Routine offering of HIV testing to hospitalized pediatric patients at university teaching hospital, Lusaka, Zambia: acceptability and feasibility

Characteristics and outcomes of HIV-infected youth and young adolescents enrolled in HIV care in Kenya

BACKGROUND

The number of youth and adolescents (10-24 years) with HIV infection has increased substantially presenting unique challenges to effective health service delivery.

METHODS

We examined routinely collected patient-level data for antiretroviral treatment (ART)-naive HIV-infected patients, aged 10-24 years, enrolled in care during 2006-2011 at 109 ICAP-supported health facilities in three provinces in Kenya. Loss to follow-up (LTF) was defined as having no clinic visit for 12 months prior to ART initiation (pre-ART) and 6 months for ART patients. Competing risk and Kaplan-Meier estimators were used to calculate LTF and death rates. Sub-distributional and Cox proportional-hazards models were used to identify potential predictors of death and LTF.

RESULTS

Overall 22 832 patients were enrolled in care at 10-24 years of age, 69.5% were aged 20-24 years, and 82% were female. Median CD4(+) cell count was 332 cells/μl (interquartile range 153-561); 70.8% were WHO stage I/II. Young adolescents (10-14 years) had more advanced WHO stage and lower median CD4(+) cell count compared to youth (15-24 years) at enrollment (284 vs. 340 cells/μl; P < 0.0001). Cumulative incidence of LTF and death at 24 months for pre-ART patients was 46.1% [95% confidence interval (CI) 45.4-46.8%) and 2.1% (95% CI 1.9-2.3%), respectively. For those on ART, 32.2% (95% CI 31.1-33.3%) were LTF and 3.9% (95% CI 1.7-2.3%) died within 24 months. LTF among pre-ART and ART patients was twice as high among youth compared to young adolescents.

CONCLUSION

LTF of young people with HIV in this Kenyan cohort was high and notably greater among youth compared to young adolescents. Novel strategies targeting these populations are urgently needed to improve retention.

Trends in HIV infection in the First Affiliated Hospital of Harbin, China

Background

Major hospitals in most Chinese cities have the capability to perform HIV testing. However, it is not a routine test for all patients and, as a result, many patients are not aware of their HIV status. To understand the rate of HIV infection and the factors associated with infection, we tested serum to determine HIV status and analyzed factors associated with HIV infection.

Methods

We collected blood samples from 348,151 patients who visited the First Affiliated Hospital of Harbin Medical University from 1 January 2007 to 31 December 2012. Serum was screened with an ELISA. If the test was positive, we conducted two additional ELISAs: a repeat with the initial kit and one with another kit. If there was a positive result with either of these two ELISA kits, western blotting was performed at Harbin Centers for Disease Control and Prevention.

Results

The HIV positivity rate of inpatients significantly increased during the course of this study. HIV infection in patients appeared to differ by sex, age, occupation, marital status, educational level, and route of infection. HIV was more prevalent in men than in women. More than 80% of HIV-positive patients had not received higher (>12 years) education. From 2007 to 2012, HIV-positive patients were mainly infected through sexual transmission. For sexually acquired infections, the rate of HIV infections through homosexual contact has increased rapidly in recent years, and ranged from 36.4% to 65.1%.

Conclusions

The number of patients diagnosed as HIV positive has increased in recent years. Offering routine HIV testing in hospitals is feasible and can increase linkage to HIV care and treatment for many individuals.

Electronic supplementary material

The online version of this article (doi:10.1186/s12879-014-0605-1) contains supplementary material, which is available to authorized users.

[Acceptability of HIV testing provided to infants in pediatric services in Cote d'Ivoire, meanings for pediatric diagnostic coverage]

PROBLEM

HIV testing in children had rarely been a central concern for researchers. When pediatric tracking retained the attention, it was more to inform on the diagnosis tools' performances rather than the fact the pediatric test can be accepted or refused. This article highlights the parents' reasons which explain why pediatric HIV test is accepted or refused.

OBJECTIVE

To study among parents, the explanatory factors of the acceptability of pediatric HIV testing among infant less than six months.

METHODS

Semi-structured interview with repeated passages in the parents of infants less than six months attending in health care facilities for the pediatric weighing/vaccination and consultations.

