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

Differentiated community-based point-of-care early infant diagnosis to improve HIV diagnosis and ART initiation among infants and young children in Zambia: a quasi-experimental cohort study

INTRODUCTION

An estimated 800 000 children (<15 years) globally living with HIV remain undiagnosed. To reach these children with timely HIV testing services during infancy, we implemented a community-based differentiated care model using mobile point-of-care (POC) technology for early infant diagnosis (EID) of HIV, and assessed its effects on EID positivity, antiretroviral therapy (ART) initiation and 3-month retention in care.

METHODS

Between 1 June 2019 and 31 May 2020 at six health facilities in Lusaka, Zambia, we enrolled mother-infant pairs (MIPs) at high risk for vertical transmission of HIV based on missing or late infant EID testing or other maternal risk factors. We offered these MIPs community POC EID testing (post-intervention), and compared their outcomes to historical high-risk controls at the same sites (1 June 2017-31 May 2018; pre-intervention). We used propensity score matched weighting and mixed effects regression modelling to estimate outcome differences pre-intervention and post-intervention, and to identify MIP characteristics predictive of vertical transmission of HIV.

RESULTS

2577 MIPs were included in the analysis: 1763 and 814 high-risk MIPs from the pre-intervention and post-intervention periods, respectively. Infant HIV positivity was significantly higher in the post-intervention (2.2%) vs pre-intervention (1.1%) period (p=0.038), however this difference was attenuated (0.83%, 95% CI: -0.50%, 2.15%) after adjusting for differences in maternal age, maternal antenatal care visits, infant birth month and facility. During the post-intervention period, MIPs where the mother disengaged from care were 12.97 (95% CI: 2.41, 69.98) times as likely to have an infant diagnosed with HIV vs those in which the infant received late EID testing without maternal care disengagement. Among 18 infants diagnosed with HIV by the intervention, 16 (88.9%) initiated same-day ART and all continued ART at 3-month follow-up.

CONCLUSION

Community-based differentiated care employing POC EID technology increased testing positivity in unadjusted analyses, and resulted in high ART initiation and early care retention, suggesting it may be a promising approach for reaching infants and young children living with HIV being missed by current facility-based approaches.

TRIAL REGISTRATION NUMBER

This trial is registered under the following Clinicaltrials.gov Identifier: NCT03133728.

Monitoring and evaluation of HIV screening and testing of hospitalized infants and their mothers

SETTING

Improved HIV monitoring and evaluation (M&E) is urgently needed to help close gaps in inpatient infant provider-initiated testing and counseling (PITC) and pediatric case identification. A revised reporting system was piloted on the Breastfeeding Ward at Hospital Central de Maputo in Maputo, Mozambique.

OBJECTIVE

To demonstrate how a simplified reporting system designed for pediatric inpatient ward registers can be used to easily calculate key PITC indicators, including testing coverage, HIV status, linkage to antiretroviral therapy, maternal testing, and point-of-care nucleic acid testing.

DESIGN

This was a retrospective review of PITC data documented in the ward discharge register for all inpatient infants with charts closed from January 1 to June 30, 2020.

RESULTS

At chart closure, 97.7% of infants (477/488) had known serostatus: 76.3% were not exposed (364/477), 15.3% were exposed (73/477), 1.9% definitively non-infected (9/477), and 6.5% infected (31/477). There was a 26.9% positivity rate (14/52) for infant point-of-care nucleic acid testing. Of all HIV-infected infants, 80.6% (25/31) were linked to antiretroviral therapy by the time of discharge. Preferred maternal testing was done in 80.5% of eligible mothers (276/343), with 3.0% newly positive (8/276).

CONCLUSION

This straightforward PITC reporting system enabled simple calculation of key indicators needed for standard M&E, contributed to quality improvement efforts to increase testing coverage, and could be easily adapted for use in other settings.

Cost-effectiveness of Routine Provider-Initiated Testing and Counseling for Children With Undiagnosed HIV in South Africa

BACKGROUND

We compared the cost-effectiveness of pediatric provider-initiated HIV testing and counseling (PITC) vs no PITC in a range of clinical care settings in South Africa.

METHODS

We used the Cost-Effectiveness of Preventing AIDS Complications Pediatric model to simulate a cohort of children, aged 2-10 years, presenting for care in 4 settings (outpatient, malnutrition, inpatient, tuberculosis clinic) with varying prevalence of undiagnosed HIV (1.0%, 15.0%, 17.5%, 50.0%, respectively). We compared "PITC" (routine testing offered to all patients; 97% acceptance and 71% linkage to care after HIV diagnosis) with no PITC. Model outcomes included life expectancy, lifetime costs, and incremental cost-effectiveness ratios (ICERs) from the health care system perspective and the proportion of children with HIV (CWH) diagnosed, on antiretroviral therapy (ART), and virally suppressed. We assumed a threshold of $3200/year of life saved (YLS) to determine cost-effectiveness. Sensitivity analyses varied the age distribution of children seeking care and costs for PITC, HIV care, and ART.

RESULTS

PITC improved the proportion of CWH diagnosed (45.2% to 83.2%), on ART (40.8% to 80.4%), and virally suppressed (32.6% to 63.7%) at 1 year in all settings. PITC increased life expectancy by 0.1-0.7 years for children seeking care (including those with and without HIV). In all settings, the ICER of PITC vs no PITC was very similar, ranging from $710 to $1240/YLS. PITC remained cost-effective unless undiagnosed HIV prevalence was <0.2%.

CONCLUSIONS

Routine testing improves HIV clinical outcomes and is cost-effective in South Africa if the prevalence of undiagnosed HIV among children exceeds 0.2%. These findings support current recommendations for PITC in outpatient, inpatient, tuberculosis, and malnutrition clinical settings.

Finding Children Living With HIV in Low-prevalence Countries: HIV Prevalence and Testing Yield From 5 Entry Points in Ethiopia

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.

The Etiology of Pneumonia in HIV-infected Zambian Children: Findings From the Pneumonia Etiology Research for Child Health (PERCH) Study

BACKGROUND

Despite recent declines in new pediatric HIV infections and childhood HIV-related deaths, pneumonia remains the leading cause of death in HIV-infected children under 5. We describe the patient population, etiology and outcomes of childhood pneumonia in Zambian HIV-infected children.

METHODS

As one of the 9 sites for the Pneumonia Etiology Research for Child Health study, we enrolled children 1-59 months of age presenting to University Teaching Hospital in Lusaka, Zambia, with World Health Organization-defined severe and very severe pneumonia. Controls frequency-matched on age group and HIV infection status were enrolled from the Lusaka Pediatric HIV Clinics as well as from the surrounding communities. Clinical assessments, chest radiographs (CXR; cases) and microbiologic samples (nasopharyngeal/oropharyngeal swabs, blood, urine, induced sputum) were obtained under highly standardized procedures. Etiology was estimated using Bayesian methods and accounted for imperfect sensitivity and specificity of measurements.

