The Cascade of Care From Routine Point-of-Care HIV Testing at Birth: Results From an 18-Months Pilot Program in Eswatini

Abstract

Background: HIV testing at birth may improve early treatment, but concerns remain about feasibility and retention of infants in care. In 2017, point-of-care (POC) HIV birth testing was introduced into routine care at 3 high-volume maternity health facilities in Eswatini. Methods: POC birth testing was offered to HIV-exposed infants (HEI) born at, or presenting to, 3 maternities within 3 days of birth. Data were collected from a project-specific EID test request form and routine registers on all tests conducted from August 1, 2017 to November 30, 2018, including retesting at 6-8 weeks for infants testing negative at birth and six-month retention in HIV care and viral load suppression among infants testing HIV-positive at birth. Results: Of 4322 eligible HEI, 3311 (76.6%) were tested. Twenty-six HIV-infected infants were identified (positivity rate 0.8%) and 25 initiated on antiretroviral therapy (ART) (96.1%). The median time from sample collection to ART initiation was 20.50 days (IQR 14-45). Twenty-one (84%) ART-initiated infants were on ART at 6 months after initiation. Nineteen infants (90.5%) had viral load test information at 6 months and 16 (84.2%) were virally suppressed. Of 3126 HEI testing negative at birth, 3004 (96.1%) were linked to laboratory databases and 2744 (91.3%) were retested at 6-8 weeks, with 9 (0.3%) additional infants testing HIV-positive. Conclusions: Uptake of POC birth testing was high in Eswatini with low HIV positivity. Almost all infants identified HIV-positive at birth were initiated on ART, with high retention in care and viral suppression. Birth testing did not seem to significantly reduce subsequent 6-8-week testing.

Programmatic evaluation of feasibility and efficiency of at birth and 6-week, point of care HIV testing in Kenyan infant

“…Our data indicated that infants who received an at birth POC test were more likely to receive a second POC test by 12 weeks of age, compared to those who did not receive an at birth POC test. While a case-control study from South Africa indicated that high-risk infants who received at birth PCR testing were less likely to receive a repeat test than matched controls who did not receive an at birth test [19], our study and other similar studies from Eswatini, also did not support this finding [43]. Similarly, qualitative data suggests that mothers would find an initial negative result at birth encouraging and would motivate continued engagement in care [30].…”

“…This indicates that with minimal extra training and support, clinical staff already employed within the hospital can successfully process POC samples using GeneX. The at birth POC error rate observed in our study (8.5%) was higher than at 6 weeks (2.6%), however comparable to that observed in other studies (4.8%-11%) [17,27,43]. Higher error rates at birth could be a result of difficulty collecting adequate sample from infants.…”

“The right time is just after birth”: acceptability of point-of-care birth testing in Eswatini: qualitative results from infant caregivers, health care workers, and policymakers

“…This study complements previous quantitative findings from the same overall study [14], and is a critical first step in understanding the value and feasibility of birth testing.…”

“…More education and support are still needed, especially on the importance of treatment for positive infants, and about linkage to and continuation in care. Acceptance of birth testing was high, but quantitative data indicate a lower proportion of caregivers whose infants are immediately (within 14 days or diagnosis) started on ARVs [14]. This could be for multiple reasons, including the ease of an onsite test with no travel; the fact that the test is a one-time event unlike medications; the ability to test in secret without other family members; and that many women delivered alone and may have had autonomy to accept testing where they may not be able to accept medications once other family members are involved.…”

“…With funding from Unitaid, the Elizabeth Glaser Pediatric AIDS Foundation (EGPAF) worked with the Ministry of Health of the Kingdom of Eswatini to pilot POC birth testing in three health facility maternity units, starting in 2016, building on an existing program of early infant testing using POC platforms. POC testing has been shown to reduce median turnaround time of results at 6 week testing from 55 to 0 days [13] and has also been shown to be feasible for testing at birth [14,15]. The opportunity to offer POC birth testing allows most caregivers to receive results before they are discharged from the hospital after delivery, or shortly thereafter, and thus can improve the survival chances of those found to be infected by starting treatment earlier.…”