HIV This Week

Effect of provider-initiated testing and counselling and integration of ART services on access to HIV diagnosis and treatment for children in Lilongwe, Malawi: a pre- post comparison.

Weigel R, Kamthunzi P, Mwansambo C, Phiri S, Kazembe PN. BMC Pediatr. 2009. 9(1):80.

The HIV prevalence in Malawi is 12 % and Kamuzu Central Hospital, in the capital Lilongwe, is the main provider of adult and paediatric HIV services in the central region. The Lighthouse at Kamuzu Central Hospital offers voluntary HIV testing and counselling for adults and children. In June 2004, Lighthouse was the first clinic to provide free antiretroviral treatment in the public sector, but few children accessed the services. In response, provider-initiated HIV testing and counselling and an antiretroviral treatment clinic were introduced at the paediatric department at Kamuzu Central Hospital in Quarter 4 (Q4) 2004. The authors analysed prospectively collected, aggregated data of quarterly reports from Q1 2003 to Q4 2006 from opt-in HIV testing and counselling centre registers, antiretroviral treatment registers and clinic registrations at the antiretroviral treatment clinics of both Lighthouse and the paediatric department. By comparing data of both facilities before (Q1 2003 to Q3 2004), and after the introduction of the services at the paediatric department (Q4 2004 to Q4 2006), they assessed the effect of this intervention on the uptake of HIV services for children at Kamuzu Central Hospital. Overall, 3971 children were tested for HIV, 2428 HIV-infected children were registered for care and 1218 started antiretroviral treatment. Between the two periods, the median (IQR) number of children being tested, registered and starting antiretroviral treatment per quarter rose from 101 (53-109) to 358 (318-440), 56 (50-82) to 226 (192-234) and 18 (8-23) to 139 (115-150), respectively. The median proportion of tested clients per quarter that were children rose from 3.8% (2.7-4.3) to 9.6% (8.8 to 10.0) (p=0.0009) and the proportion of antiretroviral treatment starters that were children rose from 6.9% (4.9-9.3) to 21.1% (19.2-24.2) (p=0.0036). The proportion of registered children and adults starting antiretroviral treatment each quarter increased similarly, from 26% to 53%, and 20% to 52%, respectively. Implementation of provider-initiated HIV testing and counselling and integration of antiretroviral treatment services within the paediatric ward are likely to be the main reasons for improved access to HIV testing and counselling and antiretroviral treatment for children at Kamuzu Central Hospital, and can be recommended to other hospitals with paediatric inpatients in resource limited settings with high HIV prevalence.

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Editors’ note: Even though providers initiated an offer of HIV testing and counselling with the caregivers of only 10% of admitted children at the Kamazu Central Hospital, there was a marked increase in the absolute numbers and proportions of children tested for HIV and started on antiretroviral treatment at this facility, compared to the era of parent/caregiver-initiated voluntary testing and counselling. It is unclear whether this modest increase in provider-initiated testing and counselling made the difference or whether it was the advent of free antiretroviral treatment that changed both client and health worker attitudes towards HIV counselling and testing. In any case, 41% of all children tested at the hospital were tested through the paediatric ward and the yield there was high, providing an additional entry point to antiretroviral treatment for children in Lilongwe.

“It’s better not to know”: perceived barriers to HIV voluntary counseling and testing among sub-Saharan African migrants in Belgium.

Manirankunda L, Loos J, Alou TA, Colebunders R, Nöstlinger C. AIDS Educ Prev. 2009. 21:582-93.

This study explored perceptions, needs, and barriers of sub-Saharan African migrants in relation to HIV voluntary counselling and testing. Using an inductive qualitative methodological approach, data were obtained from focus group discussions. Results showed that participants were in principle in favour of voluntary counselling and testing. However, they indicated that barriers outweighed advantages. Such barriers included fear of positive test results and its related personal and social consequences, lack of information, lack of preventive health behaviour, denial of HIV risk, and missed opportunities. Limited financial resources were only a concern for some subgroups like young people, asylum seekers, and recent migrants. This study identified multiple and intertwined barriers to voluntary counselling and testing from a community perspective. In order to promote voluntary counselling and testing, interventions such as raising awareness through culturally sensitive education should be adopted at community level. At level of service provision, provider initiated HIV testing including target group tailored counselling should be promoted.