RESULTS

Of the 617 cases and 686 controls enrolled in Zambia over a 24-month period, 103 cases (16.7%) and 85 controls (12.4%) were HIV infected and included in this analysis. Among the HIV-infected cases, 75% were <1 year of age, 35% received prophylactic trimethoprim-sulfamethoxazole, 13.6% received antiretroviral therapy and 36.9% of caregivers reported knowing their children's HIV status at time of enrollment. A total of 35% of cases had very severe pneumonia and 56.3% had infiltrates on CXR. Bacterial pathogens [50.6%, credible interval (CrI): 32.8-67.2], Pneumocystis jirovecii (24.9%, CrI: 15.5-36.2) and Mycobacterium tuberculosis (4.5%, CrI: 1.7-12.1) accounted for over 75% of the etiologic fraction among CXR-positive cases. Streptococcus pneumoniae (19.8%, CrI: 8.6-36.2) was the most common bacterial pathogen, followed by Staphylococcus aureus (12.7%, CrI: 0.0-25.9). Outcomes were poor, with 41 cases (39.8%) dying in hospital.

CONCLUSIONS

HIV-infected children in Zambia with severe and very severe pneumonia have poor outcomes, with continued limited access to care, and the predominant etiologies are bacterial pathogens, P. jirovecii and M. tuberculosis.

Inpatient Point-of-Care HIV Early Infant Diagnosis in Mozambique to Improve Case Identification and Linkage to Antiretroviral Therapy

Introduction of point-of-care early infant diagnosis on the inpatient wards of 2 of the largest pediatric referral hospitals in Mozambique increased HIV testing volume and pediatric HIV case identification with improved linkage to antiretroviral therapy.

Introduction:

Novel approaches to case identification and linkage to antiretroviral therapy (ART) are needed to close gaps in early infant diagnosis (EID) of HIV. Point-of-care (POC) EID is a recent innovation that eliminates the long turnaround times of conventional EID that limit patient management in the inpatient setting. The initial deployment of POC EID in Mozambique focused primarily on outpatient clinics; however, 2 high-volume tier-4 pediatric referral hospitals were also included.

Methods:

To assess the impact of inpatient POC EID, a retrospective review of testing and care data from Hospital Central de Beira (HCB) and Hospital Central de Maputo (HCM) was performed for the period September 2017 to July 2018, with comparison to the 8-month pre-POC period when dried blood spots were used for conventional EID.

Results:

Monthly testing volume increased from 8.5 tests pre-POC to 17.6 tests with POC (P<.001). Among 511 children with POC testing, the median age was 5 months, there was ongoing breastfeeding in 326 (63.8%), and 136 (26.6%) of mothers and 146 (28.6%) of infants had not received ART or antiretroviral prophylaxis, respectively. POC tests were positive in 152 (29.7%) infants, and 52 (37.5%) had a previous negative DNA polymerase chain reaction through the conventional outpatient EID program. Linkage to ART for infants with HIV-positive tests improved 64% during the POC period (P=.002). Inpatient mortality for infected infants during the POC period was 28.2%. Excluding these deaths, 61.2% of eligible infants initiated ART as inpatients, but only 29.8% of those discharged without ART were confirmed to have initiated as outpatients.

Conclusions:

Inpatient wards are a high-yield site for EID and ART initiation that have historically been overlooked in programming for prevention of mother-to-child transmission. POC platforms represent a transformative opportunity to increase inpatient testing, make definitive diagnoses, and improve timely linkage to ART. Scale-up plans should prioritize pediatric wards.

Associations of Sociodemographic and Clinical Factors with Late Presentation for Early Infant HIV Diagnosis (EID) Services in Kenya

BACKGROUND

Understanding the missed opportunities in early infant HIV testing within the PMTCT program is essential to address any gaps. The study set out to describe the clinical and sociodemographic characteristics of the infants presenting late for early infant diagnosis in Kenya.

METHODS

We abstracted routinely collected clinical and sociodemographic characteristics, in a cross-sectional study, on all HIV-infected infants with a positive polymerase chain reaction (PCR) test from 1,346 President's Emergency Plan for AIDS Relief (PEPFAR) supported health facilities for the period October 2016 to September 2018. We used multivariate logistic regression to examine the association of sociodemographic and clinical characteristics with late (>2 months after birth) presentation for infant HIV testing.

RESULTS

Of the 4,011 HIV-infected infants identified, the median infant age at HIV diagnosis was 3 months [interquartile range (IQR), 1-16 months], and two-thirds [2,669 (66.5%)] presented late for infant HIV testing. Factors that were associated with late presentation for infant testing were: maternal ANC non-attendance, adjusted odds ratio (aOR) 1.41 (95% confidence interval (CI) 1.18 -1.69); new maternal HIV diagnosis, aOR 1.45, (95%CI 1.24 -1.7); and lack of maternal antiretroviral therapy(ART), aOR 1.94, (95% CI 1.64 - 2.30). There was a high likelihood of identifying HIV-infected infants among infants who presented for medical services in the outpatient setting (aOR 18.9; 95% CI 10.2 - 34.9) and inpatient setting (aOR 12.2; 95% CI 6.23-23.9) compared to the infants who presented late in maternity.

CONCLUSION AND GLOBAL HEALTH IMPLICATIONS

Gaps in early infant HIV testing suggest the need to increase maternal pre-pregnancy HIV diagnosis, timely antenatal care, early infant diagnosis services, early identification of mothers who seroconvert during pregnancy or breastfeeding and improved HIV screening in outpatient and inpatient settings. Early referral from the community and access to health facilities should be strengthened by the implementation of national PMTCT guidelines.

Improving inpatient provider-initiated HIV testing and counseling in Sierra Leone

Background/setting

Only 47% of HIV-positive Sierra Leoneans knew their status in 2017, making expanded HIV testing a priority. National guidelines endorse provider-initiated HIV testing and counselling (PITC) to increase testing coverage, but PITC is rarely provided in Sierra Leone. In response, a Quality Improvement Collaborative (QIC) was implemented to improve PITC coverage amongst adult inpatients.

Methods

Ten hospitals received the intervention between October 2017 and August 2018; there were no control facilites. Each hospital aimed to improve PITC coverage to ≥ 95% of eligible patients. Staff received training on PITC and QIC methods and a package of PITC best practices and tools. They then worked to identify additional contextually-appropriate interventions, conducted rapid tests of change, and tracked performance using shared indicators and time-series data. Supportive supervision bolstered QI skills, and quarterly meetings enabled diffusion of innovations while spurring friendly competition.

Results

Baseline PITC coverage was 4%. The hospital teams tested diverse interventions using QI methods, including staff training; data review meetings; enhanced workflow processes and supervision; and patient education and sensitization activities Nine hospitals reached and sustained the 95% target, and all saw rapid and durable improvement, which was sustained for a median of six months. Of the 5,238 patients tested for HIV, 311 (6%) were found to be HIV-positive and were referred for treatment. HIV rapid test kit stockouts occurred during the project period, limiting PITC services in some cases.