RESULTS

We highlight that the parents' acceptance of the pediatric HIV screening is based on three elements. Firstly, the health care workers by his speech (which indicates its own knowledge and perceptions on the infection) directed towards mothers' influences their acceptance or not of the HIV test. Secondly, the mother who by her knowledge and perceptions on HIV, whose particular status, give an impression of her own wellbeing for her and her child influences any acceptance of the pediatric HIV test. Thirdly, the marital environment of the mother, particularly characterized by the ease of communication within the couple, to speak about the HIV test and its realization for the parents or the mother only are many factors which influence the effective realization of the pediatric HIV testing. The preventive principle of HIV transmission and the desire to realize the test in the newborn are not enough alone to lead to its effective realization, according to certain mothers confronted with the father's refusal. On the other hand, the other mothers refusing the realization of the pediatric test told to be opposed to it; of course, even if their partner would accept it.

DISCUSSION

The mothers are the principal facing the pediatric HIV question and fear the reprimands and stigma. The father, the partner could be an obstacle, when he is opposed to the infant HIV testing, or also the facilitator with his realization if he is convinced. The father position thus remains essential face to the question of pediatric HIV testing acceptability. The mothers are aware of this and predict the difficulties of achieving their infant to be tested without the preliminary opinion of their partner at the same time father, and head of the family.

CONCLUSION

The issue of pediatric HIV testing, at the end of our analysis, highlights three elements which require a comprehensive management to improve the coverage of pediatric HIV test. These three elements would not exist without being influenced; therefore they are constantly in interaction and prevent or support the realization or not pediatric test. Also, with the aim to improve the pediatric HIV test coverage, it is necessary to take into account the harmonious management of these elements. Firstly, the mother alone (with her knowledge, and perceptions), its marital environment (with the proposal of the HIV test integrating (1) the partner and/or father with his perceptions and knowledge on HIV infection and (2) facility of speaking about the test and its realization at both or one about the parents, the mother) and of the knowledge, attitudes and practices about the infection of health care workers of the sanitary institution.

RECOMMENDATIONS

Our recommendations proposed taking into account a redefinition of the HIV/AIDS approach towards the families exposed to HIV and a more accentuated integration of the father facilitating their own HIV test acceptation and that of his child.

Early infant diagnosis of HIV infection in low-income and middle-income countries: does one size fit all?

Despite expansion of services for prevention of mother-to-child transmission of HIV (PMTCT), about 700 infants acquire HIV every day. Early initiation of antiretroviral therapy for HIV-infected infants reduces mortality but requires diagnosis by virological testing, which is complex, expensive, and inaccessible in many settings. Little cost-effectiveness evidence exists about different strategies to deliver early infant diagnosis services. Cost-effectiveness will vary depending on entry points for testing, underlying prevalences of HIV, PMTCT coverage, treatment availability, programme attrition, and other factors. Appropriate policy responses are therefore context-specific. In most cases, early infant diagnosis should be concentrated at entry points where underlying infant HIV prevalence is highest (eg, malnutrition wards). This strategy contrasts with the tendency at present to test mainly within PMTCT programmes. If testing is undertaken in PMTCT programmes with high coverage, addition of a virological test at birth might have advantages, including greater predictive value, earlier diagnosis, and better infant follow-up. National programme managers should recognise the opportunity costs of the limited resources available, acknowledge the changing scenario of PMTCT scale-up, ensure implementation of provider-initiated testing and counselling, and tailor early infant diagnosis programmes to maximise health gains for children.

From patient to person: the need for an 'HIV trajectories' perspective in the delivery of prevention of mother-to-child-transmission services

Accelerated efforts to end vertical HIV transmission have resulted in a 52% decrease in new infections among children since 2001. However, current approaches to prevent mother-to-child-transmission (PMTCT) assume a linearity and universality. These insufficiently guide clinicians and programmes toward interventions that comprehensively address the varying and changing needs of clients. This results in high levels of loss-to-follow-up at each step of the PMTCT cascade. Current PMTCT approaches must be adapted to respond to the different and complex realities of women, children and families affected by HIV. Drawing on the concept of an 'HIV trajectories,' we screened peer-reviewed literature for promising PMTCT approaches and selected 13 articles for qualitative review when the described intervention involved more than a biomedical approach to PMTCT and mother-child HIV treatment and care. Our qualitative analysis revealed that interventions which integrated elements of the 'HIV trajectories' perspective and built on people living with HIV support/network, community health worker, primary healthcare and early childhood development platforms were successful because they recognized that HIV is an illness, experienced, moderated and managed by numerous factors beyond biomedical interventions alone.On the basis of this review, we call for the adoption of an 'HIV trajectories' perspective that can help assess the comprehensiveness of care provided to women, children and families affected by HIV and can inform the planning and delivery of HIV and related services so that they more adequately respond to the varying needs of clients on different 'HIV trajectories'.