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Editors’ note: This first qualitative community-based study of the barriers to uptake of voluntary counselling and testing among sub-Saharan migrants in Belgium found that previously acquired experiences in their countries of origin negatively influenced testing uptake. The images of relatives or friends, who had been ill and died of AIDS, shaped attitudes toward knowledge of serostatus, as did the considerable responsibilities that many recent migrants have toward family and community members back home. Focus group participants indicated that provider-initiated discussions of HIV testing, combined with the testimonies of people living with HIV and in good health on how to live with HIV, would help reduce fears of HIV testing and counselling. Efforts to reduce stigma, increase social support, and increase testing uptake in a culturally sensitive manner will increase the proportion of migrants wanting to learn their HIV status.

Home testing for HIV infection in resource-limited settings.

Ganguli I, Bassett IV, Dong KL, Walensky RP. Curr HIV/AIDS Rep. 2009;6:217-23.

Among an estimated 33 million individuals who are infected with HIV worldwide, only 10% are aware of their status. HIV testing is the cornerstone to preventing further transmission and to caring for those infected, particularly as access to treatment improves in resource-limited settings. However, efforts to expand testing through facilities-based testing have not achieved adequate testing coverage, prompting efforts to reach more individuals through strategies such as home-based HIV testing. Home testing is showing promising early results in some high-prevalence, resource-limited settings. This article reviews the mechanisms and literature to date of this door-to-door approach.

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Editors’ note: This review contrasts the literature on self-specimen collection and self-testing at home in the United States of America with ‘counsellor-initiated home-based testing’ in high HIV prevalence resource-limited settings. Those most likely to benefit from the latter may be the poor who have the lowest uptake of traditional, facility-based testing and counselling. Home-based testing in low- and middle-income settings may reach couples and families more efficiently than other strategies but individuals and the public will only benefit if there are strong links to effective HIV prevention, medical care, and psychosocial support for those who learn their test result.

Aghokeng AF, Mpoudi-Ngole E, Dimodi H, Atem-Tambe A, Tongo M, Butel C, Delaporte E, Peeters M. PLoS One. 2009 ;4:e7702.

Increased access to HIV testing is essential in working towards universal access to HIV prevention and treatment in resource-limited countries. The authors evaluated currently used HIV diagnostic tests and algorithms in Cameroon for their ability to correctly identify HIV infections. They estimated sensitivity, specificity, and positive and negative predictive values of 5 rapid/simple tests, of which 3 were used by the national program, and 2 fourth generation ELISAs. The reference panel included 500 locally collected samples; 187 HIV -1 M, 10 HIV-1 O, 259 HIV negative and 44 HIV indeterminate plasmas. None of the 5 rapid assays and only 1 ELISA reached the current WHO/UNAIDS recommendations on performance of HIV tests of at least 99% sensitivity and 98% specificity. Overall, sensitivities ranged between 94.1% and 100%, while specificities were 88.0% to 98.8%. The combination of all assays generated up to 9% of samples with indeterminate HIV status, because they reacted discordantly with at least one of the different tests. Including HIV indeterminate samples in test efficiency calculations significantly decreased specificities to a range from 77.9% to 98.0%. Finally, two rapid assays failed to detect all HIV-1 group O variants tested, with one rapid test detecting only 2 out of 10 group O specimens. In the era of antiretroviral therapy scaling-up in Africa, significant proportions of false positive but also false negative results are still observed with HIV screening tests commonly used in Africa, resulting in inadequate treatment and prevention strategies. Depending on tests or algorithms used, up to 6% of HIV-1 M and 80% of HIV-1 O infected patients in Cameroon do not receive antiretroviral therapy and adequate counselling to prevent further transmission due to low sensitivities. Also, the use of tests with low specificities could imply inclusion of up to 12% HIV negative people in antiretroviral therapy programs and increase budgets in addition to inconveniences caused to patients.

