An overview of recent evidence on barriers and facilitators to HIV testing

Country uptake of WHO recommendations on differentiated HIV testing services approaches: a global policy review

OBJECTIVES

In 2015 and 2016, WHO issued guidelines on HIV testing services (HTS) highlighting recommendations for a strategic mix of differentiated HTS approaches. The policy review examines the uptake of differentiated HTS approaches recommendations in national policies.

METHODS

Data were extracted from national policies published between January 2015 and June 2019. The WHO-recommended HTS approaches included facility-based testing, community-based testing, HIV self-testing and provider-assisted referral (or assisted partner notification). Other supportive recommendations include pre-test information, post-test counselling, lay provider testing and rapid testing. Descriptive analyses were conducted to examine inclusion of recommendations in national policies.

RESULTS

Of 194 countries worldwide, 65 published policies were identified; 24 WHO Africa region (AFR) countries (51%, 24/47), 21 WHO European region (EUR) (40%, 21/53), 6 WHO Eastern Mediterranean region (EMR) (29%, 6/21), 5 Pan-American region (AMR) (14%, 5/35), 5 Western Pacific Region (WPR) (19%, 5/27) and 4 WHO South East Asia Region (SEAR) (36%, 4/11). Only five countries included all recommendations. 63 included a minimum of one. 85% (n=55) included facility-based testing for pregnant women, 75% (n=49) facility-based testing for key populations, 74% (n=48) community-based testing for key populations, 69% (n=45) rapid testing, 57% (n=37) post-test counselling, 45% (n=29) lay provider testing, 38% (n=25) HIV self-testing, 29% (n=19) pre-test information and 25% (n=16) provider-assisted referral. The proportion in each region that included at least one recommendation were: 100% AFR (24/47), 100% EMR (6/6), 100% AMR (5/5), 100% WPR (5/5), 100% SEAR (4/4) and 95% EUR (20/21). AFR followed by EMR included the highest number of reccomendations.

CONCLUSION

There was substantial variability in the uptake of the WHO-differentiated HTS recommendations. Those in EMR included the most WHO-differentiated HTS recommendation followed by AFR. Countries within AMR included the least number of recommendations. Ongoing advocacy and efforts are needed to support the uptake of the WHO-differentiated HTS recommendations in country policies as well as their implementation.

HIV Late Presenters in Asia: Management and Public Health Challenges

Many individuals are diagnosed with human immunodeficiency virus (HIV) infection at an advanced stage of illness and are considered late presenters. We define late presentation as a CD4 cell count below 350 cells/mm³ at the time of HIV diagnosis, or presenting with an AIDS-defining illness regardless of CD4 count. Across Asia, an estimated 34-72% of people diagnosed with HIV are late presenters. HIV late presenters generally have a higher disease burden and higher comorbidity such as opportunistic infections than those who are diagnosed earlier. They also have a higher mortality rate and generally exhibit poorer immune recovery following combined antiretroviral therapy (cART). As such, late HIV presentation leads to increased resource burden and costs to healthcare systems. HIV late presentation also poses an increased risk of community transmission since the transmission rate from people unaware of their HIV status is approximately 3.5 times higher than that of early presenters. There are several factors which contribute to HIV late presentation. Fear of stigmatisation and discrimination are significant barriers to both testing and accessing treatment. A lack of perceived risk and a lack of knowledge by individuals also contribute to late presentation. Lack of referral for testing by healthcare providers is another identified barrier in China and may extend to other regions across Asia. Effective strategies are still needed to reduce the incidence of late presentation across Asia. Key areas of focus should be increasing community awareness of the risk of HIV, reducing stigma and discrimination in testing, and educating healthcare professionals on the need for early testing and on the most effective ways to engage with people living with HIV. Recent initiatives such as intensified patient adherence support programs and HIV self-testing also have the potential to improve access to testing and reduce late diagnosis.

Dispositifs de dépistage des infections sexuellement transmissibles à domicile : quelle prise en compte des populations LGBT ?

INTRODUCTION

Every days, more than one million people are infected with a sexually transmitted infection worlwide. In France, screening mainly rely on medical laboratories, private or public, with e prescription. Those tests face structural ans social barriers for LGBT people that could be partially lifted using at home self sampling. Using a narrative review, we will study how the needs of those populations are adressed in existing at home self sampling interventions.

