HIV This Week

Universal HIV testing of infants at immunization clinics: an acceptable and feasible approach for early infant diagnosis in high HIV prevalence settings.

Rollins N, Mzolo S, Moodley T, Esterhuizen T, van Rooyen H. AIDS. 2009; 10;23:1851-7.

Rollins and colleagues set out to determine the acceptability and feasibility of universal HIV testing of 6-week-old infants attending immunization clinics to achieve early diagnosis of HIV and referral for HIV treatment and care services. The study design was an observational cohort within which routine HIV testing of infants was offered to all mothers bringing infants for immunizations at three clinics in KwaZulu Natal. Blood samples were collected by heel prick onto filter paper. Dried blood spots were tested for HIV antibodies and, if present, were tested for HIV DNA by PCR. Exit interviews were requested of all mothers irrespective of whether they had agreed to infant testing or not. Of 646 mothers bringing infants for immunizations, 584 (90.4%) agreed to HIV testing of their infant and 332 (56.8%) subsequently returned for results. Three hundred and thirty-two of 646 (51.4%) mothers and infants thereby had their HIV status confirmed or reaffirmed by the time the infant was 3 months of age. Overall, 247 of 584 (42.3%) infant dried blood spot samples had HIV antibodies indicating maternal HIV status. Of these, 54 (21.9%) samples were positive for HIV DNA by PCR. This equates to 9.2% (54/584) of all infants tested. The majority of mothers interviewed said they were comfortable with testing of their infant at immunization clinics and would recommend it to others. Screening of all infants at immunization clinics is acceptable and feasible as a means for early identification of HIV-infected infants and referral for antiretroviral therapy. 

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Editors’ note: With HIV infection widespread across KwaZulu-Natal, it is encouraging that 98% of the 90% of women who consented to have their baby tested reported having been tested themselves before. Linking HIV testing to immunisation visits during the first 3 months of life was convenient for mothers. High maternal antibody levels in infants at that age increased test sensitivity so that PCR testing could be used solely for those who had been exposed to HIV. Earlier infant diagnosis means earlier medical assessment and access to antiretroviral treatment. More work is needed to encourage mothers to return in a timely way for their child’s results (only mothers had the code to link up with the results) and to talk with other women about the advantages of knowing their child’s status (e.g. infant feeding choices to reduce post-natal HIV transmission, initiation of antiretroviral treatment if already infected, as per WHO guidelines for infants).

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

Kankasa C, Carter RJ, Briggs N, Bulterys M, Chama E, Cooper ER, Costa C, Spielman E, Katepa-Bwalya M, M’soka T, Ou CY, Abrams EJ. J Acquir Immune Defic Syndr. 2009;51:202-8.

The difficulties diagnosing infants and children with HIV infection have been cited as barriers to increasing the number of children receiving antiretroviral therapy worldwide. Kankasa and colleagues implemented routine HIV antibody counselling and testing for paediatric patients hospitalized at the University Teaching Hospital, a national reference centre, in Lusaka, Zambia. They also introduced HIV DNA polymerase chain reaction testing for early infant diagnosis. Caregivers/parents of children admitted to the hospital wards were routinely offered HIV counselling and testing for their children. HIV antibody positive (HIV+) children <18 months of age were tested with PCR for HIV DNA. From January 1, 2006, to June 30, 2007, among 15,670 children with unknown HIV status, 13,239 (84.5%) received counselling and 11,571 (87.4%) of those counselled were tested. Overall, 3373 (29.2%) of those tested were seropositive. Seropositivity was associated with younger age: 69.6% of those testing HIV antibody positive were <18 months of age. The proportion of counselled children who were tested increased each quarter from 76.0% in January to March 2006 to 88.2% in April to June 2007 (P < 0.001). From April 2006 to June 2007, 1276 polymerase chain reaction tests were done; 806 (63.2%) were positive. The rate of PCR positivity increased with age from 22% in children <6 weeks of age to 61% at 3-6 months and to 85% at 12-18 months (P < 0.001). Routine counselling and offers of antibody testing of paediatric inpatients can identify large numbers of HIV-seropositive children in high prevalence settings. The high rate of HIV infection in hospitalized infants and young children also underscores the urgent need for early infant diagnostic capacity in high prevalence settings.

Editors’ note: Globally, the number of children under 15 years of age who received antiretroviral treatment rose from 198,000 in 2007 to 275, 000 in 2008; however, a striking 62% of children in low- and middle-income countries who need antiretroviral treatment are not receiving it. Among the many barriers to overcome in the scale-up of paediatric HIV treatment to universal access, the major gatekeeper is identifying children with HIV infection. Before the study began in this Lusaka referral hospital, children were sent to adjacent voluntary testing and counselling centres for determination of serostatus. The uptake of paediatric testing among caregivers that were counselled on the wards increased over time to an overall 87%. The result was that 29% of the children tested were found to be HIV-antibody positive, 63% of whom were infected. There is no doubt that referral hospitals in high HIV prevalence countries can increase paediatric-testing uptake dramatically if HIV counselling and testing are offered routinely at the point of care .