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Editors’ note: False-positive and false-negative HIV test results have negative implications for both individuals and programmes – all efforts must be made to minimise them. The first step is to evaluate assay performance using a serum panel from patients infected with subtypes that are circulating locally and the second step is instituting ongoing quality control. Inadequate sensitivity (ability to correctly identify presence of infection) and specificity (ability to correctly identify lack of infection) mean that infections are missed which can delay treatment or, on the other hand, that people who are not infected believe that they are, with personal and programmatic costs. When test kits are chosen by officials on the basis of lower price rather than performance efficacy, the results can be dire. This article should be essential reading for all national laboratory directors .

Comparing Couples’ and Individual Voluntary Counseling and Testing for HIV at Antenatal Clinics in Tanzania: A Randomized Trial.

Becker S, Mlay R, Schwandt HM, Lyamuya E. AIDS Behav 2009. Sep. [Epub ahead of print]

Voluntary counselling and testing for couples is an important HIV-prevention effort in sub-Saharan Africa where a substantial proportion of HIV transmission occurs within stable partnerships. This study aimed to determine the acceptance and effectiveness of couples voluntary counselling and testing as compared to individual voluntary counselling and testing. 1,521 women attending three antenatal clinics in Dar es Salaam were randomized to receive individual voluntary counsellingduring that visit or couples voluntary counselling with their husbandsat a subsequent visit. The proportion of women receiving test results in the couples voluntary counselling and testing arm was significantly lower than in the individual voluntary counselling and testing arm (39 vs. 71%). HIV prevalence overall was 10%. In a subgroup analysis of HIV-positive women, those who received couples voluntary counselling and testing were more likely to use preventive measures against transmission (90 vs. 60%) and to receive nevirapine for themselves (55 vs. 24%) and their infants (55 vs. 22%) as compared to women randomized to individual voluntary counselling and testing. Uptake of couples voluntary counselling and testing is low in the antenatal clinic setting. Community mobilization and couple-friendly clinics are needed to promote couples voluntary counselling and testing.

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Editors’ note: In this study, only 16% of the women randomised to the couples voluntary counselling and testing arm were counselled, tested, and shared results together with their husbands/cohabiting partners. This is an opportunity to learn together about HIV transmission, discuss personal and combined risks, and develop a collaborative plan to prevent further transmission, assisted by a professional. Antenatal clinics are clearly either not perceived by men as male-friendly places or not perceived by couples as couple-friendly places. Given that a considerable proportion of HIV transmission in sub-Saharan Africa is occurring within married or cohabiting couples and given that individual testing and counselling addresses only half of the sexual partnership, strategies to create new social norms to increase the acceptability of couple testing and determine the best venues for it are urgently needed.

Moodley D, Esterhuizen TM, Pather T, Chetty V, Ngaleka L. High HIV incidence during pregnancy: compelling reason for repeat HIV testing. AIDS. 2009 May 18. [Epub ahead of print]

The objective of this study was to determine the incidence of HIV during pregnancy as defined by seroconversion using a repeat HIV rapid testing strategy during late pregnancy. In this cross-sectional study nested in a prevention of mother-to-child transmission program, pregnant women were retested between 36 and 40 weeks of gestation, provided that they had been tested HIV negative at least 3 months prior. Among the 2377 HIV-negative women retested, 1099 (46.2%) and 1278 (53.4%) were tested at urban and rural health facilities, respectively. Seventy-two women (3%) were HIV-positive (679 woman years of exposure) yielding a HIV incidence rate of 10.7/100 woman years [95% confidence interval (CI) 8.2-13.1]. HIV incidence in pregnancy was higher but not statistically significant at the urban facilities (12.4/100 woman years versus 9.1/100 woman years) and at least two-fold higher among the 25-29 and 30-34-year age groups (3.8 and 4.5%, respectively) as compared with the less than 20-year age group (1.9%). Single women were at 2.5 times higher risk of seroconverting during pregnancy (P = 0.017). HIV incidence during pregnancy was four times higher than in the non-pregnant population reported in a recent survey. Public health programs need to continue to reinforce prevention strategies and HIV retesting during pregnancy. The latter also offers an additional opportunity to prevent mother-to-child transmission and further horizontal transmission. Further research is required to understand the cause of primary HIV infection in pregnancy.