PURPOSE OF RESEARCH

Describe the adaptation of home sampling system to MSM, WSW and transgender peoples.

RESULTS

Nine interventions met our inclusion criteria, eight in English spoken countries. Studies did not systematically reported data on sexual orientation. Transgender people, when identified, were rarely a larger group enough to be the subject of sub-analysis. Infections tested were CT and NG for three intervention, HIV only for one, CT,NG and HIV for five, and one also add HCV.

CONCLUSIONS

Standing as a complement to physical testing services, at home self-sampling intervention could benefit from an advertisement to WSW and from the integration of wider sexual health services.

Suboptimal Follow-Up on HIV Test Results among Young Men Who Have Sex with Men: A Community-Based Study in Two U.S. Cities

Frequent HIV testing and knowledge of HIV serostatus is the premise before timely access to HIV prevention and treatment services, but a portion of young men who have sex with men (YMSM) do not always follow up on their HIV test results after HIV testing, which is detrimental to the implementation of HIV prevention and care among this subgroup. The comprehensive evaluation of factors associated with inconsistent follow-up on HIV test results may inform relevant interventions to address this critical issue among YMSM. To this end, we conducted a cross-sectional study in Nashville, Tennessee and Buffalo, New York from May 2019 to May 2020 to assess demographic, behavioral, and psychosocial correlates of inconsistent follow-up on HIV test results among YMSM. Of the 347 participants, 27.1% (n = 94) reported inconsistent follow-up on their HIV test results. Multivariable logistic regression showed that inconsistent follow-up on HIV test results was positively associated with condomless receptive anal sex, group sex, recreational drug use before or during sex, internalized homophobia, and stress; while negatively associated with housing stability, social support, and general resilience. Future HIV prevention intervention efforts should target these modifiable determinants to enhance the follow-up on HIV test results among YMSM.

Informed consent for HIV screening in the emergency departments and human rights in patient care: seeking the right balance

HIV exceptionalism refers to the fact that the illness is so different from other diseases that testing needs a special approach to informed consent. HIV infected people often visit health clinics, especially emergency departments, years before receiving a diagnosis without being tested for HIV. There is considerable public interest in increasing HIV testing in emergency departments. However, because these departments are sensitive environments that primarily provide urgent and emergency care, a number of ethical questions have been raised about the appropriateness of these settings for the implementation of universal screening programs. Human rights in patient care therefore constitutes an essential theoretical framework for analyzing ethical and legal dilemmas that arise in clinical encounters, thus strengthening the application of human rights principles to the context of patient care.

Implementing community-based Dried Blood Spot (DBS) testing for HIV and hepatitis C: a qualitative analysis of key facilitators and ongoing challenges

Background

In 2018, the Community-Based Research Centre (CBRC) invited gay, bisexual, trans, queer men and Two-Spirit and non-binary people (GBT2Q) at Pride Festivals across Canada to complete in-person Sex Now surveys and provide optional dried blood spot (DBS) samples screening for human immunodeficiency virus (HIV) and hepatitis C virus (HCV). As there is a lack of research evaluating the implementation of DBS sampling for GBT2Q in community settings, we aimed to evaluate this intervention, identifying key facilitators and ongoing challenges to implementing community-based DBS screening for HIV/HCV among GBT2Q.

Methods

We conducted sixteen one-on-one interviews with individuals involved with the community-based DBS collection protocol, including research staff, site coordinators, and volunteer DBS collectors. Most individuals involved with DBS collection were “peers” (GBT2Q-identified). The Consolidated Framework for Implementation Research (CFIR) guided our data collection and analysis.

Results

Interviewees felt that DBS collection was a low-barrier, cost-effective, and simple way for peers to quickly screen a large number of Sex Now respondents. Interviewees also noted that the community and peer-based aspects of the research helped drive recruitment of Sex Now respondents. Most interviewees felt that the provision of results took too long, and that some Sex Now respondents would have preferred to receive their test results immediately (e.g., rapid or point-of-care testing).

Conclusion

Peer-based DBS sampling can be an effective and relatively simple way to screen GBT2Q at Pride Festivals for more than one sexually transmitted and blood borne infection.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-022-13525-x.