Pediatric malignancies, treatment outcomes and abandonment of pediatric cancer treatment in Zambia

BACKGROUND

There exist significant challenges to the receipt of comprehensive oncologic treatment for children diagnosed with cancer in sub-Saharan Africa. To better define those challenges, we investigated treatment outcomes and risk factors for treatment abandonment in a cohort of children diagnosed with cancer at the University Teaching Hospital (UTH), the site of the only pediatric oncology ward in Zambia.

METHODS

Using an established database, a retrospective cohort study was conducted of children aged 0-15 years admitted to the pediatric oncology ward between July 2008 and June 2010 with suspected cancer. Diagnosis, mode of diagnosis, treatment outcome, and risk factors for abandonment of treatment were abstracted from this database and clinical medical records.

RESULTS

Among 162 children treated at the UTH during the study time period that met inclusion criteria, only 8.0% completed a treatment regimen with most of the patients dying during treatment or abandoning care. In multivariable analysis, shorter distance from home to the UTH was associated with a lower risk of treatment abandonment (Adjusted Odds Ratio [aOR]  = 0.48 (95% confidence interval [CI] 0.23-0.97). Conversely maternal education less than secondary school was associated with increased risk for abandonment (aOR = 1.65; 95% CI 1.05-2.58).

CONCLUSIONS

Despite availability of dedicated pediatric oncology treatment, treatment completion rates are poor, due in part to the logistical challenges faced by families, low educational status, and significant distance from the hospital. Alternative treatment delivery strategies are required to bring effective pediatric oncology care to the patients in need, as their ability to come to and remain at a central tertiary care facility for treatment is limited. We suggest that the extensive system now in place in most of sub-Saharan Africa that sustains life-long antiretroviral therapy for children with human immunodeficiency virus (HIV) infection be adapted for pediatric cancer treatment to improve outcome.

Temporal trends in the characteristics of children at antiretroviral therapy initiation in southern Africa: the IeDEA-SA Collaboration

BACKGROUND

Since 2005, increasing numbers of children have started antiretroviral therapy (ART) in sub-Saharan Africa and, in recent years, WHO and country treatment guidelines have recommended ART initiation for all infants and very young children, and at higher CD4 thresholds for older children. We examined temporal changes in patient and regimen characteristics at ART start using data from 12 cohorts in 4 countries participating in the IeDEA-SA collaboration.

METHODOLOGY/PRINCIPAL FINDINGS

Data from 30,300 ART-naïve children aged <16 years at ART initiation who started therapy between 2005 and 2010 were analysed. We examined changes in median values for continuous variables using the Cuzick's test for trend over time. We also examined changes in the proportions of patients with particular disease severity characteristics (expressed as a binary variable e.g. WHO Stage III/IV vs I/II) using logistic regression. Between 2005 and 2010 the number of children starting ART each year increased and median age declined from 63 months (2006) to 56 months (2010). Both the proportion of children <1 year and ≥10 years of age increased from 12 to 19% and 18 to 22% respectively. Children had less severe disease at ART initiation in later years with significant declines in the percentage with severe immunosuppression (81 to 63%), WHO Stage III/IV disease (75 to 62%), severe anemia (12 to 7%) and weight-for-age z-score<-3 (31 to 28%). Similar results were seen when restricting to infants with significant declines in the proportion with severe immunodeficiency (98 to 82%) and Stage III/IV disease (81 to 63%). First-line regimen use followed country guidelines.

CONCLUSIONS/SIGNIFICANCE

Between 2005 and 2010 increasing numbers of children have initiated ART with a decline in disease severity at start of therapy. However, even in 2010, a substantial number of infants and children started ART with advanced disease. These results highlight the importance of efforts to improve access to HIV diagnostic testing and ART in children.

The acceptability and feasibility of routine pediatric HIV testing in an outpatient clinic in Durban, South Africa

BACKGROUND

Limited access to HIV testing of children impedes early diagnosis and access to antiretroviral therapy. Our objective was to evaluate the feasibility and acceptability of routine pediatric HIV testing in an urban, fee-for-service, outpatient clinic in Durban, South Africa.

METHODS

We assessed the number of patients (0-15 years) who underwent HIV testing upon physician referral during a baseline period. We then established a routine, voluntary HIV testing study for pediatric patients, regardless of symptoms. Parents/caretakers were offered free rapid fingerstick HIV testing of their child. For patients <18 months, the biological mother was offered HIV testing and HIV DNA polymerase chain reaction was used to confirm the infant's status. The primary outcome was the HIV testing yield, defined as the average number of positive tests per month during the routine compared with the baseline period.