Editors’ note: Condom use, multiple sex partners, and the frequency of sexual activity were not significantly different between HIV-negative and seroconverting women in this study, giving support to the idea that hormonal changes affecting either genital mucosa or immune responses may be key. The striking HIV incidence of 10.7 per 100 women-years underscores the importance of counselling and community education about HIV prevention in pregnancy, as has been done for cigarette smoking and alcohol, to protect pregnant women. Repeat HIV testing offers an additional opportunity to prevent mother-to-child and sexual transmission, along with clinical assessment and care for women who seroconvert.

Helleringer S, Kohler HP, Frimpong JA, Mkandawire J. Increasing Uptake of HIV Testing and Counseling Among the Poorest in Sub-Saharan Countries Through Home-Based Service Provision. J Acquir Immune Defic Syndr. 2009 Apr 6. [Epub ahead of print].

Uptake of HIV testing and counselling is lower among members of the poorest households in sub-Saharan countries, thereby creating significant inequalities in access to HIV testing and counselling and possibly antiretroviral treatment. Helleringer and colleagues set out to measure uptake of home-based HIV testing and counselling and estimate HIV prevalence among members of the poorest households in a sub-Saharan population. Residents of 6 villages of Likoma Island ( Malawi) aged 18-35 and their spouses were offered home-based HIV testing and counselling services. Socioeconomic status, HIV testing history, and HIV risk factors were assessed. Differences in uptake of HIV testing and counselling and in HIV infection prevalence between members of households in the lowest income quartile and the rest of the population were estimated using logistic regression. Members of households in the lowest income quartile were significantly less likely to have ever used facility-based HIV testing and counselling services than the rest of the population (odds ratio = 0.60, 95% confidence interval (CI): 0.36 to 0.97). In contrast, they were significantly more likely to use home-based HIV testing and counselling services provided during the study (adjusted odds ratio = 1.70, 95% CI: 1.04 to 2.79). Socioeconomic differences in uptake of home-based HIV testing and counselling were not due to underlying differences in socioeconomic characteristics or HIV risk factors. The prevalence of HIV was significantly lower among members of the poorest households tested during home-based HIV testing and counselling than among the rest of the population (adjusted odds ratio = 0.37, 95% CI: 0.14 to 0.96). HIV testing and counselling uptake was high during a home-based HIV testing and counselling campaign on Likoma Island, particularly among the poorest. Home-based HIV testing and counselling has the potential to significantly reduce existing socioeconomic gradients in HIV testing and counselling uptake and help mitigate the impact of AIDS on the most vulnerable households.

Editors’ note: Less than a quarter of this study population had participated in facility-based HIV testing and counselling but more than 75% accepted to be tested and immediately retrieved their test results at home. HIV prevalence overall was 8%. This is the first study to document the impact that a home-based approach can have in increasing uptake of HIV testing and counselling among young adults in the poorest households. Young women from these households were the least likely to have used facility-based testing and were the second most likely to participate in home-based HIV testing and counselling after their male counterparts. Reaching out to poorer people in their homes can help ensure that access to HIV prevention and treatment services is more equitable.