Informed consent for HIV screening in the emergency departments and human rights in patient care: seeking the right balance

Abstract HIV exceptionalism refers to the fact that the illness is so different from other diseases that testing needs a special approach to informed consent. HIV infected people often visit health clinics, especially emergency departments, years before receiving a diagnosis without being tested for HIV. There is considerable public interest in increasing HIV testing in emergency departments. However, because these departments are sensitive environments that primarily provide urgent and emergency care, a number of ethical questions have been raised about the appropriateness of these settings for the implementation of universal screening programs. Human rights in patient care therefore constitutes an essential theoretical framework for analyzing ethical and legal dilemmas that arise in clinical encounters, thus strengthening the application of human rights principles to the context of patient care.

Automated STI/HIV risk assessments: Testing an online clinical algorithm in Ottawa, Canada

Despite the ongoing transmission of sexually transmitted infections (STIs) and HIV, many people became unable to access testing due to COVID-19. To address this, we created a mail-out HIV self-test kit, which could be delivered without restrictions in our region. The uptake and feedback from this project made us realize that comprehensive STI testing was being sought. To ensure testing occurred correctly-that is, it would be targeted at the persons most affected by STIs/HIV-we automated clinical decision-making. We built this model based on a 2-by-2 matrix that plots the risk of STI/HIV transmission and risk of STI/HIV exposure. The intercept of these two measures classifies a person as low, medium, or high risk. After automating this logic, 16 expert clinicians in STI/HIV care tested this system with over 400 test patient cases and refined the algorithm until it yielded the exact outcomes that these clinicians would offer patients based on guidelines. Findings of interest are that the scale of the y-axis is exponential, in that risk factors for exposure do not climb cumulatively but do so according to a quadratic equation. This helps ensure that testing services are targeted at those who are most inequitably burdened by these infections.

Perceived Stigma as a Contextual Barrier to Early Uptake of HIV Testing, Treatment Initiation, and Disclosure; the Case of Patients Admitted with AIDS-Related Illness in a Rural Hospital in South Africa

We explored the extent to which perceived HIV-related stigma influences the disclosure and concealment of HIV status to family among adult patients hospitalised for AIDS-related illness, and described reports of negative responses and enacted stigma following disclosure. We conducted interviews with a purposeful sample of 28 adult patients in a rural South African hospital. Data analysis was deductive and inductive and followed the thematic approach. We found evidence of delayed HIV diagnosis and initiation of treatment. There was delayed and selective disclosure as well as concealment of the HIV-positive status. The disclosure was delayed for months or even years. During that time, there was active concealment of the HIV status to avoid stigma from family, friends, and community. When disclosure occurred, there was selective disclosure to close family members who would keep the secret and respond favorably. Although the participants disclosed mostly to close family, some of their post-disclosure experiences included incidents of enacted stigma and discrimination. The fear of perceived stigma and self-stigma influenced the active concealment of their HIV status from others. Continuous concealment of one's HIV status and delayed disclosure limit the opportunities for support and care. There is a need to take into consideration the interaction between HIV-related stigma and disclosure to develop disclosure-counselling strategies in primary health care settings.

Understanding barriers and facilitators to HIV testing in Canada from 2009-2019: A systematic mixed studies review

BACKGROUND

HIV testing is a core pillar of Canada's approach to sexually transmitted and blood-borne infection (STBBI) prevention and treatment and is critical to achieving the first Joint United Nations Programme on HIV/AIDS (UNAIDS) 90-90-90 target. Despite progress toward this goal, many Canadians remain unaware of their status and testing varies across populations and jurisdictions. An understanding of drivers of HIV testing is essential to improve access to HIV testing and reach the undiagnosed.

OBJECTIVE

To examine current barriers and facilitators of HIV testing across key populations and jurisdictions in Canada.

METHODS

A systematic mixed studies review of peer-reviewed and grey literature was conducted identifying quantitative and qualitative studies of barriers and facilitators to HIV testing in Canada published from 2009 to 2019. Studies were screened for inclusion and identified barriers and facilitators were extracted. The quality of included studies was assessed and results were summarized.