Conclusions

The intervention led to swift and sustained improvement in inpatient PITC coverage and to the diagnosis of hundreds of people living with HIV. Sierra Leone’s Ministry of Health and Sanitation plans to take the initiative to national scale, with close attention to the issue of test kit stockouts.

[Access to the management of HIV infected children: Overview of the healthcare supply in Cameroon in 2014]

BACKGROUND

In Cameroon in 2012, the proportion (15%) of children eligible for antiretroviral treatment (ART) was one of the lowest among the 21 Global Fund priority countries. The objective of this study was to carry out a situational analysis of the existing care offer for pediatric HIV in Cameroon.

METHODS

A descriptive cross-sectional study was conducted over a 4-month period (April to August 2014) in 12 healthcare facilities in 7 regions of Cameroon selected by systematic sampling. The data were collected in a self-administered questionnaire filled out by the caregiving and administrative personnel included in the study.

RESULTS

All in all, 142 persons in charge of pediatric HIV treatment were included in the study, of whom 115 were working at the operational level: 59 (51.2%) health personnel, 44 (38.3%) community agents and 12 (10.4%) department heads; the other 27 exercised responsibilities at the regional (19) and the local (8) levels. An overwhelming majority of the caregivers involved in pediatric VIH treatment were nurses, a factor necessitating the delegation of medical tasks institutionalized in Cameroon. Few standardized nationwide documents take into account these treatment modalities. Inadequate dissemination of the documents at all levels of the healthcare pyramid may justify the non-compliance with the care protocols that has been observed in the training programs dedicated to the subject.

CONCLUSION

The updating and large-scale dissemination of standardized nationwide documents taking into account the specificities of HIV-infected children are required to improve implementation at the operational level of the Cameroonian healthcare system of the existing guidelines for pediatric HIV 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.

Impact of WHO guidelines on trends in HIV testing and ART initiation among children living with HIV in Zambia

BACKGROUND

About 13 years since the introduction of antiretroviral therapy (ART) for children living with HIV (CLHIV) in Zambia, HIV/AIDS testing and treatment guidelines for children have evolved over the years with limited documentation of long-term trends in the numbers testing HIV positive and initiating ART. We examined trends in HIV testing and ART initiation in Zambia.

METHODS

We conducted a retrospective cohort study using routinely collected patient level data from 496 health facilities across Zambia. We used Poisson regression to derive incident rate ratios and 95% confidence intervals (95% CI) for background characteristics and used a Cuzick non-parametric test for trends to test the 13-year trends. Median time from testing to ART initiation in days and incidence rates were derived using life tables in survival analysis. We used multi-level random effects Poisson regression model to determine variations in time from HIV testing to ART initiation by facility.

RESULTS

Overall, the cumulative proportion of the children who tested positive and initiated antiretroviral therapy (ART for HIV) from 2004 to 2017 was 69% (n = 99 592). During the period under review proportions of ART initiation increased from 52% in 2004-2006 to 97% in 2016-2017 (P < 0.001) and time from testing to ART initiation reduced from a median of 17 days IQR (1-161) in 2004 to one day IQR (1-14), P < 0.001 in 2016-2017. CLHIV were 15 times more likely to be initiated on ART in 2016-17 compared to period 2004-6 (IRR = 15.2, 95% CI 14.7-15.7). Time to ART initiation increased with age and was higher in rural health facilities compared to urban facilities. About 11% of the variability in time to ART initiation in children could be attributed to differences between facilities.

CONCLUSIONS

The substantial increase in ART initiation and reduction in time to ART initiation among CLHIV identified in this study, reflects improvements in the paediatric HIV programme in Zambia in relation to health care delivery and adherence to national testing and treatment guidelines that were adapted from WHO guidelines. However, age-related differentials in rates of ART initiation suggests that urgent interventions are needed to sustain and further improve programme performance.

Survival of Children Living With HIV on Art in Zambia: A 13-Years Retrospective Cohort Analysis

Background: Research conducted before the introduction of anti-retroviral therapy (ART), showed that the majority of children living with HIV (CLHIV) would die before their second birthday. In Zambia, ART was rolled out to the public health system in 2004 with subsequent improved survival in CLHIV. However, the survival rates of CLHIV on ART in Zambia since 2004 have not been extensively documented. We assessed survival experiences and the factors associated with survival in CLHIV on ART in Zambia.

Methods: We conducted a retrospective cohort analysis of CLHIV (aged up to 15 years) using routinely collected data from health facilities across Zambia, over 13 years to ascertain mortality rates. We explored survival factors using Cox regression giving adjusted hazard ratios (AHR) and 95% confidence intervals (95% CI). Nelson Aalen estimates were used to show the cumulative hazards of mortality for different levels of explanatory factors.

Results: A total of 65,448 eligible children, were initiated on ART between 2005 and 2018, of which 33,483 (51%) where female. They contributed a total survival time of 275,715-person years at risk during which 3,265 children died which translated into an incidence rate of 1.1 deaths per 100 person-years during the review period. Mortality rates were highest in children in the first year of life (Mortality rate 2.24; 95% CI = 2.08–2.42) and during the first year on ART (Mortality rate 3.82 95% CI = 3.67–3.98). Over 50% of the children had been on ART for 5–10 years by 2018, and they had the lowest risk of mortality compared to children who had been on ART for <5 years.

Conclusions: Children with HIV in Zambia are surviving much longer than was predicted before ART was introduced 14 years ago. This key finding adds to the literature on analysis of survival in CLHIV in low income settings like Zambia. However, this survival is dependent on the age at which ART is initiated and the time on ART highlighting the need to increase investments in early infant diagnosis (EID) to ensure timely HIV testing and ART initiation for CLHIV.

Implementation of prevention of mother-to-child transmission (PMTCT) in South Africa: outcomes from a population-based birth cohort study in Paarl, Western Cape

OBJECTIVES

The coverage of prevention of mother-to-child transmission (PMTCT) services in South Africa is variable. Identifying gaps in the implementation of these services is necessary to isolate steps needed to further reduce paediatric infections and eliminate transmission.

SETTING

Two primary care clinics in Paarl, South Africa.

PARTICIPANTS

1225 pregnant women; inclusion criteria were 18 years or older, clinic attendance and remaining in area for at least 1 year.

METHODS

Data were collected through the Drakenstein Child Health Study, a population-based birth cohort in a periurban area of the Western Cape, South Africa. A combination of clinic records, hospital records, national database searches and maternal self-report were collected during the study.

RESULTS

Of the 1225 mothers enrolled in the cohort between 2012 and 2015, 260 (21%) were confirmed HIV infected antenatally and 1 mother tested positive in the postnatal period. Of those with documentation (n=250/260, 96%), the majority (99%) received antiretroviral prophylaxis or therapy (ART) before labour; however, there was a high rate of defaulting from ART noted during pregnancy (20%). All HIV-exposed infants with data received antiretroviral prophylaxis, 35% were exclusively breast fed until 6 weeks and 16% for 6 months. There were two cases of infant HIV infection (0.8%) who were initiated on ART but had complicated histories.