Obare F, Fleming P, Anglewicz P, Thornton R, Martinson F, Kapatuka A, Poulin M, Watkins S, Kohler HP. Acceptance of repeat population-based voluntary counseling and testing for HIV in rural Malawi. Sex Transm Infect 2008 Oct 16. [Epub ahead of print]

Obare and colleagues set out to examine the acceptance of repeat population-based voluntary counselling and testing for HIV in rural Malawi. Behavioural and biomarker data were collected in 2004 and 2006 from approximately 3,000 adult respondents. In 2004, oral swab specimens were collected and analyzed using enzyme-linked immunosorbent assay (ELISA) and confirmatory Western blot tests while finger-prick rapid testing was done in 2006. The authors use cross-tabulations with chi-square tests and significance tests of proportions to determine the statistical significance of differences in acceptance of voluntary counselling and testing by year, individual characteristics, and HIV risk. First, over 90% of respondents in each round accepted HIV test, despite variations in testing protocols. Second, the percentage of individuals who obtained their test results significantly increased from 67% in 2004 when the results were provided in randomly selected locations several weeks after the specimens were collected, to 98% in 2006 when they were made available immediately within the home. Third, whereas there were significant variations in the socio-demographic and behavioural profiles of those who were successfully contacted for a second HIV test, this was not the case for those who accepted repeat voluntary counselling and testing. This suggests that variations in the success of repeat testing might come from contacting the individuals rather than from accepting the test or knowing the results. Repeat HIV testing at home by trained health care workers from outside the local area, and with either saliva or blood, is almost universally acceptable in rural Malawi, and thus likely to be acceptable in similar contexts.

Editors’ note: Both the distance people must travel to receive their HIV results and the delay between the time of testing and availability of results can reduce the numbers of people who receive their test results. This study reveals persistently high HIV testing acceptance levels when people are offered at-home testing and immediate test results. Reasons for this may include both reduced transport costs and the perception that at-home testing is more confidential than clinic-based testing.

Khumalo-Sakutukwa G, Morin SF, Fritz K, Charlebois ED, Rooyen HV, Chingono A, Modiba P, Mrumbi K, Visrutaratna S, Singh B, Sweat M, Celentano DD, Coates TJ; for the NIMH Project Accept Study Team. Project Accept (HPTN 043): A Community-Based Intervention to Reduce HIV Incidence in Populations at Risk for HIV in Sub-Saharan Africa and Thailand. J Acquir Immune Defic Syndr 2008 Oct 16. [Epub ahead of print]

Changing community norms to increase awareness of HIV status and reduce HIV-related stigma has the potential to reduce the incidence of HIV-1 infection in the developing world. Khumalo-Sakutukwa and colleagues developed and implemented a multilevel intervention providing community-based HIV mobile voluntary counselling and testing, community mobilization, and post test support services. Forty-eight communities in Tanzania, Zimbabwe, South Africa, and Thailand were randomized to receive the intervention or clinic-based standard voluntary counselling and testing, the comparison condition. The authors monitored utilization of community-based HIV mobile voluntary counselling and testing and clinic-based standard voluntary counselling and testing by community of residence at 3 sites, which was used to assess differential uptake. They also developed quality assurance procedures to evaluate staff fidelity to the intervention. In the first year of the study, a 4-fold increase in testing was observed in the intervention versus comparison communities. The authors also found an overall 95% adherence to intervention components. Study outcomes, including prevalence of recent HIV infection and community-level HIV stigma, will be assessed after 3 years of intervention. The provision of mobile services, combined with appropriate support activities, may have significant effects on utilization of voluntary counselling and testing. These findings also provide early support for community mobilisation as a strategy for increasing testing rates.

Editors’ note: Project Accept is the first international community-randomised controlled phase III trial (48 communities in 4 countries) to determine the effects of a multi-level structural intervention with HIV incidence and stigma reduction as primary end points. Its theoretical foundations are diffusion of innovation, tipping point theory, and social action theory. This first report of process data for the first year of the trial shows a significant difference in HIV testing uptake, providing early validation of the intervention’s theoretical model.

Mkwanazi NB, Patel D, Newell ML, Rollins NC, Coutsoudis A, Coovadia HM, Bland RM. Africa Centre for Health and Population Studies, University of KwaZulu-Natal, Durban, South Africa. Rapid testing may not improve uptake of HIV testing and same day results in a rural South African community: a cohort study of 12,000 women. PLoS ONE. 2008;3(10):e3501.