RESULTS

Forty-three relevant studies were identified. Common barriers emerge across key populations and jurisdictions, including difficulties accessing testing services, fear and stigma surrounding HIV, low risk perception, insufficient patient confidentiality and lack of resources for testing. Innovative practices that could facilitate HIV testing were identified, such as new testing settings (dental care, pharmacies, mobile units, emergency departments), new modalities (oral testing, peer counselling) and personalized sex/gender and age-based interventions and approaches. Key populations also face unique sociocultural, structural and legislative barriers to HIV testing. Many studies identified the need to offer a broad range of testing options and integrate testing within routine healthcare practices.

CONCLUSION

Efforts to improve access to HIV testing should consider barriers and facilitators at the level of the individual, healthcare provider and policy and should focus on the accessibility, inclusivity, convenience and confidentiality of testing services. In addition, testing services must be adapted to the unique needs and contexts of key populations.

Respect women, promote health and reduce stigma: ethical arguments for universal hepatitis C screening in pregnancy

In the USA, there are missed opportunities to diagnose hepatitis C virus (HCV) in pregnancy because screening is currently risk-stratified and thus primarily limited to individuals who disclose history of injection drug use or sexually transmitted infection risks. Over the past decade, the opioid epidemic has dramatically increased incidence of HCV and a feasible, well-tolerated cure was introduced. Considering these developments, recent evidence suggests universal HCV screening in pregnancy would be cost-effective and several professional organisations have called for updated national policy. Historically, universal screening has been financially disincentivised on the healthcare system level, particularly since new diagnoses may generate an obligation to provide expensive treatments to a population largely reliant on public health resources. Here, we provide ethical arguments supporting universal HCV screening in pregnancy grounded in obligations to respect for persons, beneficence and justice. First, universal prenatal HCV screening respects pregnant women as persons by promoting their long-term health outside of pregnancy. Additionally, universal screening would optimise health outcomes within current treatment guidelines and may support research on treatment during pregnancy. Finally, universal screening would avoid potential harms of risk-stratifying pregnant women by highly stigmatised substance use and sexual behaviours.

Expanding access to HIV testing through Canadian community pharmacies: findings from the APPROACH study

Background

There is a need for acceptable and feasible HIV testing options to ensure people living with HIV know their status so they can access care. Pharmacist-provided HIV point-of-care testing (POCT) may overcome testing barriers, including privacy concerns, testing wait times, and improve accessibility. In the APPROACH study, we aimed to develop and assess an HIV POCT program in community pharmacies for future scale up and evaluation. This paper describes the program uptake, participant and pharmacist experiences, and implementation factors.

Methods

A pharmacist-provided HIV POCT program was offered in 4 pharmacies in two Canadian provinces. A mixed methods design incorporated self-report questionnaire data, participant telephone interviews, pharmacist focus groups, workload analysis, and situational analysis to assess the uptake, acceptability and feasibility of the HIV POCT program.

Results

Over the 6-month pilot, 123 HIV tests were performed. One new case of HIV was identified; this participant was linked with confirmatory testing and HIV care. Participants were predominantly male (76%), with a mean age of 35 years. This was the first HIV test for 27% participants, and 75% were at moderate to very high risk of undiagnosed HIV infection, by Denver HIV Risk Score. Questionnaires and telephone interviews showed participants were very satisfied with the program; 99% agreed HIV POCT should be routinely offered in pharmacies and 78% were willing to pay for the service. Participants felt the pharmacy was convenient, discreet, and that the pharmacist was supportive and provided education about how to reduce their future risk. Pharmacists felt prepared, confident, and expressed professional satisfaction with offering HIV POCT. Community and public health supports, clear linkage to care plans to refer participants with positive HIV POCT results, and provision of counselling tools were important enabling factors for the program. Pharmacist remuneration, integration with existing healthcare systems, and support for ongoing promotion of HIV POCT availability in pharmacies were identified as needs for future scale-up and sustainability.

Conclusions

A successful model of pharmacy-based POCT, including linkage to care, was developed. Further research is needed to determine the effectiveness and cost-effectiveness of this approach in finding new diagnoses and linking them with care.

Trial registration

Retrospectively registered with clinicaltrials.gov (NCT03210701) on July 6, 2017.

Missed opportunities for earlier diagnosis of HIV in British Columbia, Canada: A retrospective cohort study

BACKGROUND

Late HIV diagnosis is associated with increased AIDS-related morbidity and mortality as well as an increased risk of HIV transmission. In this study, we quantified and characterized missed opportunities for earlier HIV diagnosis in British Columbia (BC), Canada.