CONCLUSION

Despite the low transmission rate in this cohort, reaching elimination will require further work, and this study illustrates several areas to improve implementation of PMTCT services and reduce paediatric infections including retesting at-risk HIV-negative mothers through the duration of breast feeding, infant HIV testing at any admission in addition to routine testing and improved counselling to prevent defaulting from treatment. Better data surveillance systems are essential for determining the implementation of PMTCT guidelines.

Impact of a Comprehensive Adolescent-Focused Case Finding Intervention on Uptake of HIV Testing and Linkage to Care Among Adolescents in Western Kenya

Background:

Low HIV testing uptake prevents identification of adolescents living with HIV and linkage to care and treatment. We implemented an innovative service package at health care facilities to improve HIV testing uptake and linkage to care among adolescents aged 10–19 years in Western Kenya.

Methods:

This quasi-experimental study used preintervention and postintervention data at 139 health care facilities (hospitals, health centers, and dispensaries). The package included health worker capacity building, program performance monitoring tools, adolescent-focused HIV risk screening tool, and adolescent-friendly hours.

The study population was divided into early (10–14 years) and late (15–19 years) age cohorts. Implementation began in July 2016, with preintervention data collected during January–March 2016 and postintervention data collected during January–March 2017. Descriptive statistics were used to analyze the numbers of adolescents tested for HIV, testing HIV-positive, and linked to care services. Preintervention and postintervention demographic and testing data were compared using the Poisson mean test. χ² testing was used to compare the linkage to care rates.

Results:

During the preintervention period, 25,520 adolescents were tested, 198 testing HIV-positive (0.8%) compared with 77,644 adolescents tested with 534 testing HIV-positive (0.7%) during the postintervention period (both P-values <0.001). The proportion of HIV-positive adolescents linked to care increased from 61.6% to 94.0% (P < 0.001). The increase in linkage to care was observed among both age cohorts and within each facility type (both P-values <0.001).

Conclusions:

The adolescent-focused case finding intervention package led to a significant increase in both HIV testing uptake and linkage to care services among adolescents in Western Kenya.

Prevalence and route of transmission of undiagnosed human immunodeficiency virus infection among children using provider-initiated testing and counselling strategy in Ido-Ekiti, Nigeria: a cross-sectional study

INTRODUCTION

Ninety-one percent of global Human Immunodeficiency Virus (HIV) infection in children occurs in sub-Saharan Africa. Provider Initiated Testing and Counselling (PITC) Strategy is a means of reducing missed opportunities for HIV exposed or infected children. The present study determined the prevalence of HIV infection using PITC Strategy among children seen at the Paediatric Emergency Unit of Federal Medical Centre (FMC), Ido-Ekiti, and the possible route of transmission.

METHODS

Cross-sectional study on prevalence of HIV infection using PITC model. 530 new patients whose HIV serostatus were unknown and aged 15 years or below were recruited consecutively and offered HIV testing. Serial algorithm testing for HIV infection using Determine HIV-1/2 and Uni-Gold rapid test kits was adopted. Seropositive patients younger than eighteen months had HIV Deoxyribonucleic Acid Polymerase Chain Reaction (HIV DNA PCR) test for confirmation.

RESULTS

Twenty-four (4.5%) of the 530 patients were confirmed to have HIV infection; of whom 19 (79.2%) were less than 18 months of old; with age range of 5 to 156 months. Fifteen (62.5%) of the infected children were females; likewise, the gender specific infection rate was higher (%) among the females compared with (%) among the males. Two of the HIV infected children's mothers were late, while the remaining 22 mothers (%) were HIV seropositive. Mother-to-child-transmission was the most likely route of transmission in the children.

CONCLUSION

PITC strategy is vital to the early diagnosis and effective control of HIV infection in children. However, this cannot be totally effective if PMTCT is not optimized.

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

Setting

Eleven pediatric wards in Maputo Province, Mozambique.

Objective

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

Design

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

Results

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

Conclusion

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

Predictors of loss to follow-up among children on long-term antiretroviral therapy in Zambia (2003-2015)

Background

Retention in care is critical for children living with HIV taking antiretroviral therapy (ART). Loss to follow-up (LTFU) is high in HIV treatment programs in resource limited settings. We estimated the cumulative incidence of LTFU and identified associated risk factors among children on ART at Livingstone Central Hospital (LCH), Zambia.

Methods

Using a retrospective cohort study design, we abstracted data from medical records of children who received ART between 2003 and 2015. Loss to follow-up was defined as no clinical and pharmacy contact for at least 90 days after the child missed their last scheduled clinical visit. Non-parametric competing risks models were used to estimate the cumulative incidence of death, LTFU and transfer. Cause-specific Cox regression was used to estimate the hazard ratios of the risk factors of LTFU.

Results

A total of 1039 children aged 0–15 years commenced ART at LCH between 2003 and 2015. Median duration of follow-up was 3.8 years (95% CI: 1.2–6.5), median age at ART initiation was 3.6 years (IQR: 1.3–8.6), 179 (17%) started treatment during their first year of life. At least 167 (16%) were LTFU and we traced 151 (90%). Of those we traced, 39 (26%) had died, 71 (47%) defaulted, 20 (13%) continued ART at other clinics and 21 (14%) continued treatment with gaps. The cumulative incidence of LTFU for the entire cohort was 2.7% (95% CI: 1.9–3.9) at 3 months, 4.1% (95% CI: 2.9–5.4) at 6 months and 14.1% (95% CI: 12.4–16.9) after 5 years on ART. Associated risk factors were: 1) non-disclosure of HIV status at baseline, aHR = 1.9 (1.2–2.9), 2) No phone ownership, aHR = 2.1 (1.6–2.9), 3) starting treatment between 2013 to 2015, aHR = 5.6 (2.2–14.1).

Conclusion

Among the children LTFU mortality and default were substantially high. Children who started treatment in recent years (2013–2015) had the highest hazard of LTFU. Lack of access to a phone and non-disclosure of HIV-status to the index child was associated with higher hazards of LTFU. We recommend re-enforcement of client counselling and focused follow-up strategies using modern technology such as mobile phones as adjunct to current approaches.

Care Continuum and Postdischarge Outcomes Among HIV-Infected Adults Admitted to the Hospital in Zambia

Background

We characterized the extent of antiretroviral therapy (ART) experience and postdischarge mortality among hospitalized HIV-infected adults in Zambia.

Methods

At a central hospital with an opt-out HIV testing program, we enrolled HIV-infected adults (18+ years) admitted to internal medicine using a population-based sampling frame. Critically ill patients were excluded. Participants underwent a questionnaire regarding their HIV care history and CD4 count and viral load (VL) testing. We followed participants to 3 months after discharge. We analyzed prior awareness of HIV-positive status, antiretroviral therapy (ART) use, and VL suppression (VS; <1000 copies/mL). Using Cox proportional hazards regression, we assessed risk factors for mortality.

