
Abstract
BACKGROUND Using an HIV pretest screening tool to identify children most at risk for HIV infection may be a more efficient and cost-effective approach to identify children living with HIV in resource-limited settings. These tools seek to reduce overtesting of children by increasing the positive predictive value while ensuring a high negative predictive value for those screened for HIV. METHODS This qualitative study in Malawi evaluated acceptability and usability of a modified version of the Zimbabwe HIV screening tool to identify children aged 2-14 years most-at-risk. The tool included additional questions about previous hospitalisations due to malaria and prior documented diagnoses. Sixteen interviews were conducted with expert clients (ECs), trained peer-supporters, which administered the screening tool and 12 interviews with biological and non-biological caregivers of screened children. All interviews were audiorecorded, transcribed and translated. Transcripts were analysed manually using a short-answer analysis, compiling responses for each question by study participant group. Summary documents were generated, identifying common and outlier perspectives. RESULTS The HIV paediatric screening tool was generally accepted by caregivers and ECs, with both groups seeing the benefit of the tool and promoting its use. The ECs who were primarily responsible for implementing the tool initially struggled with acceptance of the tool but started to accept it after additional training and mentorship was provided. Overall, caregivers accepted having their children tested for HIV, although non-biological caregivers expressed hesitancy in giving consent for HIV testing. ECs reported challenges with the ability for non-biological caregivers to answer some questions. CONCLUSION This study found general acceptance of paediatric screening tools in children in Malawi and identified some minor challenges that raise important considerations for tool implementation. These include the need for a thorough orientation of the tools for the healthcare workers and caregivers, appropriate space at the facility, and adequate staffing and commodities.
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Affiliation(s)
- Leila Katirayi
- Research Department, Elizabeth Glaser Pediatric AIDS Foundation, Washington, District of Columbia, USA
| | - Thulani Maphosa
- Research Department, Elizabeth Glaser Pediatric AIDS Foundation, Lilongwe, Malawi
| | - Kwashie Kudiabor
- Strategic Information and Evaluation Department, Elizabeth Glaser Pediatric AIDS Foundation, Lilongwe, Malawi
| | - Dumbani Kayira
- Care and Treatment Department, Centers for Disease Control and Prevention, Lilongwe, Malawi
| | - Jessica Gross
- Division of Global HIV and Tuberculosis, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Susan Hrapcak
- Division of Global HIV and Tuberculosis, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Rachel Chamanga
- Research Department, Elizabeth Glaser Pediatric AIDS Foundation, Lilongwe, Malawi
| | - Harrid Nkhoma
- Research Department, Elizabeth Glaser Pediatric AIDS Foundation, Lilongwe, Malawi
| | - Paul Puleni
- Programs Department, Elizabeth Glaser Pediatric AIDS Foundation, Lilongwe, Malawi
| | - Alice Maida
- Care and Treatment Department, Centers for Disease Control and Prevention, Lilongwe, Malawi
| | - Allan Ahimbisibwe
- Programs Department, Elizabeth Glaser Pediatric AIDS Foundation, Lilongwe, Malawi
| | - Godfrey Woelk
- Research Department, Elizabeth Glaser Pediatric AIDS Foundation, Washington, District of Columbia, USA
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Teferi W, Gutreuter S, Bekele A, Ahmed J, Ayalew J, Gross J, Kumsa H, Antefe T, Mengistu S, Mirkovic K, Dziuban EJ, Ross C, Belay Z, Tilahun T, Kassa D, Hrapcak S. Adapting strategies for effective and efficient pediatric HIV case finding in low prevalence countries: risk screening tool for testing children presenting at high-risk entry points in Ethiopia. BMC Infect Dis 2022; 22:480. [PMID: 35596158 PMCID: PMC9121612 DOI: 10.1186/s12879-022-07460-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2022] [Accepted: 05/11/2022] [Indexed: 11/17/2022] Open
Abstract