RESULTS

Over a 5-month baseline testing period, 931 pediatric patients registered for outpatient care. Of the 124 (13%) patients who underwent testing on physician referral, 21 (17%, 95% confidence interval: 11-25%) were HIV infected. During a 13-month routine testing period, 2790 patients registered for care and 2106 (75%) were approached for participation. Of these, 1234 were eligible and 771 (62%) enrolled. Among those eligible, 637 (52%, 95% confidence interval: 49-54%) accepted testing of their child or themselves (biological mothers of infants <18 months). There was an increase in the average number of HIV tests during the routine compared with the baseline HIV testing periods (49 versus 25 tests/month, P = 0.001) but no difference in the HIV testing yield during the testing periods (3 versus 4 positive HIV tests/month, P = 0.06). However, during the routine testing period, HIV prevalence remains extraordinarily high with 39 (6%, 95% confidence interval: 4-8%) newly diagnosed HIV-infected children (median 7 years, 56% female).

CONCLUSIONS

Targeted and symptom-based testing referral identifies an equivalent number of HIV-infected children as routine HIV testing. Routine HIV testing identifies a high burden of HIV and is a feasible and moderately acceptable strategy in an outpatient clinic in a high prevalence area.

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.

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.

Positive attitudes to pediatric HIV testing: findings from a nationally representative survey from Zimbabwe

OBJECTIVE

Early HIV testing and diagnosis are paramount for increasing treatment initiation among children, necessary for their survival and improved health. However, uptake of pediatric HIV testing is low in high-prevalence areas. We present data on attitudes towards pediatric testing from a nationally representative survey in Zimbabwe.

METHODS

All 18-24 year olds and a proportion of 25-49 year olds living in randomly selected enumeration areas from all ten Zimbabwe provinces were invited to self-complete an anonymous questionnaire on a personal digital assistant, and 16,719 people agreed to participate (75% of eligibles).

RESULTS

Most people think children can benefit from HIV testing (91%), 81% of people who looked after children know how to access testing for their children and 92% would feel happier if their children were tested. Notably, 42% fear that, if tested, children may be discriminated against by some community members and 28% fear their children are HIV positive. People who fear discrimination against children who have tested for HIV are more likely than their counterparts to perceive their community as stigmatizing against HIV positive people (43% vs. 29%). They are also less likely to report positive attitudes to HIV themselves (49% vs. 74%). Only 28% think it is possible for children HIV-infected at birth to live into adolescence without treatment. Approximately 70% of people (irrespective of whether they are themselves parents) think HIV-infected children in their communities can access testing and treatment.

CONCLUSIONS

Pediatric HIV testing is the essential gateway to prevention and care services. Our data indicate positive attitudes to testing children, suggesting a conducive environment for increasing uptake of pediatric testing in Zimbabwe. However, there is a need to better understand the barriers to pediatric testing, such as stigma and discrimination, and address the gaps in knowledge regarding HIV/AIDS in children.

PEPFAR scale-up of pediatric HIV services: innovations, achievements, and challenges

HIV/AIDS has had a profound impact on children around the world since the start of the epidemic. There are currently 3.4 million children under the age of 15 years living with HIV globally, and more than 450,000 children currently receiving lifesaving antiretroviral treatment. This article describes efforts supported by the President's Emergency Plan for AIDS Relief (PEPFAR) to expand access to treatment for children living with HIV in high-burden countries. The article also highlights a series of case studies that illustrate the impact that the PEPFAR initiative has had on the pediatric HIV epidemic. Through its support of host governments and partner organizations, the PEPFAR initiative has expanded HIV testing and treatment for pregnant women to reduce vertical transmission of HIV, increased access to early infant diagnosis for HIV-exposed infants, improved training and resources for clinicians who provide pediatric care and antiretroviral treatment, and, through public-private partnerships with pharmaceutical manufacturers, helped increase the number of medications available for the treatment of HIV-infected children in resource-limited settings.

Institutionalizing provider-initiated HIV testing and counselling for children: an observational case study from Zambia

Background

Provider-initiated testing and counselling (PITC) is a priority strategy for increasing access for HIV-exposed children to prevention measures, and infected children to treatment and care interventions. This article examines efforts to scale-up paediatric PITC at a second-level hospital located in Zambia’s Southern Province, and serving a catchment area of 1.2 million people.