Results

Among 1283 adults, HIV status was available for 1132 (88.2%), and 762 (67.3%) were HIV-positive. In the 239 who enrolled, the median age was 36 years, 59.7% were women, and the median CD4 count was 183 cells/mm³. Active tuberculosis or Cryptococcus coinfection was diagnosed in 82 (34.3%); 93.3% reported prior awareness of HIV status, and 86.2% had ever started ART. In the 64.0% with >6 months on ART, 74.4% had VS. The majority (92.5%) were discharged, and by 3 months, 48 (21.7%) had died. Risk of postdischarge mortality increased with decreasing CD4, and there was a trend toward reduced risk in those treated for active tuberculosis.

Conclusions

Most HIV-related hospitalizations and deaths may now occur among ART-experienced vs -naïve individuals in Zambia. Development and evaluation of inpatient interventions are needed to mitigate the high risk of death in the postdischarge period.

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

Introduction

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

Methods

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

Findings

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

Conclusions

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

Long-term survival outcomes of HIV infected children receiving antiretroviral therapy: an observational study from Zambia (2003-2015)

Background

In 2017, 64% of children living with HIV in Zambia accessed Antiretroviral Therapy (ART). Despite expanded ART coverage, there is paucity of information on effectiveness of pediatric ART in reducing mortality. The aim of this research is to describe treatment outcomes, measure mortality rates and assess predictors of mortality among children receiving ART.

Methods

Using a retrospective cohort study design, we abstracted routinely collected clinical data from medical records of children from birth to 15 years old, who had received ART for at least 6 months at Livingstone Central Hospital in Southern Province Zambia, between January 2003 and June 2015. The primary outcome was death. Cause of death was ascertained from medical records and death certificates. Distribution of survival times according to baseline covariates were estimated using Kaplan Meier and Cox Proportional Hazards methods.

Results

Overall, 1039 children were commenced on ART during the study period. The median age at treatment initiation was 3.6 years (IQR: 1.3–8.6) and 520 (50%) children were female. Of these, 71 (7%) died, 164 (16%) were lost to follow-up, 210 (20%) transferred and 594 (56%) were actively on treatment. After 4450 person years, mortality rate was 1.6/100 (95% CI: 1.4–1.8). Mortality was highest during the first 3 months of treatment (11.7/100 (95% CI: 7.6–16.3). In multivariable proportional hazards regression, the adjusted hazards of death were highest among children aged < 1 year (aHR = 3.1 (95% CI: 1.3–6.4), compared to those aged 6–15 years, WHO stage 4 (aHR =4.8 (95% CI: 2.3–10), compared to WHO stage 1 and 2. In the sensitivity analysis to address bias due to loss to follow-up, mortality increased 5 times when we assumed that all the children who were lost to follow up died within 90 days of their last visit.

Conclusion

We observed low attrition due to mortality among children on ART. Loss to follow-up was high (16%). Mortality was highest during the first 3 months of treatment. Children aged less than one year and those with advanced WHO disease stage had higher mortality. We recommend effective interventions to improve retention in care and early diagnosis of HIV in children.

Electronic supplementary material

The online version of this article (10.1186/s12889-019-6444-7) contains supplementary material, which is available to authorized users.

Feasibility and utility of active case finding of HIV-infected children and adolescents by provider-initiated testing and counselling: evidence from the Laquintinie hospital in Douala, Cameroon

BACKGROUND

Universal HIV testing and treatment of infected children remain challenging in resource-limited settings (RLS), leading to undiagnosed children/adolescents and limited access to pediatric antiretroviral therapy (ART). Our objective was to evaluate the feasibility of active cases finding of HIV-infected children/adolescents by provider-initiated testing and counseling in a health facility.

METHODS

A cross-sectional prospective study was conducted from January through April 2016 at 6 entry-points (inpatient, outpatient, neonatology, immunization/family planning, tuberculosis, day-care units) at the Laquintinie Hospital of Douala (LHD), Cameroon. At each entry-point, following counseling with consenting parents, children/adolescents (0-19 years old) with unknown HIV status were tested using the Rapid Diagnostic Test (RDT) (Determine®) and confirmed with a second RDT (Oraquick®) according to national guidelines. For children less than 18 months, PCR was performed to confirm every positive RDT. Community health workers linked infected participants by accompanying them from the entry-point to the treatment centre for an immediate ART initiation following the « test and treat » strategy. Statistical analysis was performed, with p < 0.05 considered significant.

RESULTS

Out of 3439 children seen at entry-points, 2107 had an unknown HIV status (61.3%) and HIV testing acceptance rate was 99.9% (2104). Their mean age was 2.1 (Sd = 2.96) years, with a sex ratio boy/girl of 6/5. HIV prevalence was 2.1% (44), without a significant difference between boys and girls (p = 0.081). High rates of HIV-infection were found among siblings/descendants (22.2%), TB treatment unit attendees (11.4%) and hospitalized children/adolescents (5.6%); p < 0.001. Up to 95.4% (42/44) of those infected children/adolescents were initiated on ART. Overall, 487 (23.2%) deaths were registered (122 per month) and among them, 7 (15.9%) were HIV-positive; mainly due to tuberculosis and malnutrition.

CONCLUSION

The consistent rate of unknown HIV status among children/adolescents attending health facilities, the high acceptability rates of HIV testing and linkage to ART, underscore the feasibility and utility of an active case finding model, using multiple entry-points at the health facility, in achieving the 90-90-90 targets for paediatric HIV/AIDS in RLS.

Bedside paediatric HIV testing in Malawi: Impact on testing rates

Background

Provider initiated testing and counselling (PITC) is recommended for all inpatients in Malawi if they have not been tested in the previous 3 months. However testing rates remain low among children. We audited the effect of implementing a bedside diagnostic HIV testing service to determine if it would improve testing rates amongst paediatric inpatients.

Methods

We audited the existing HIV testing service to determine the numbers of children being tested for HIV. This was followed by the introduction of a bedside diagnostic service followed by re-audit. Bedside testing was facilitated by health systems strengthening measures including identification of suitable counsellors, appropriate supervision and remuneration.

Results

In the initial audit in March-April 2014, 85 (63%) of 135 children had documented HIV tests.. Following implementation of the bedside HIV testing service, there was a significant increase in the proportion of children whose HIV status was known. On re-audit in July 2015, 110 (94.8%) of 116 children had documented HIV tests (p<0.001). Of those with documented tests, 94.5% had been tested within the last 3-months compared to 61% in 2014. Following the introduction of the service, the proportion of children tested for HIV during admission increased from 31.9% to 68.1% (p<0.001).

Conclusions

Implementation of a bedside testing service at Queen Elizabeth Central Hospital significantly increased HIV testing among paediatric inpatients. This has important implications in establishing earlier treatment, reducing HIV-associated morbidity and mortality.