Background Implementing effective and efficient case-finding strategies is crucial to increasing pediatric antiretroviral therapy coverage. In Ethiopia, universal HIV testing is conducted for children presenting at high-risk entry points including malnutrition treatment, inpatient wards, tuberculosis (TB) clinics, index testing for children of positive adults, and referral of orphans and vulnerable children (OVC); however, low positivity rates observed at inpatient, malnutrition and OVC entry points warrant re-assessing current case-finding strategies. The aim of this study is to develop HIV risk screening tool applicable for testing children presenting at inpatient, malnutrition and OVC entry points in low-HIV prevalence settings. Methods The study was conducted from May 2017–March 2018 at 29 public health facilities in Amhara and Addis Ababa regions of Ethiopia. All children 2–14 years presenting to five high-risk entry points including malnutrition treatment, inpatient wards, tuberculosis (TB) clinics, index testing for children of positive adults, and referral of orphans and vulnerable children (OVC) were enrolled after consent. Data were collected from registers, medical records, and caregiver interviews. Screening tools were constructed using predictors of HIV positivity as screening items by applying both logistic regression and an unweighted method. Sensitivity, specificity and number needed to test (NNT) to identify one new child living with HIV (CLHIV) were estimated for each tool. Results The screening tools had similar sensitivity of 95%. However, the specificities of tools produced by logistic regression methods (61.4 and 65.6%) which are practically applicable were higher than those achieved by the unweighted method (53.6). Applying these tools could result in 58‒63% reduction in the NNT compared to universal testing approach while maintaining the overall number of CLHIV identified. Conclusion The screening tools developed using logistic regression method could significantly improve HIV testing efficiency among children presenting to malnutrition, inpatient, and OVC entry points in Ethiopia while maintaining case identification. These tools are simplified to practically implement and can potentially be validated for use at various entry points. HIV programs in low-prevalence countries can also further investigate and optimize these tools in their settings.
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Affiliation(s)
- Wondimu Teferi
- Centers for Disease Control and Prevention, US Embassy Entoto Road, P.O.B 1014, Addis Ababa, Ethiopia.
| | - Steve Gutreuter
- Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | | | - Jelaludin Ahmed
- Centers for Disease Control and Prevention, US Embassy Entoto Road, P.O.B 1014, Addis Ababa, Ethiopia
| | - Jemal Ayalew
- Ethiopia Public Health Association, Addis Ababa, Ethiopia
| | - Jessica Gross
- Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Hanna Kumsa
- Addis Ababa City Administration Health Bureau, Addis Ababa, Ethiopia
| | | | | | - Kelsey Mirkovic
- Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Eric J Dziuban
- Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Christine Ross
- Centers for Disease Control and Prevention, US Embassy Entoto Road, P.O.B 1014, Addis Ababa, Ethiopia
| | - Zena Belay
- Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Tsegaye Tilahun
- United States Agency for International Development, Addis Ababa, Ethiopia
| | - Desta Kassa
- Ethiopian Public Health Institute, Addis Ababa, Ethiopia
| | - Susan Hrapcak
- Centers for Disease Control and Prevention, Atlanta, Georgia, USA
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Ong JJ, Coulthard K, Quinn C, Tang MJ, Huynh T, Jamil MS, Baggaley R, Johnson C. Risk-Based Screening Tools to Optimise HIV Testing Services: a Systematic Review. Curr HIV/AIDS Rep 2022; 19:154-165. [PMID: 35147855 PMCID: PMC8832417 DOI: 10.1007/s11904-022-00601-5] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/31/2022] [Indexed: 12/31/2022]
Abstract
PURPOSE OF REVIEW Effective ways to diagnose the remaining people living with HIV who do not know their status are a global priority. We reviewed the use of risk-based tools, a set of criteria to identify individuals who would not otherwise be tested (screen in) or excluded people from testing (screen out). RECENT FINDINGS Recent studies suggest that there may be value in risk-based tools to improve testing efficiency (i.e. identifying those who need to be tested). However, there has not been any systematic reviews to synthesize these studies. We identified 18,238 citations, and 71 were included. The risk-based tools identified were most commonly from high-income (51%) and low HIV (<5%) prevalence countries (73%). The majority were for "screening in" (70%), with the highest performance tools related to identifying MSM with acute HIV. Screening in tools may be helpful in settings where it is not feasible or recommended to offer testing routinely. Caution is needed for screening out tools, where there is a trade-off between reducing costs of testing with missing cases of people living with HIV.
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Affiliation(s)
- J J Ong
- Central Clinical School, Monash University, Melbourne, Australia.
- Melbourne Sexual Health Centre, The Alfred Hospital, Melbourne, Australia.