Methods and Principal Findings

Our retrospective case study examined best practices and enabling factors for rapid institutionalization of PITC in Livingstone General Hospital. Methods included clinical observations, key informant interviews with programme management, and a desk review of hospital management information systems (HMIS) uptake data following the introduction of PITC. After PITC roll-out, the hospital experienced considerably higher testing uptake. In a 36-month period following PITC institutionalization, of total inpatient children eligible for PITC (n = 5074), 98.5% of children were counselled, and 98.2% were tested. Of children tested (n = 4983), 15.5% were determined HIV-infected; 77.6% of these results were determined by DNA polymerase chain reaction (PCR) testing in children under the age of 18 months. Of children identified as HIV-infected in the hospital’s inpatient and outpatient departments (n = 1342), 99.3% were enrolled in HIV care, including initiation on co-trimoxazole prophylaxis. A number of good operational practices and enabling factors in the Livingstone General Hospital experience can inform rapid PITC institutionalization for inpatient and outpatient children. These include the placement of full-time nurse counsellors at key areas of paediatric intake, who interface with patients immediately and conduct testing and counselling. They are reinforced through task-shifting to peer counsellors in the wards. Nurse counsellor capacity to draw specimen for DNA PCR for children under 18 months has significantly enhanced early infant diagnosis. The hospital’s bolstered antiretroviral supply chain, package of on-site HIV services, and follow-up care for children and families improved the continuum of service uptake.

Conclusions and Significance

The clinical impact and operational experience emphasizes that institutional PITC is a feasible strategy for increasing access to paediatric HIV care, particularly in generalized epidemic settings.

Perception of risk of vertically acquired HIV infection and acceptability of provider-initiated testing and counseling among adolescents in Zimbabwe

OBJECTIVES

We investigated attitudes toward provider-initiated HIV testing and counseling (PITC) in the suburbs of Harare, Zimbabwe, where late presentation after mother-to-child HIV transmission (MTCT) is a major cause of adolescent mortality.

METHODS

Adolescents (10-18 years) attending 2 primary clinics were offered PITC. Participants completed a questionnaire investigating acceptability of PITC, and in-depth interviews with 41 adolescents and 30 guardians explored understanding of long-term survival after MTCT.

RESULTS

Of 506 participants, 16 were known to be HIV-positive; of the remaining 490, only 5 (1%) declined HIV testing. Infected adolescents and their guardians often anticipated a positive result and reported being advised by relatives (but not health workers) to be tested because of chronic illness, especially if parents or siblings had died or were HIV-infected. However, HIV-negative participants were not aware that long-term survival following MTCT could occur. All adolescents felt that HIV diagnosed at their age would be assumed to have been sexually acquired regardless of the true mode of transmission.

CONCLUSIONS

Including late diagnosis of MTCT in pretest counseling and health educational messages may facilitate PITC for older children and adolescents, especially for those who have not had their sexual debut.

Pneumonia and malnutrition are highly predictive of mortality among African children hospitalized with human immunodeficiency virus infection or exposure in the era of antiretroviral therapy

OBJECTIVE

To identify clinical characteristics predicting death among inpatients who are infected with or exposed to human immunodeficiency virus (HIV) during a period of pediatric antiretroviral therapy scale-up in sub-Saharan Africa.

STUDY DESIGN

Retrospective review of medical records from every child with HIV infection (n = 834) or exposure (n = 351) identified by routine inpatient testing in Kamuzu Central Hospital, Lilongwe, Malawi, September 2007 through December 2008.

RESULTS

The inpatient mortality rate was high among children with HIV infection (16.6%) and exposure (13.4%). Clinically diagnosed Pneumocystis pneumonia or very severe pneumonia independently predicted death in inpatients with HIV infection (OR 14; 95% CI 8.2 to 23) or exposure (OR 21; CI 8.4 to 50). Severe acute malnutrition independently predicted death in children who are HIV infected (OR 2.2; CI 1.7 to 3.9) or exposed (OR 5.1; CI 2.3 to 11). Other independent predictors of death were septicemia, Kaposi sarcoma, meningitis, and esophageal candidiasis for children infected with HIV, and meningitis and severe anemia for inpatients exposed to HIV.

CONCLUSIONS

Severe respiratory tract infections and malnutrition are both highly prevalent and strongly associated with death among hospitalized children who are HIV infected or exposed. Novel programmatic and therapeutic strategies are urgently needed to reduce the high mortality rate among inpatients with HIV infection and HIV exposure in African pediatric hospitals.

Routine inpatient human immunodeficiency virus testing system increases access to pediatric human immunodeficiency virus care in sub-Saharan Africa

BACKGROUND

Routine Human Immunodeficiency Virus (HIV) testing, called provider-initiated opt-out HIV testing and counseling (PITC), is recommended in African countries with high HIV prevalence. However, it is unknown whether PITC increases access to pediatric HIV care. In 2008, the Baylor International Pediatric AIDS Initiative implemented PITC (BIPAI-PITC) at a Malawian hospital. We sought to evaluate the influence of BIPAI-PITC, compared with nonroutine HIV testing (NRT), on pediatric HIV care access.