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

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

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

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

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

Facilitators and barriers for HIV-testing in Zambia: A systematic review of multi-level factors

It was estimated that 1.2 million people live with HIV/AIDS in Zambia by 2015. Zambia has developed and implemented diverse programs to reduce the prevalence in the country. HIV-testing is a critical step in HIV treatment and prevention, especially among all the key populations. However, there is no systematic review so far to demonstrate the trend of HIV-testing studies in Zambia since 1990s or synthesis the key factors that associated with HIV-testing practices in the country. Therefore, this study conducted a systematic review to search all English literature published prior to November 2016 in six electronic databases and retrieved 32 articles that meet our inclusion criteria. The results indicated that higher education was a common facilitator of HIV testing, while misconception of HIV testing and the fear of negative consequences were the major barriers for using the testing services. Other factors, such as demographic characteristics, marital dynamics, partner relationship, and relationship with the health care services, also greatly affects the participants' decision making. The findings indicated that 1) individualized strategies and comprehensive services are needed for diverse key population; 2) capacity building for healthcare providers is critical for effectively implementing the task-shifting strategy; 3) HIV testing services need to adapt to the social context of Zambia where HIV-related stigma and discrimination is still persistent and overwhelming; and 4) family-based education and intervention should involving improving gender equity.

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

BACKGROUND/OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSION AND GLOBAL HEALTH IMPLICATIONS

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

Scaling up Pediatric HIV Testing by Incorporating Provider-Initiated HIV Testing Into all Child Health Services in Hurungwe District, Zimbabwe

BACKGROUND

Practical ways are needed to scale-up pediatric HIV testing in sub-Saharan Africa, where testing is usually limited to HIV-exposed children in maternal and child health clinics.

METHODS

We implemented an enhanced pediatric HIV testing program in 33 health facilities in Zimbabwe by integrating HIV testing into all pediatric health services. We collected individual data on children tested by having health care workers complete a program-specific child health booklet. We compared numbers of children tested before and during the program using routinely collected aggregate program data reported by health facilities.

RESULTS

A total of 12,556 children aged 0-5 years were recorded in child health booklets; 9431 (75.1%) had information on HIV testing, of whom 7326 (77.7%) were tested; 7167 had test results of whom 122 (1.7%) were HIV-infected. Among children seen in outpatient clinics, 82.1% were tested compared with 66.5% tested among children seen in maternal/child health clinics. Of the 122 HIV-infected children identified, 77 (63.1%) could be missed under existing pediatric testing guidelines. The number of HIV-infected children identified during the 6-month program increased by 55% compared with the prior 6-month period (RR = 1.55, 95% CI: 1.22 to 1.96). Factors independently associated with HIV infection included being malnourished (adjusted odds ratio [AOR] = 7.7, 95% CI: 2.1 to 28.6), being exposed to TB (AOR = 8.1, 95% CI: 2.0 to 32.2), and having an HIV-infected mother (AOR = 41.6, 95% CI: 15.9 to 108.8).

CONCLUSIONS

Integrating HIV testing into all pediatric health services is feasible and can assist in identifying HIV-infected children who could be missed in current testing guidelines.

Rapid Diagnostic Testing of Hospitalized Malawian Children Reveals Opportunities for Improved HIV Diagnosis and Treatment

Recent World Health Organization (WHO) guidelines recommend antiretroviral therapy (ART) for all HIV-infected people; previously CD4+ T lymphocyte quantification (CD4 count) or clinical staging determined eligibility for children ≥ 5 years old in low- and middle-income countries. We examined positive predictive value (PPV) of a rapid diagnostic test (RDT) algorithm and ART eligibility for hospitalized children with newly diagnosed HIV infection. We enrolled 363 hospitalized Malawian children age 2 months to 16 years with two serial positive HIV RDT from 2013 to 2015. Children aged ≤ 18 months whose nucleic acid testing was negative or unavailable were later excluded from the analysis (N = 16). If RNA PCR was undetectable, human immunodeficiency virus (HIV) enzyme immunoassay (EIA) and western blot (WB) were performed. Those with negative or discordant EIA and WB were considered HIV negative and excluded from further analysis (N = 6). ART eligibility was assessed using age, CD4 count, and clinical HIV stage. Among 150 patients with HIV RNA PCR results, 15 had undetectable HIV RNA. Of those, EIA and WB were positive in nine patients and negative or discordant in six patients. PPV of serial RDT was 90% versus RNA PCR alone and 96% versus combined RNA PCR, EIA, and WB. Of all patients aged ≥ 5 years, 8.9% were ineligible for ART under previous WHO guidelines. Improved HIV testing algorithms are needed for accurate diagnosis of HIV infection in children as prevalence of pediatric HIV declines. Universal treatment will significantly increase the numbers of older children who qualify for ART.

Community intervention improves knowledge of HIV status of adolescents in Zambia: findings from HPTN 071-PopART for youth study

OBJECTIVE

To determine the uptake of home-based HIV counselling and testing (HCT) in four communities of the HPTN 071 (PopART) trial in Zambia among adolescents aged 15-19 years and explore factors associated with HCT uptake.

DESIGN

The PopART for youth study is a three-arm community-randomized trial in 12 communities in Zambia and nine communities in South Africa which aims to evaluate the acceptability and uptake of a HIV prevention package, including universal HIV testing and treatment, among young people. The study is nested within the HPTN 071 (PopART) trial.

METHODS

Using a door-to-door approach that includes systematically revisiting households, all adolescents enumerated were offered participation in the intervention and verbal consent was obtained. Data were analysed from October 2015 to September 2016.

RESULTS

Among 15 456 enumerated adolescents, 11 175 (72.3%) accepted the intervention. HCT uptake was 80.6% (8707/10 809) and was similar by sex. Adolescents that knew their HIV-positive status increased almost three-fold, from 75 to 210. Following visits from community HIV care providers, knowledge of HIV status increased from 27.6% (3007/10 884) to 88.5% (9636/10 884). HCT uptake was associated with community, age, duration since previous HIV test; other household members accepting HCT, having an HIV-positive household member, circumcision, and being symptomatic for STIs.

CONCLUSION

Through a home-based approach of offering a combination HIV prevention package, the proportion of adolescents who knew their HIV status increased from ∼28 to 89% among those that accepted the intervention. Delivering a community-level door-to-door combination, HIV prevention package is acceptable to many adolescents and can be effective if done in combination with targeted testing.

Underutilisation of routinely collected data in the HIV programme in Zambia: a review of quantitatively analysed peer-reviewed articles

Background

The extent to which routinely collected HIV data from Zambia has been used in peer-reviewed published articles remains unexplored. This paper is an analysis of peer-reviewed articles that utilised routinely collected HIV data from Zambia within six programme areas from 2004 to 2014.

Methods

Articles on HIV, published in English, listed in the Directory of open access journals, African Journals Online, Google scholar, and PubMed were reviewed. Only articles from peer-reviewed journals, that utilised routinely collected data and included quantitative data analysis methods were included. Multi-country studies involving Zambia and another country, where the specific results for Zambia were not reported, as well as clinical trials and intervention studies that did not take place under routine care conditions were excluded, although community trials which referred patients to the routine clinics were included. Independent extraction was conducted using a predesigned data collection form. Pooled analysis was not possible due to diversity in topics reviewed.