- Department of Clinical Research, London School of Hygiene and Tropical Medicine, London, UK.
| | - K Coulthard
- Melbourne Sexual Health Centre, The Alfred Hospital, Melbourne, Australia
| | - C Quinn
- Global HIV, Hepatitis and STIs Programmes, World Health Organization, Geneva, Switzerland
| | - M J Tang
- Central Clinical School, Monash University, Melbourne, Australia
| | - T Huynh
- Central Clinical School, Monash University, Melbourne, Australia
| | - M S Jamil
- Global HIV, Hepatitis and STIs Programmes, World Health Organization, Geneva, Switzerland
| | - R Baggaley
- Global HIV, Hepatitis and STIs Programmes, World Health Organization, Geneva, Switzerland
| | - C Johnson
- Global HIV, Hepatitis and STIs Programmes, World Health Organization, Geneva, Switzerland
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Does Venue of HIV Testing and Results Disclosure in the Context of a Research Study Affect Adolescent Health and Behavior? Results from a Study in Western Kenya. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:ijerph19063249. [PMID: 35328936 PMCID: PMC8953200 DOI: 10.3390/ijerph19063249] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/30/2021] [Revised: 03/06/2022] [Accepted: 03/07/2022] [Indexed: 02/04/2023]
Abstract
Ethical concerns about risks to minor adolescents participating in HIV prevention research is a barrier to their inclusion. One concern is whether HIV testing and results disclosure venue affects the health and behavior of adolescent participants. We assessed for differential effects on quality of life (QOL), depressive symptoms, and sexual behavior due to (1) testing venue (home or health facility) and (2) test result (HIV-positive, HIV-negative, indeterminate). We collected data at three timepoints (baseline, 2-month follow-up, 12-month follow-up) from 113 Kenyan adolescents aged 15-19 (51% female). We analyzed the data using linear mixed effects models for the QOL and depressive symptoms outcomes and a logistic model for the sexual behavior outcome. Results showed a small mental health benefit for adolescents tested for HIV at a health facility compared with home. There was little evidence that testing venue influenced sexual behavior or that test results moderated the effects of HIV testing across all outcomes. The decision to conduct HIV testing at home or a health facility may not be very consequential for adolescents' health and behavior. Findings underscore the need to critically examine assumptions about adolescent vulnerability to better promote responsible conduct of HIV prevention research with youth in sub-Saharan Africa.
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Finding Children Living With HIV in Low-prevalence Countries: HIV Prevalence and Testing Yield From 5 Entry Points in Ethiopia. Pediatr Infect Dis J 2021; 40:1090-1095. [PMID: 34609102 PMCID: PMC8721595 DOI: 10.1097/inf.0000000000003324] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Limited data in low HIV prevalence settings such as Ethiopia limit policy development and implementation of optimized pediatric testing approaches to close the treatment gap. This study aimed to determine HIV prevalence, testing yield and factors associated with HIV among children at 5 entry points. METHODS We conducted a cross-sectional study from May 2017 to March 2018 in 29 public health facilities in Amhara and Addis Ababa regions in Ethiopia. Children 2-14 years were enrolled through 5 entry points. Data were obtained from registers, medical records and interviews with caregivers. HIV prevalence and testing yields were calculated for each entry point. Mixed-effects logistic regression analysis identified factors associated with undiagnosed HIV. RESULTS The study enrolled 2166 children, of whom 94 were HIV positive (40 newly diagnosed). HIV prevalence and testing yield were the highest among children of HIV-positive adults (index testing; 8.2% and 8.2%, respectively) and children presenting to tuberculosis clinics (7.9% and 1.8%) or with severe malnutrition (6.5% and 1.4%). Factors associated with undiagnosed HIV included tuberculosis or index entry point [adjusted odds ratio (aOR), 11.97; 95% CI 5.06-28.36], deceased mother (aOR 4.55; 95% CI 1.30-15.92), recurrent skin problems (aOR 17.71; 95% CI 7.75-40.43), severe malnutrition (aOR 4.56; 95% CI 2.04-10.19) and urban residence (aOR 3.47; 95% CI 1.03-11.66). CONCLUSIONS Index testing is a critical strategy for pediatric case finding in Ethiopia. Strategies and resources can prioritize minimizing missed opportunities in implementing universal testing for very sick children (tuberculosis, severe malnutrition) and implementing targeted testing in other entry points through use of factors associated with HIV.