METHODS

Retrospective data from 7077 pediatric inpatients were collected during sequential 4-month periods of NRT and BIPAI-PITC. In-hospital and 1-year outcomes for 337 HIV-infected and HIV-exposed uninfected inpatients not previously enrolled in HIV care were analyzed to assess the clinical influence of each testing strategy.

RESULTS

During BIPAI-PITC, a greater proportion of all hospitalized children received HIV testing (81.0% vs. 33.3%, P < 0.001), accessed inpatient HIV-trained care (7.5% vs. 2.4%, P < 0.001), enrolled into an outpatient HIV clinic after discharge (3.2% vs. 1.3%, P < 0.001), and initiated antiretroviral therapy (ART) after hospitalization (1.1% vs. 0.6%, P = 0.010) compared with NRT. Additionally, BIPAI-PITC increased the proportion of hospitalized HIV-infected and HIV-exposed uninfected children receiving DNA polymerase chain reaction testing (73.5% vs. 35.2%, P < 0.001), but did not improve outpatient enrollment or ART initiation of identified HIV-infected patients.

CONCLUSIONS

BIPAI-PITC increases access to inpatient and outpatient pediatric HIV care for hospitalized children, including DNA polymerase chain reaction testing and ART. Broader implementation of BIPAI-PITC or similar approaches, along with more pediatric HIV-trained clinicians and improved defaulter-tracking methods, would improve pediatric HIV service utilization globally.

Inadequate coordination of maternal and infant HIV services detrimentally affects early infant diagnosis outcomes in Lilongwe, Malawi

OBJECTIVE

To assess the continuity of care and outcome of pediatric HIV prevention, testing, and treatment services, focusing on early infant diagnosis with DNA polymerase chain reaction (PCR).

DESIGN

A retrospective observational cohort.

METHODS

Maternal HIV antibody, infant HIV DNA PCR test results, and outcome data from HIV-infected infants from the prevention of mother-to-child transmission, early infant diagnosis, and pediatric HIV treatment programs operating in Lilongwe, Malawi, between 2004 and 2008 were collected, merged, and analyzed.

RESULTS

Of the 14,669 pregnant women who tested HIV antibody positive, 7875 infants (53.7%) received HIV DNA PCR testing. One thousand eighty-four infants (13.8%) were HIV infected. Three hundred twenty (29.5%) children enrolled into pediatric HIV care, with 202 (63.1%) at the Baylor Center of Excellence. Among these, antiretroviral therapy was initiated on 110 infants (54.5%) whose median age was 9.1 months (interquartile range, 5.4-13.8) and a median of 2.5 months (interquartile range, 1.4-5.2) after HIV clinic registration. Sixty-nine HIV-infected infants (34.2%) died or were lost by December 2008. Initiation of antiretroviral therapy increased the likelihood of survival 7-fold (odds ratio, 7.1; 95% confidence interval, 3.68 to 13.70).

CONCLUSIONS

Separate programs for maternal and infant HIV prevention and care services demonstrated high attrition rates of HIV-exposed and HIV-infected infants, elevated levels of mother-to-child transmission, late infant diagnosis, delayed pediatric antiretroviral therapy initiation, and high HIV-infected infant mortality. Antiretroviral therapy increased HIV-infected infant survival, emphasizing the urgent need for improved service coordination and strategies that increase access to infant HIV diagnosis, improve patient retention, and reduce antiretroviral therapy initiation delays.

Kaposi sarcoma in South African children

BACKGROUND

The incidence of Kaposi's sarcoma (KS) in sub-Saharan Africa, increased tens of times since the onset of the AIDS epidemic. There is, however, very little literature concerning the clinical features of this disease, its management and outcome in HIV-positive children in Africa. This study describes retrospectively the clinical presentation of the malignancy, its management and outcome, in a series of HIV-positive children.

PATIENTS AND METHODS

Seventy children with KS and HIV infection were admitted consecutively from January 1998 to December 2009 in South African hospitals. Clinical data were extracted from tumor registries and patient records and analyzed.

RESULTS

The average age in this series was 73 months. The males/females ratio was 1.59:1. Skin lesions were present in 36 out of 63 cases (57.14%), followed by lymph node lesions (28 cases, 44.44%). The mean CD4+ lymphocyte count was 440 (SD = 385). The average CD4+ percentage was 12.20% (SD = 9.13). Only 14 patients (20%) were taking combined antiretrovirals at the time of diagnosis; a further 35 were given HIV treatment after diagnosis. Thirty-two patients (45.71%) survived only 4 months on average; 10 were lost to follow-up; and 28 (40%) were alive, with an average follow-up of 16 months. Antiretrovirals improved survival (P = 0.001).