DESIGN

Retrospective cohort.

METHODS

A missed opportunity was defined as a healthcare encounter due to a clinical manifestation which may be caused by HIV infection, or is frequently present among those with HIV infection, but no HIV diagnosis followed within 30 days. We developed an algorithm to identify missed opportunities within one, three, and five years prior to diagnosis. The algorithm was applied to the BC STOP HIV/AIDS population-based cohort. Eligible individuals were ≥18 years old, and diagnosed from 2001-2014. Multivariable logistic regression identified factors associated with missed opportunities.

RESULTS

Of 2119 individuals, 7%, 12% and 14% had ≥1 missed opportunity during one, three and five years prior to HIV diagnosis, respectively. In all analyses, individuals aged ≥40 years, heterosexuals or people who ever injected drugs, and those residing in Northern health authority had increased odds of experiencing ≥1 missed opportunity. In the three and five-year analysis, individuals with a CD4 count <350 cells/mm3 were at higher odds of experiencing ≥1 missed opportunity. Prominent missed opportunities were related to recurrent pneumonia, herpes zoster/shingles among younger individuals, and anemia related to nutritional deficiencies or unspecified cause.

CONCLUSIONS

Based on our newly-developed algorithm, this study demonstrated that HIV-diagnosed individuals in BC have experienced several missed opportunities for earlier diagnosis. Specific clinical indicator conditions and population sub-groups at increased risk of experiencing these missed opportunities were identified. Further work is required in order to validate the utility of this proposed algorithm by establishing the sensitivity, specificity, positive and negative predictive values corresponding to the incidence of the clinical indicator conditions among both HIV-diagnosed and HIV-negative populations.

Addressing the rising rates of gonorrhea and drug-resistant gonorrhea: There is no time like the present

Increasing rates of gonococcal (GC) infection and antimicrobial resistant (AMR) GC, are a serious public health concern for Canada and around the world. Previously recommended treatments are ineffective against many of the gonorrhea strains circulating today. The current recommendation for combination therapy is now being threatened by globally emerging and increasingly resistant strains. It is important that coordinated efforts be made now to ensure these new global strains do not become established in Canada. Otherwise, we will be faced with the possibility of persistent GC infection which can lead to pelvic inflammatory disease, infertility and chronic pelvic pain in women; and epididymitis in men. The presence of GC can also increase the risk of HIV acquisition and transmission. There are a number of reasons why we are facing this public health threat. GC infection is often asymptomatic and it is highly transmissible. People may hesitate to seek testing (or to offer testing). Treatment is complex: recommendations vary by site of infection and risk of resistance. Sexual contact during travel is an important source of imported emerging resistant global strains. The new screening and diagnostic Nucleic Acid Amplification Test (NAAT) is excellent but has decreased the number of cultures being done and therefore our capacity to track AMR-GC. There are four key actions that clinicians and front-line public health professionals can take to stem the increase in rates of GC and drug resistant GC. First, normalize and increase GC screening based on risk factors and emphasize the need for safer sex practices. NAAT is useful for screening, but culture is still needed for extra-genital sites. Second, conduct pretravel counselling and include a travel history as part of the risk assessment. Third, use culture along with NAAT to establish the diagnosis and follow up for test-of-cure. Finally, refer to the most current Canadian Guidelines on Sexually Transmitted Infections or provincial/territorial recommendations on combination therapies for patients and their contacts as recommendations may have changed in response to evolving AMR-GC trends.

Assessing uptake of national HIV screening and testing guidance-Part 2: Knowledge, comfort and practice

Background

The Public Health Agency of Canada's (PHAC) HIV Screening and Testing Guide (the Guide) provides guidance to health care providers regarding who, when and how often to screen for HIV. HIV screening and testing is important in meeting the Joint United Nations Programme on HIV/AIDS' (UNAIDS) 90-90-90 targets towards HIV elimination.

Objective

To determine health care providers' levels of knowledge about and comfort with aspects of HIV testing, and to determine whether their HIV testing practices are consistent with the recommendations in the Guide.

Methods

An open, anonymous online survey that included questions on knowledge, comfort and HIV testing practices was developed with stakeholders, validated and pre-tested. It was then disseminated to a convenience sample of health care providers across Canada between June and August 2016.