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Tippett Barr BA, Lowrance D, Johnson CC, Baggaley RC, Rogers JH, Balachandra SK, Barker J, Kalua T, Bunga S, Low-Beer D, Payne D, Bulterys MG, Jahn A. Treatment-adjusted prevalence to assess HIV testing programmes. Bull World Health Organ 2021; 99:874-882. [PMID: 34866683 PMCID: PMC8640683 DOI: 10.2471/blt.21.286388] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2021] [Revised: 09/03/2021] [Accepted: 09/03/2021] [Indexed: 11/27/2022] Open
Abstract
Scale-up of human immunodeficiency virus (HIV) testing and antiretroviral therapy (ART) for people living with HIV has been increasing in sub-Saharan Africa. As a result, areas with high HIV prevalence are finding a declining proportion of people testing positive in their national testing programmes. In eastern and southern Africa, where there are settings with adult HIV prevalence of 12% and above, the positivity from national HIV testing services has dropped to below 5%. Identifying those in need of ART is therefore becoming more costly for national HIV programmes. Annual target-setting assumes that national testing positivity rates approximate that of population prevalence. This assumption has generated an increased focus on testing approaches which achieve higher rates of HIV positivity. This trend is a departure from the provider-initiated testing and counselling strategy used early in the global HIV response. We discuss a new indicator, treatment-adjusted prevalence, that countries can use as a practical benchmark for estimating the expected adult positivity in a testing programme when accounting for both national HIV prevalence and ART coverage. The indicator is calculated by removing those people receiving ART from the numerator and denominator of HIV prevalence. Treatment-adjusted prevalence can be readily estimated from existing programme data and population estimates, and in 2019, was added to the World Health Organization guidelines for HIV testing and strategic information. Using country examples from Kenya, Malawi, South Sudan and Zimbabwe we illustrate how to apply this indicator and we discuss the potential public health implications of its use from the national to facility level.
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Affiliation(s)
- Beth A Tippett Barr
- US Centers for Disease Control and Prevention, Center for Global Health, PO Box 606, Village Market, 00621 Nairobi, Kenya
| | - David Lowrance
- Global HIV, Hepatitis and STI programmes, World Health Organization, Geneva, Switzerland
| | - Cheryl Case Johnson
- Global HIV, Hepatitis and STI programmes, World Health Organization, Geneva, Switzerland
| | - Rachel Clare Baggaley
- Global HIV, Hepatitis and STI programmes, World Health Organization, Geneva, Switzerland
| | - John H Rogers
- US Centers for Disease Control and Prevention, Division of Global HIV & Tuberculosis, Zimbabwe
| | - Shirish K Balachandra
- US Centers for Disease Control and Prevention, Division of Global HIV & Tuberculosis, Zimbabwe
| | - Joseph Barker
- US Centers for Disease Control and Prevention, Center for Global Health, PO Box 606, Village Market, 00621 Nairobi, Kenya
| | - Thokozani Kalua
- Ministry of Health, Department of HIV/AIDS, Lilongwe, Malawi
| | - Sudhir Bunga
- US Centers for Disease Control and Prevention, Division of Global HIV & Tuberculosis, Juba, South Sudan
| | - Daniel Low-Beer
- Global HIV, Hepatitis and STI programmes, World Health Organization, Geneva, Switzerland
| | - Danielle Payne
- US Centers for Disease Control and Prevention, Division of Global HIV & Tuberculosis, Lilongwe, Malawi
| | - Marc G Bulterys
- US Centers for Disease Control and Prevention, Center for Global Health, PO Box 606, Village Market, 00621 Nairobi, Kenya
| | - Andreas Jahn
- International Training and Education Center for Health (I-TECH), University of Washington, Seattle, United States of America
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Katureebe C, Ashburn K, Machekano R, Gill MM, Gross J, Kazooba P, Kiyonga A, Taasi G, Adler M, Nazziwa E, Rivadeneira ED, Kekitiinwa A, Magongo E, Matovu JB, Nantume S, Bitarakwate E. Developing and Validating an Effective Pediatric and Adolescent HIV Testing Eligibility Screening Tool for High-Volume Entry Points in Uganda. J Acquir Immune Defic Syndr 2021; 88:290-298. [PMID: 34651604 PMCID: PMC10203979 DOI: 10.1097/qai.0000000000002775] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2021] [Accepted: 06/17/2021] [Indexed: 11/26/2022]
Abstract
