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

Abstract

Objectives Few routine systems exist to test older, asymptomatic children for HIV. Testing all children in the population has high uptake but is inefficient, while 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. Following implementation of active referral, the rate of pediatric HIV testing increased 3.8-fold from 3.5 to 13.6 children tested per month, (RR: 3.8, 95%CI: 2.3–6.1). 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% and median age was 8 years (IQR: 2–11); one 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.

Active case finding: comparison of the acceptability, feasibility and effectiveness of targeted versus blanket provider-initiated-testing and counseling of HIV among children and adolescents in Cameroon

“…In the tPITC group, we found an HIV positivity rate (case detection rate/yield) of 3.5%, which was closer to the 4.0% but lower than the 7.4% reported by Saeed et al in Malawi [ 15 ] and Wagner et alin Kenya [ 16 ], respectively. The HIV prevalence (4.3%) in the general population in Cameroon (4.3%) [ 17 ] is lower compared to Malawi (9.2%) and Kenya (5.4%) [ 8 ] and this may explain the lower HIV positivity rate observed among the pediatric and adolescent population in our study compared to Malawi and Kenya as reported in the aforementioned studies.…”

“…In our study, according to the parents’ declarations, the main reasons for their inability to return to the hospital with their children for HIV testing included the lack of transport fare (38.3%), children not living with them (25.6%), and the lack of time (10.5%). These reasons should be taken with caution because the HIV testing uptake could have also been limited by parental’ levels barriers, notably fear of self-disclosure, stigma and discrimination as reported by previous studies [ 4 , 16 , 20 – 22 ]. There is a need for qualitative research to provide in-depth information on parental barriers to the uptake of HIV testing for children in the context of tPITC approach implementation.…”

“…This may be attributable to the fact that the tPITC parents living with HIV were initially seen in the hospital in the first place for their own care, and their children were less likely to be present. Similarly, low uptake of HIV testing among children in tPITC was reported in Kenya where only 14% of parents who had initially consented to test children had followed through with the testing [ 16 ]. In our study, according to the parents’ declarations, the main reasons for their inability to return to the hospital with their children for HIV testing included the lack of transport fare (38.3%), children not living with them (25.6%), and the lack of time (10.5%).…”

Increasing pediatric HIV testing positivity rates through focused testing in high-yield points of service in health facilities—Nigeria, 2016-2017

“…The entry point for HIV testing in children influences the proportion of cases found [16][17][18]. A study by Wagner et al conducted in Nairobi, Kenya, where HIV-infected adults were encouraged to bring their children for HIV testing (family index testing), found that the rate of pediatric HIV testing increased 3.8-fold from 3.5% to 13.6% [16]. A similar study by Lewis Kulzer et al conducted in the Nyanza province in Kenya reported that HIV testing through the family index approach increased case detection among children [17].…”

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

“…HIV testing offered to children or sexual contacts of individuals living with HIV) is anticipated to have higher uptake and yield compared to universal HIV testing approaches. When implemented in Malawi, Kenya, Lesotho and Cameroon, index-linked testing for children did result in a higher yield of HIV (proportion of eligible children who test positive) compared to universal testing, but uptake of testing (proportion of eligible children tested) remained suboptimal, ranging from 14 to 71% [ 6 – 8 ].…”