CONCLUSIONS

The often present skin lesions facilitated the diagnosis; lymphadenopathy was less frequently seen than skin lesions. Antiretroviral drugs were associated with higher survival rate. The mortality remains high in spite of antiretrovirals and cytostatics.

A comparison of HIV detection rates using routine opt-out provider-initiated HIV testing and counseling versus a standard of care approach in a rural African setting

BACKGROUND

Routine opt-out provider-initiated HIV testing and counseling (PITC) remains underutilized in sub-Saharan Africa. By selectively targeting clients who either volunteer or have clinical indications of HIV disease, standard approaches to HIV counseling and testing are presumed more cost-efficient than PITC.

METHODS

One thousand two hundred twenty-one patients aged 15– 49 years were seen by 22 practitioners in a mobile clinic in southern Zambia. A random sample of physicians was assigned to administer PITC, whereas the remaining practitioners offered standard non- PITC (ie, voluntary or diagnostic). Questionnaires assessed patient demographics and attitudes toward HIV. HIV detection rates were stratified by referral type, demographics, and HIV-related knowledge and attitudes.

RESULTS

HIV prevalence was 10.6%. Infection rates detected using PITC [11.1%; 95% confidence interval (CI): 8.8% to 13.5%] and standard non-PITC (10.0%; 95% CI: 7.5% to 12.5%) did not significantly differ (odds ratio = 1.01; 95% CI: 0.67 to 1.52; P = 0.95). Patients who did not request testing or demonstrate clinical indicators of HIV did not have significantly higher HIV prevalence than those who did (odds ratio = 0.83; 95% CI: 0.55 to 1.24; P = 0.36). Implementation of PITC was highly acceptable and produced a 3-fold increase in patients tested per practitioner compared with standard non-PITC (114 vs. 34 patients per practitioner, respectively).

CONCLUSIONS

PITC detected a comparable HIV infection rate as a standard non-PITC approach among rural adults seeking primary care services. Widespread implementation of PITC may therefore lead to significantly more cases of HIV detected.

HIV testing for children in resource-limited settings: what are we waiting for?

Scott Kellerman and Shaffiq Essajee argue that the time has come to increase access to HIV testing for children, especially in sub-Saharan Africa.

Lessons learned from family-centred models of treatment for children living with HIV: current approaches and future directions

BACKGROUND

Despite strong global interest in family-centred HIV care models, no reviews exist that detail the current approaches to family-centred care and their impact on the health of children with HIV. A systematic review of family-centred HIV care programmes was conducted in order to describe both programme components and paediatric cohort characteristics.

METHODS

We searched online databases, including PubMed and the International AIDS Society abstract database, using systematic criteria. Data were extracted regarding programme setting, staffing, services available and enrolment methods, as well as cohort demographics and paediatric outcomes.

RESULTS

The search yielded 25 publications and abstracts describing 22 separate cohorts. These contained between 43 and 657 children, and varied widely in terms of staffing, services provided, enrolment methods and cohort demographics. Data on clinical outcomes was limited, but generally positive. Excellent adherence, retention in care, and low mortality and/or loss to follow up were documented.

CONCLUSIONS

The family-centred model of care addresses many needs of infected patients and other household members. Major reported obstacles involved recruiting one or more types of family members into care, early diagnosis and treatment of infected children, preventing mortality during children's first six months of highly active antiretroviral therapy, and staffing and infrastructural limitations. Recommendations include: developing interventions to enrol hard-to-reach populations; identifying high-risk patients at treatment initiation and providing specialized care; and designing and implementing evidence-based care packages. Increased research on family-centred care, and better documentation of interventions and outcomes is also critical.

Introducing a multi-site program for early diagnosis of HIV infection among HIV-exposed infants in Tanzania

Background

In Tanzania, less than a third of HIV infected children estimated to be in need of antiretroviral therapy (ART) are receiving it. In this setting where other infections and malnutrition mimic signs and symptoms of AIDS, early diagnosis of HIV among HIV-exposed infants without specialized virologic testing can be a complex process. We aimed to introduce an Early Infant Diagnosis (EID) pilot program using HIV DNA Polymerase Chain Reaction (PCR) testing with the intent of making EID nationally available based on lessons learned in the first 6 months of implementation.