INTRODUCTION Because of low pediatric HIV prevalence, more tests are needed to find 1 HIV-positive child compared with adults. In Uganda, the number needed to test (NNT) to find 1 new HIV-positive child was 64 in outpatient departments (OPDs) and 31 through index testing. We aimed to develop and validate a pediatric (1.5-14 years) screening tool to optimize testing approaches. METHODS Phase 1 evaluated the performance of 10 screening questions in 14 OPDs using a variable selection algorithm to evaluate combinations of screening questions. Using logistic regression, we identified the number of screening questions with the best predictive accuracy using the receiver operation characteristic curve. Phase 2 validated the proposed tool in 15 OPDs and 7 orphan and vulnerable children programs. We estimated sensitivity, specificity, and NNT accounting for intercluster correlations. RESULTS A total of 3482 children were enrolled. The optimal model included reported HIV-positive maternal status or 2/5 symptoms (sickly in the last 3 months, recurring skin problems, weight loss, not growing well, and history of tuberculosis). The proposed tool had sensitivity of 83.6% [95% confidence interval (CI): 68.1 to 92.4] and specificity of 62.5% (95% CI: 55.0 to 69.4). The tool was validated in a sample of 11,342 children; sensitivity was 87.8% (95% CI: 80.9 to 92.5) and specificity 62.6% (95% CI: 54.8 to 69.7) across OPDs and community sites. In OPDs, sensitivity was 88.1% (95% CI: 80.8 to 92.8) and specificity 69.0% (95% CI: 61.9 to 75.3). The NNT was 43 (95% CI: 28 to 67) across settings and 28 (95% CI: 20 to 38) for OPD. CONCLUSIONS This HIV screening tool has high sensitivity and reasonable specificity, increasing testing efficiency and yield for children and adolescents.
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Affiliation(s)
| | - Kim Ashburn
- Elizabeth Glaser Pediatric AIDS Foundation, Washington, D.C., U.S.A
| | | | - Michelle M. Gill
- Elizabeth Glaser Pediatric AIDS Foundation, Washington, D.C., U.S.A
| | - Jessica Gross
- Maternal and Child Health Branch, Division of Global HIV and TB, Centers for Disease Control and Prevention, Atlanta, U.S.A
| | | | | | | | - Michelle Adler
- Division of Global HIV and TB, Centers for Disease Control and Prevention, Kampala, Uganda
| | - Esther Nazziwa
- Division of Global HIV and TB, Centers for Disease Control and Prevention, Kampala, Uganda
| | - Emilia D. Rivadeneira
- Maternal and Child Health Branch, Division of Global HIV and TB, Centers for Disease Control and Prevention, Atlanta, U.S.A
| | | | | | | | - Sophie Nantume
- Division of Global HIV and TB, Centers for Disease Control and Prevention, Kampala, Uganda
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Jahun I, Dirlikov E, Odafe S, Yakubu A, Boyd AT, Bachanas P, Nzelu C, Aliyu G, Ellerbrock T, Swaminathan M. Ensuring Optimal Community HIV Testing Services in Nigeria Using an Enhanced Community Case-Finding Package (ECCP), October 2019-March 2020: Acceleration to HIV Epidemic Control. HIV AIDS (Auckl) 2021; 13:839-850. [PMID: 34471388 PMCID: PMC8403567 DOI: 10.2147/hiv.s316480] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2021] [Accepted: 06/19/2021] [Indexed: 12/01/2022] Open
Abstract
Purpose The 2018 Nigeria HIV/AIDS Indicator and Impact Survey (NAIIS) showed Nigeria’s progress toward the UNAIDS 90-90-90 targets: 47% of HIV-positive individuals knew their status; of these, 96% were receiving antiretroviral therapy (ART); and of these, 81% were virally suppressed. To improve identification of HIV-positive individuals, Nigeria developed an Enhanced Community Case-Finding Package (ECCP). We describe ECCP implementation in nine states and assess its effect. Methods ECCP included four core strategies (small area estimation [SAE] of people living with HIV [PLHIV], map of HIV-positive patients by residence, HIV risk-screening tool [HRST], and index testing [IT]) and four supportive strategies (alternative healthcare outlets, performance-based incentives for field testers, Project Extension for Community Healthcare Outcomes, and interactive dashboards). ECCP was deployed in nine of 10 states prioritized for ART scale-up. Weekly program data (October 2019–March 2020) were tracked and analyzed. Results Of the total 774 LGAs in Nigeria, using SAE, 103 (13.3%) high-burden LGAs were identified, in which 2605 (28.0%) out of 9,294 hotspots were prioritized by mapping newly identified PLHIV by residential addresses. Over 22 weeks, among 882,449 individuals screened using HRST, 723,993 (82.0%) were eligible and tested for HIV (state range, 43.7–90.4%), out of which 20,616 were positive. Through IT, an additional 3,724 PLHIV were identified. In total, 24,340 PLHIV were identified and 97.4% were linked to life-saving antiretroviral therapy. The number of newly identified PLHIV increased 17-fold over 22 weeks (week 1: 89; week 22: 1,632). Overall mean HIV positivity rate by state was 3.3% (range, 1.8–6.4%). Conclusion Using ECCP in nine states in Nigeria increased the number of PLHIV in the community who knew their status, allowing them to access life-saving care and decreasing the risk of HIV transmission.