Results

A total of 69 articles were extracted for review. Of these, 7 were excluded. From the 62 articles reviewed, 39 focused on HIV treatment and retention in care, 15 addressed prevention of mother-to-child transmission, 4 assessed social behavioural change, and 4 reported on voluntary counselling and testing. In our search, no articles were found on condom programming or voluntary male medical circumcision. The most common outcome measures reported were CD4+ count, clinical failure or mortality. The population analysed was children in 13 articles, women in 16 articles, and both adult men and women in 33 articles.

Conclusion

During the 10 year period of review, only 62 articles were published analysing routinely collected HIV data in Zambia. Serious consideration needs to be made to maximise the utility of routinely collected data, and to benefit from the funds and efforts to collect these data. This could be achieved with government support of operational research and publication of findings based on routinely collected Zambian HIV data.

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

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Integration of HIV Testing into Maternal, Newborn, and Child Health Weeks for Improved Case Finding and Linkage to Prevention of Mother-to-Child Transmission Services in Benue State, Nigeria

Background

In Nigeria, maternal, newborn, and child health (MNCH) weeks are campaign-like events designed to accelerate progress toward Millennium Development Goals. The authors examined whether integrating HIV testing into MNCH weeks was feasible and could lead to increased case finding and linkage to prevention of mother-to-child transmission (PMTCT) services.

Methods

Pregnant women attending MNCH week during the first week of December 2014 in 13 local government areas in Benue State were provided with HIV tests and referrals to PMTCT services. Demographic, past antenatal care (ANC), and HIV testing information were collected using a structured questionnaire. We used routine ANC/PMTCT data from national electronic system (DHIS-2) to compare with the results obtained from MNCH week.

Results

A total of 50,271 pregnant women with a median age of 25 years (IQR: 21–29) were offered HIV testing. About 50,253 (99.96%) agreed to get HIV testing, with 1,063 (2.1%) testing positive. Six hundred forty-four (60.6%) of those with positive results were linked to PMTCT. In multivariate analysis, marital status, gestation age, and those with no ANC visit during this pregnancy were associated with a positive HIV test. Approximately 30% (50,253 versus 39,080) more pregnant women received HIV testing in MNCH week compared to those who received HIV testing in routine ANC services in 2013. Of the 50,253 who accepted testing, 15,611 (31.1%) did not attend ANC during this pregnancy, of which 9,615 (61.6%) had not had any previous HIV tests. Four hundred forty-two (4.6%) of these 9,615 tested HIV-positive.

Conclusion

Integration of HIV testing into MNCH weeks is feasible and improved uptake of HIV testing and linkage to care. However, the rate of HIV positivity was lower than that reported by previous studies. The findings indicate that MNCH weeks provides opportunity to reach those who do not attend ANC services for HIV care.

Assessment of provider-initiated HIV screening in Nigeria with sub-Saharan African comparison

BACKGROUND

Despite Nigeria's high HIV prevalence, voluntary testing and counselling rates remain low. UNAIDS/WHO/CDC recommends provider-initiated testing and counselling (PITC) for HIV in settings with high HIV prevalence. We aimed to assess the acceptability and logistical feasibility of the PITC strategy among adolescents and adults in a secondary health care centre in Idekpa Benue state, Nigeria.

METHOD

All patients (aged ≥ 13 years) who visited the out-patient department and antenatal care unit of General Hospital Idekpa, Benue state, Nigeria were offered PITC for HIV. The intervention was implemented by trained health professionals for the period spanning (June to December 2010).

RESULTS

Among the 212 patients who were offered PITC for HIV, 199 (94%) accepted HIV testing, 10 patients (4.7%) opted out and 3 patients (1.4%) were undecided. Of the 199 participants who were tested for HIV, 9% were HIV seropositive. The PITC strategy was highly acceptable and feasible, and increased the number of patients who tested for HIV by 5% compared to voluntary counselling and testing. Findings from this assessment were consistent with those from other sub-Saharan African countries (such as Uganda and South Africa).

CONCLUSION

PITC for HIV was highly acceptable and logistically feasible, and resulted in an increased rate of HIV testing among patients. Public health initiatives (such as the PITC strategy) that facilitate early detection of HIV and referral for early treatment should be encouraged for broader HIV control and prevention in Nigerian communities.

A clinical guidance tool to improve the care of children hospitalized with severe pneumonia in Lusaka, Zambia

Background

Pneumonia is the leading infectious cause of death among children, with approximately half of deaths attributable to pneumonia occurring in limited health resource settings of sub-Saharan Africa. Clinical guidance tools and checklists have been used to improve health outcomes and standardize care. This study was conducted to evaluate the impact of a clinical guidance tool designed to improve outcomes for children hospitalized with severe pneumonia in Zambia.

Methods

This study was conducted at University Teaching Hospital in Lusaka, Zambia from October 10, 2011 to March 21, 2014 among children 1 month to 5 years of age with severe pneumonia. In March 2013, a clinical guidance tool was implemented to standardize and improve care. In-hospital mortality pre-and post-implementation was compared.

Results

Four hundred forty-three children were enrolled in the pre-intervention period and 250 in the post-intervention period. Overall, 18.2 % of children died during hospitalization, with 44 % of deaths occurring within the first 24 h after admission. Mortality was associated with HIV infection status, pneumonia severity, and weight-for-height z-score. Despite improving and standardizing the care received, the clinical guidance tool did not significantly reduce mortality (relative risk: 0.89; 95 % CI: 0.65, 1.23). The tool appeared to be more effective among HIV-exposed but uninfected children and children younger than 6 months of age.

Conclusions

Simple tools are needed to ensure that children hospitalized with pneumonia receive the best possible care in accordance with recommended guidelines. The clinical guidance tool was well-accepted and easy to use and succeeded in standardizing and improving care. Further research is needed to determine if similar interventions can improve treatment outcomes and should be implemented on a larger scale.

Electronic supplementary material

The online version of this article (doi:10.1186/s12887-016-0665-z) contains supplementary material, which is available to authorized users.

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

BACKGROUND

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

METHODS

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

FINDINGS

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

INTERPRETATION

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

FUNDING

None.

Implementation and Operational Research: The Effectiveness of Routine Opt-Out HIV Testing for Children in Harare, Zimbabwe

HIV testing is the entry point to access HIV care. For HIV-infected children who survive infancy undiagnosed, diagnosis usually occurs on presentation to health care services. We investigated the effectiveness of routine opt-out HIV testing (ROOT) compared with conventional opt-in provider-initiated testing and counseling (PITC) for children attending primary care clinics.

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

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

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

INTRODUCTION

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

DISCUSSION

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

CONCLUSIONS

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

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

INTRODUCTION

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

DISCUSSION

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

CONCLUSIONS

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

Enhancing Maternal and Child Health using a Combined Mother & Child Health Booklet in Kenya

Under Kenyan guidelines, HIV-exposed infants should be tested for HIV DNA at 6 weeks or at first clinical contact thereafter, as infants come for immunization. Following the introduction of early infant diagnoses programmes, however, many infants were not being tested and linked to care and treatment. We developed the Mother & Child Health Booklet to help relate mothers' obstetrical history to infants' healthcare providers to facilitate follow-up and timely management. The booklet contains information on the mother's pregnancy, delivery and postpartum course and her child's growth and development, immunization, nutrition and other data need to monitor the child to 5 years of age. It replaced three separate record clinical cards. In a 1 year pilot evaluation of the booklet in Nyanza province in 2007-08, the number of HIV DNA tests on infants increased by 34% from 9966 to 13 379. The booklet was subsequently distributed nationwide in 2009. Overall, the numbers of infants tested for HIV DNA rose from 27 000 in 2007 to 60 000 in 2012, which represents approximately 60% of the estimated HIV-exposed infants in Kenya. We believe that the booklet is an important strategy for identifying and treating infected infants and, thus, in progress toward Millennium Development Goal 4.

