Task Shifting Routine Inpatient Pediatric HIV Testing Improves Program Outcomes in Urban Malawi: A Retrospective Observational Study

Abstract

BackgroundThis study evaluated two models of routine HIV testing of hospitalized children in a high HIV-prevalence resource-constrained African setting. Both models incorporated “task shifting,” or the allocation of tasks to the least-costly, capable health worker.Methods and FindingsTwo models were piloted for three months each within the pediatric department of a referral hospital in Lilongwe, Malawi between January 1 and June 30, 2008. Model 1 utilized lay counselors for HIV testing instead of nurses and clinicians. Model 2 further shifted program flow and advocacy responsibilities from counselors to volunteer parents of HIV-infected children, called “patient escorts.” A retrospective review of data from 6318 hospitalized children offered HIV testing between January-December 2008 was conducted. The pilot quarters of Model 1 and Model 2 were compared, with Model 2 selected to continue after the pilot period. There was a 2-fold increase in patients offered HIV testing with Model 2 compared with Model 1 (43.1% vs 19.9%, p<0.001). Furthermore, patients in Model 2 were younger (17.3 vs 26.7 months, p<0.001) and tested sooner after admission (1.77 vs 2.44 days, p<0.001). There were no differences in test acceptance or enrollment rates into HIV care, and the program trends continued 6 months after the pilot period. Overall, 10244 HIV antibody tests (4779 maternal; 5465 child) and 453 DNA-PCR tests were completed, with 97.8% accepting testing. 19.6% of all mothers (n = 1112) and 8.5% of all children (n = 525) were HIV-infected. Furthermore, 6.5% of children were HIV-exposed (n = 405). Cumulatively, 72.9% (n = 678) of eligible children were evaluated in the hospital by a HIV-trained clinician, and 68.3% (n = 387) successfully enrolled into outpatient HIV care.Conclusions/SignificanceThe strategy presented here, task shifting from lay counselors alone to lay counselors and patient escorts, greatly improved program outcomes while only marginally increasing operational costs. The wider implementation of this strategy could accelerate pediatric HIV care access in high-prevalence settings.

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

“…7 Paediatric inpatient programmes were the most common context (17), 6,7,10,[13][14][15][16][17][18][19][21][22][23][24][25]29,30 followed by nutrition centres (four), 9,11,12,27 EPI centres (three), 20 programmes (three). 8,20,31 The assessment for quality showed that most of the included studies (20) [9][10][11][12][15][16][17][18][19][20][22][23][24][25][26][27][28][29][30][31] were of fair or good quality and the remainder (six) [6][7][8]13,…”

“…We did a stratifi ed analysis of paediatric HIV prevalence in southern and eastern Africa (20 studies) 8,[10][11][12][13][14][15][16][17][18][19][20][21][22][24][25][26][27]28,29 versus that in west and central Africa (four). 9,23,28,31 Paediatric HIV prevalence across contexts in southern and eastern Africa was 17·8% (95% CI 12·8-22·7) and prevalence in west and central Africa was 9·8% (95% CI 4·2-15·3).…”

“…Because of the small numbers of studies from Asia and Oceania, these geographical settings were not included in stratifi ed analyses. We did stratifi ed analysis examining universal (eight studies) 7,16,18,19,22,23,25,29 versus triggered testing (nine) 6,10,[13][14][15][16]22,24,30 in inpatient settings. Paediatric HIV prevalence detected via triggered testing (21·3%, CI 11·6-31·0) was slightly, but not signifi cantly (p=0·95), higher than that detected with universal testing (21·2%, 13·8-28·7; appendix pp 10-11).…”

“…6,9,11,12,16,18-20,22,26,29,31 11 of these studies were from sub-Saharan Africa 9,11,12,16,18-20,22,26,29,31 and one was from India. 6 These studies examined inpatient settings (six), 6,16,18,19,22,29 nutrition centres (three), 9,11,13 EPI centres (two), 20,26 and outpatient settings (two), 20,31 with one study examining both outpatient and EPI centres. 20 The unweighted mean for caregiver acceptance across twelve studies (13 settings) was 92·2% (range 73-100).…”

“…19,20,26 These studies examined three contexts: inpatient (one study), 18 EPI (two), 20,26 and outpatient (one). 20 The proportion of caregivers who returned for test results was reported to be 25% in the outpatient setting, 56·8% in EPI centres, 26 and 78·6% in the inpatient centres.…”