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Affiliation(s)
- Ibrahim Jahun
- US Centers for Disease Control and Prevention, Division of Global HIV and TB, Center for Global Health - Nigeria, Abuja Federal Capital Territory, Nigeria
| | - Emilio Dirlikov
- US Centers for Disease Control and Prevention, Division of Global HIV and TB, Center for Global Health, Atlanta, GA, USA
| | - Solomon Odafe
- US Centers for Disease Control and Prevention, Division of Global HIV and TB, Center for Global Health - Nigeria, Abuja Federal Capital Territory, Nigeria
| | - Aminu Yakubu
- US Centers for Disease Control and Prevention, Division of Global HIV and TB, Center for Global Health - Nigeria, Abuja Federal Capital Territory, Nigeria
| | - Andrew T Boyd
- US Centers for Disease Control and Prevention, Division of Global HIV and TB, Center for Global Health, Atlanta, GA, USA
| | - Pamela Bachanas
- US Centers for Disease Control and Prevention, Division of Global HIV and TB, Center for Global Health, Atlanta, GA, USA
| | | | - Gambo Aliyu
- National Agency for the Control of AIDS (NACA), Abuja, Federal Capital Territory, Nigeria
| | - Tedd Ellerbrock
- US Centers for Disease Control and Prevention, Division of Global HIV and TB, Center for Global Health, Atlanta, GA, USA
| | - Mahesh Swaminathan
- US Centers for Disease Control and Prevention, Division of Global HIV and TB, Center for Global Health - Nigeria, Abuja Federal Capital Territory, Nigeria
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Scale-up of antiretroviral treatment access among people living with HIV in Rivers State, Nigeria, 2019--2020. AIDS 2021; 35:1127-1134. [PMID: 33946087 PMCID: PMC8366506 DOI: 10.1097/qad.0000000000002858] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
OBJECTIVE The aim of this study was to describe and evaluate the impact of the programme intervention of the Rivers State Antiretroviral Treatment (ART) Surge, a collaboration between the US President's Emergency Plan for AIDS Relief (PEPFAR) and the State Ministry of Health, to increase HIV case-finding and ART access in Rivers State, the state with the largest ART gap among people living with HIV (PWH) in Nigeria. DESIGN During April 2019-September 2020, the intervention included six specific strategies: using local government area-level ART gap analysis to guide case-finding; expanding targeted community testing; tailoring comprehensive key population HIV services; engaging HIV treatment programme stakeholders; synchronizing team efforts; and using near real-time data for programme action. METHODS Weekly reported facility and community data on tests conducted, PWH diagnosed, and PWH initiated on ART were aggregated. The total number of PWH maintained on ART was reported quarterly. RESULTS During May 2019-September 2020, the weekly number of newly diagnosed PWH initiated on ART supported by PEPFAR in Rivers State increased from 82 to 1723. During October 2019-September 2020, the monthly number of people screened for HIV testing eligibility in the community increased from 44 000 to 360 000. During April 2019-September 2020, the total number of PWH on ART supported by PEPFAR statewide increased by 3.8 times, from 26 041 to 99 733. CONCLUSION The strategies applied by HIV program stakeholders contributed to scale-up of PWH identification and ART linkage within the Rivers State ART Surge. Continued gains through time indicate the importance of the application of a quality improvement approach to maintain programme flexibility and effectiveness.
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