Uptake and yield of HIV testing and counselling among children and adolescents in sub-Saharan Africa: a systematic review

INTRODUCTION

In recent years children and adolescents have emerged as a priority for HIV prevention and care services. We conducted a systematic review to investigate the acceptability, yield and prevalence of HIV testing and counselling (HTC) strategies in children and adolescents (5 to 19 years) in sub-Saharan Africa.

METHODS

An electronic search was conducted in MEDLINE, EMBASE, Global Health and conference abstract databases. Studies reporting on HTC acceptability, yield and prevalence and published between January 2004 and September 2014 were included. Pooled proportions for these three outcomes were estimated using a random effects model. A quality assessment was conducted on included studies.

RESULTS AND DISCUSSION

A total of 16,380 potential citations were identified, of which 21 studies (23 entries) were included. Most studies were conducted in Kenya (n=5) and Uganda (n=5) and judged to provide moderate (n=15) to low quality (n=7) evidence, with data not disaggregated by age. Seven studies reported on provider-initiated testing and counselling (PITC), with the remainder reporting on family-centred (n=5), home-based (n=5), outreach (n=5) and school-linked HTC among primary schoolchildren (n=1). PITC among inpatients had the highest acceptability (86.3%; 95% confidence interval [CI]: 65.5 to 100%), yield (12.2%; 95% CI: 6.1 to 18.3%) and prevalence (15.4%; 95% CI: 5.0 to 25.7%). Family-centred HTC had lower acceptance compared to home-based HTC (51.7%; 95% CI: 10.4 to 92.9% vs. 84.9%; 95% CI: 74.4 to 95.4%) yet higher prevalence (8.4%; 95% CI: 3.4 to 13.5% vs. 3.0%; 95% CI: 1.0 to 4.9%). School-linked HTC showed poor acceptance and low prevalence.

CONCLUSIONS

While PITC may have high test acceptability priority should be given to evaluating strategies beyond healthcare settings (e.g. home-based HTC among families) to identify individuals earlier in their disease progression. Data on linkage to care and cost-effectiveness of HTC strategies are needed to strengthen policies.

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

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

Implementation and Operational Research: Implementation of Routine Counselor-Initiated Opt-Out HIV Testing on the Adult Medical Ward at Kamuzu Central Hospital, Lilongwe, Malawi

The optimal approach of provider-initiated HIV testing and counseling (PITC) for inpatients in high-burden settings is unknown. We prospectively evaluated the implementation of task shifting from clinician-referral to counselor-initiated PITC on the medical wards of Kamuzu Central Hospital, Malawi. Most of patients (1905/3154, 60.4%) had an unknown admission HIV status. Counselors offered testing to 66.6% (1268/1905). HIV prevalence was 39.3%. Counselor-initiated PITC significantly increased HIV testing by 79% (643/2957 vs. 1228/3154), resulting in an almost 2-fold increase in patients with known HIV status (2447/3154 vs. 1249/3154) (both P < 0.0001), with 18.4% of those tested receiving a new diagnosis of HIV.

Effects of Antiretroviral Therapy on Kaposi's Sarcoma-Associated Herpesvirus (KSHV) Transmission Among HIV-Infected Zambian Children

BACKGROUND

The risk of Kaposi's sarcoma-associated herpesvirus (KSHV) acquisition among children is increased by HIV infection. Antiretroviral therapy (ART) was recently made widely available to HIV-infected children in Zambia. However, the impact of early ART on KSHV transmission to HIV-infected children is unknown.

METHODS

We enrolled and followed a cohort of 287 HIV-exposed, KSHV-negative children under 12 months of age from Lusaka, Zambia, to identify KSHV seroconversion events. Potential factors associated with KSHV infection-with an emphasis on HIV, ART, and immunological measures-were assessed through structured questionnaires and blood analyses. Incidence rate, Kaplan-Meier, and multivariable Cox regression models were used to assess differences in time to event (KSHV seroconversion) between groups. All statistical tests were two-sided.

RESULTS

During follow-up, 151 (52.6%) children underwent KSHV seroconversion. Based on 3552 months of follow-up, we observed similar KSHV incidence rates between HIV-infected and uninfected children. Among HIV-infected children, ART-naïve children had statistically significantly increased risk of KSHV acquisition (adjusted hazard ratio [AHR] = 5.04, 95% confidence interval [CI] = 2.36 to 10.80, P < .001). Time-updated CD4(+) T-cell percentage was also statistically significantly associated with risk of KSHV acquisition (AHR = 0.82, 95% CI = 0.74 to 0.92, P < .001), such that each 5% increase of CD4(+) T-cells represented an 18% decrease in risk of acquiring KSHV.

CONCLUSIONS

Our data suggest that early ART and prevention of immune suppression reduce the risk of KSHV acquisition among HIV-infected children in an area where both viruses are highly endemic. This study highlights the importance of programs in Africa to provide children with ART immediately after HIV infection is diagnosed.

Spatial clustering of measles cases during endemic (1998-2002) and epidemic (2010) periods in Lusaka, Zambia

BACKGROUND

Measles cases may cluster in densely populated urban centers in sub-Saharan Africa as susceptible individuals share spatially dependent risk factors and may cluster among human immunodeficiency virus (HIV)-infected children despite high vaccination coverage.

METHODS

Children hospitalized with measles at the University Teaching Hospital (UTH) in Lusaka, Zambia were enrolled in the study. The township of residence was recorded on the questionnaire and mapped; SaTScan software was used for cluster detection. A spatial-temporal scan statistic was used to investigate clustering of measles in children hospitalized during an endemic period (1998 to 2002) and during the 2010 measles outbreak in Lusaka, Zambia.

RESULTS

Three sequential and spatially contiguous clusters of measles cases were identified during the 2010 outbreak but no clustering among HIV-infected children was identified. In contrast, a space-time cluster among HIV-infected children was identified during the endemic period. This cluster occurred prior to the introduction of intensive measles control efforts and during a period between seasonal peaks in measles incidence.

CONCLUSIONS

Prediction and early identification of spatial clusters of measles will be critical to achieving measles elimination. HIV infection may contribute to spatial clustering of measles cases in some epidemiological settings.

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

Background

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

Methods

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

Results

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

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

Conclusions

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

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

BACKGROUND

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

OBJECTIVE

To determine the evidence on the outcomes of such integration.

METHODS

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

RESULTS

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

DISCUSSION

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