Methods

In September 2006, a molecular biology laboratory at Bugando Medical Center was established in order to perform HIV DNA PCR testing using Dried Blood Spots (DBS). Ninety- six health workers from 4 health facilities were trained in the identification and care of HIV-exposed infants, HIV testing algorithms and collection of DBS samples. Paper-based tracking systems for monitoring the program that fed into a simple electronic database were introduced at the sites and in the laboratory. Time from birth to first HIV DNA PCR testing and to receipt of test results were assessed using Kaplan-Meier curves.

Results

From October 2006 to March 2007, 510 HIV-exposed infants were identified from the 4 health facilities. Of these, 441(87%) infants had an HIV DNA PCR test at a median age of 4 months (IQR 1 to 8 months) and 75(17%) were PCR positive. Parents/guardians for a total of 242(55%) HIV-exposed infants returned to receive PCR test results, including 51/75 (68%) of those PCR positive, 187/361 (52%) of the PCR negative, and 4/5 (80%) of those with indeterminate PCR results. The median time between blood draw for PCR testing and receipt of test results by the parent or guardian was 5 weeks (range <1 week to 14 weeks) among children who tested PCR positive and 10 weeks (range <1 week to 21 weeks) for those that tested PCR negative.

Conclusions

The EID pilot program successfully introduced systems for identification of HIV-exposed infants. There was a high response as hundreds of HIV-exposed infants were registered and tested in a 6 month period. Challenges included the large proportion of parents not returning for PCR test results. Experience from the pilot phase has informed the national roll-out of the EID program currently underway in Tanzania.

Early versus deferred antiretroviral therapy in children in low-income and middle-income countries

PURPOSE OF REVIEW

We reviewed current literatures on early and deferred initiation of antiretroviral therapy in HIV-infected infants and children in low-income and middle-income countries.

RECENT FINDINGS

Data from children with HIV antiretroviral (Children with HIV Early Antiretroviral Therapy) study showed a significant reduction of 76% in mortality among infants who received antiretroviral therapy within 3 months of their life as opposed to those on deferred therapy. These data led World Health Organization to promptly revise the guideline to recommend initiation of antiretroviral therapy in all HIV-infected infants regardless of clinical or immunological status. The recommendation for older children is differed between guidelines of developed and developing countries. In general, higher CD4 cell count threshold is used for younger children and similar criteria to those used for adults are used once children are above 5 years of age. The randomized study of when to start antiretroviral therapy in children older than 1 year is ongoing.

SUMMARY

The current trend is to move toward early treatment to reduce morbidity and mortality, achieve immune recovery, normal growth, and development. Even though the antiretroviral rollout program has been successful in Asia and Africa, the challenges lie in diagnosing infants in a timely manner and maintaining infrastructure and resources to support life-long treatment.

Task shifting routine inpatient pediatric HIV testing improves program outcomes in urban Malawi: a retrospective observational study

BACKGROUND

This study evaluated two models of routine HIV testing of hospitalized children in a high HIV-prevalence resource-constrained African setting. Both models incorporated "task shifting," or the allocation of tasks to the least-costly, capable health worker.

METHODS AND FINDINGS

Two models were piloted for three months each within the pediatric department of a referral hospital in Lilongwe, Malawi between January 1 and June 30, 2008. Model 1 utilized lay counselors for HIV testing instead of nurses and clinicians. Model 2 further shifted program flow and advocacy responsibilities from counselors to volunteer parents of HIV-infected children, called "patient escorts." A retrospective review of data from 6318 hospitalized children offered HIV testing between January-December 2008 was conducted. The pilot quarters of Model 1 and Model 2 were compared, with Model 2 selected to continue after the pilot period. There was a 2-fold increase in patients offered HIV testing with Model 2 compared with Model 1 (43.1% vs 19.9%, p<0.001). Furthermore, patients in Model 2 were younger (17.3 vs 26.7 months, p<0.001) and tested sooner after admission (1.77 vs 2.44 days, p<0.001). There were no differences in test acceptance or enrollment rates into HIV care, and the program trends continued 6 months after the pilot period. Overall, 10244 HIV antibody tests (4779 maternal; 5465 child) and 453 DNA-PCR tests were completed, with 97.8% accepting testing. 19.6% of all mothers (n = 1112) and 8.5% of all children (n = 525) were HIV-infected. Furthermore, 6.5% of children were HIV-exposed (n = 405). Cumulatively, 72.9% (n = 678) of eligible children were evaluated in the hospital by a HIV-trained clinician, and 68.3% (n = 387) successfully enrolled into outpatient HIV care.

CONCLUSIONS/SIGNIFICANCE

The strategy presented here, task shifting from lay counselors alone to lay counselors and patient escorts, greatly improved program outcomes while only marginally increasing operational costs. The wider implementation of this strategy could accelerate pediatric HIV care access in high-prevalence settings.