Results

A total of 1,075 participants representing all Canadian provinces and territories responded to the survey, with the majority being nurses (54%) and physicians (12%). Overall, knowledge related to HIV testing was substantial, but 37% of respondents underestimated the percentage of people living with HIV in Canada who are unaware of their HIV status and only 32% of respondents knew that HIV patients are frequently symptomatic during the acute infection. Most participants were comfortable with HIV testing and approximately 50% reported offering HIV testing regularly.

Conclusions

Although overall knowledge and practice were consistent with PHAC's HIV Screening and Testing Guide, some health care providers may underestimate the magnitude of undiagnosed HIV cases in Canada and may misinterpret the symptoms of acute HIV infection. While the amplitude of these results need to be interpreted in light of the convenience sample, addressing these knowledge gaps may facilitate earlier diagnosis of HIV among those who are unaware of their HIV status.

Assessing uptake of national HIV screening and testing guidance-Part 1: Awareness, use and usefulness

BACKGROUND

In 2013, the Public Health Agency of Canada released the HIV Screening and Testing Guide (the Guide) to support routine HIV screening and testing practices of health care providers in Canada and promote early detection of new HIV cases. Little was known regarding health care providers' awareness and use of the Guide.

OBJECTIVE

To determine Canadian health care providers' awareness, use and perceived usefulness of the Guide.

METHODS

An open, anonymous online survey, including questions on awareness, use and usefulness, was developed with stakeholders, validated and pre-tested. It was then disseminated to a convenience sample of health care providers across Canada between June and August 2016.

RESULTS

A total of 1,075 participants representing all Canadian provinces and territories responded to the survey, with the majority being nurses (54%) and physicians (12%). About two-thirds of respondents (65%) were aware of the Guide; of those, approximately half used it. Thirty-five percent of participants were not aware of the Guide, including none of the 173 health care providers in primary care (family/general practice). Among participants who were aware of and used the Guide, over 80% reported incorporating recommendations from the Guide into their practice and 77% reported frequently or always being able to find information they were looking for.

CONCLUSIONS

The HIV Screening and Testing Guide appears to be very useful for those who are aware of it and use it; however, awareness of the Guide appears to be low in primary care. Although these results need to be interpreted in light of the convenience sample, it suggests broader dissemination efforts may be needed to reach all of the potential users of the Guide.

HIV in Canada: 2009 to 2014

Background

Between 1996 and 2008, the number of newly reported HIV cases in Canada fluctuated between approximately 2,100 and 2,700 cases per year.

Objective

To describe the recent trends in new diagnoses of HIV in Canada between 2009 and 2014 by age group, sex, exposure category, race/ethnicity, and region, as well as the number of perinatally HIV-exposed infants.

Methods

HIV data were compiled from two databases. The National HIV/AIDS Surveillance System is a passive surveillance system that gathers non-nominal data on a voluntary basis from all the provinces and territories of all cases that meet the national case definition, and includes data on age group, sex, race/ethnicity, country of birth, and exposure categories. The Canadian Perinatal HIV Surveillance Program is a sentinel-based surveillance system; non-nominal data is obtained through a national confidential survey completed by participating physicians.

Results

Since 2009 the number of new HIV cases has slowly but steadily declined from 2,391 cases in 2009 to 2,044 in 2014, which is the lowest number of annual HIV cases seen in the last two decades. The largest proportion (32%) of new HIV cases continues to be diagnosed among those 30 to 39 years of age, but the proportion of cases diagnosed among those 50 years of age or over has increased from 15% in 2009 to slightly over 20% in 2014. Approximately 75% of newly diagnosed cases are males and 25% females. In males, the most common exposure category (60%) was men who have sex with men. In females, the most common exposure category (66%) was heterosexual contact followed by injection drug use (27%). Race/ethnicity varied by sex. In males, over 50% were White, 14% were Aboriginal and 13% Black. In females, 35% were Black, 35% were Aboriginal and 22% were White. There were regional variations in HIV rates across Canada. Between 2009 and 2014, the number of perinatally HIV-exposed infants varied between 200 and 249 but the percentage of perinatal treatment increased from 87% in 2009 to 97% in 2014.

Conclusion

The annual number of reported HIV cases in Canada has been declining in recent years. The proportion of HIV-positive mothers receiving treatment has increased and the number of confirmed HIV-infected infants has decreased.