Rapid testing of pregnant women aims to increase uptake of HIV testing and results and thus optimize care. Mkwanazi and colleagues report on the acceptability of HIV counselling and testing, and uptake of results, before and after the introduction of rapid testing in this area. HIV counsellors offered counselling and testing to women attending 8 antenatal clinics, prior to enrolment into a study examining infant feeding and postnatal HIV transmission. From August 2001 to April 2003, blood was sent for HIV ELISA testing in line with the Prevention of Mother-to-Child Transmission (PMTCT) programme in the district. From May 2003 to September 2004 women were offered a rapid HIV test as part of the PMTCT programme, but also continued to have ELISA testing for study purposes. Of 12,323 women counselled, 5,879 attended clinic prior to May 2003, and 6,444 after May 2003 when rapid testing was introduced; of whom 4,324 (74.6%) and 4,810 (74.6%) agreed to have an HIV test respectively. Of the 4,810 women who had a rapid HIV test, only 166 (3.4%) requested to receive their results on the same day as testing, the remainder opted to return for results at a later appointment. Women with secondary school education were less likely to agree to testing than those with no education (adjusted odds ratio 0.648, p<0.001), as were women aged 21-35 (adjusted odds ratio 0.762, p<0.001) and >35 years (adjusted odds ratio 0.756, p<0.01) compared to those <20 years. Contrary to other reports, few women who had rapid tests accepted their HIV results the same day. Finding strategies to increase the proportion of pregnant women knowing their HIV results is critical so that appropriate care can be given.

Editors’ note: Rapid HIV testing avoids transportation of samples to laboratories and ensures that women presenting late in pregnancy can receive their results prior to labour and delivery. This study of rapid testing among pregnant women attending clinics that offered HIV testing from 2001 as part of a postnatal transmission study, found little interest in the same-day result that rapid testing allows. Rapid testing had no effect on the proportion of women agreeing to have an HIV test (about 75%). This could be due to women wanting time to consider their personal risks and support networks before accepting results. It is important to respect pregnant women’s abilities and readiness to receive HIV test results. Community mobilisation for stigma reduction and serostatus knowledge may work better than a technological advancement to increase the proportion of women who know their HIV status in pregnancy. Only then will the current unacceptable rates of mother-to-child transmission decrease and will more eligible women get on antiretroviral drugs for their own health.

Bwambale FM, Ssali SN, Byaruhanga S, Kalyango JN, Karamagi CA. Voluntary HIV counselling and testing among men in rural western Uganda: Implications for HIV prevention. BMC Public Health. 2008 Jul 30;8:263.

Voluntary HIV counselling and testing (VCT) is one of the key strategies in the prevention and control of HIV in Uganda. However, the utilization of VCT services particularly among men is low in Kasese district. Bwambale et al conducted a study to determine the prevalence and factors associated with VCT use among men in Bukonzo West health sub-district, Kasese district. A population-based cross-sectional study employing both quantitative and qualitative techniques of data collection was conducted between January and April 2005. Using cluster sampling, 780 men aged 18 years and above, residing in Bukonzo West health sub-district, were sampled from 38 randomly selected clusters. Data was collected on VCT use and independent variables. Focus group discussions (4) and key informant interviews (10) were also conducted. Binary logistic regression was performed to determine the predictors of VCT use among men. Overall VCT use among men was 23.3% (95% CI 17.2-29.4). Forty six percent (95% CI 40.8-51.2) had pre-test counselling and 25.9% (95%CI 19.9-31.9) had HIV testing. Of those who tested, 96% returned for post-test counselling and received HIV results. VCT use was higher among men aged 35 years and below (OR = 2.69, 95%CI 1.77-4.07), non-subsistence farmers (OR = 2.37, 95%CI 2.37), in couple testing (OR = 2.37, 95%CI 1.02-8.83) and among men with intention to disclose HIV test results to sexual partners (OR = 1.64, 95%CI 1.04-2.60). The major barriers to VCT use among men were poor utilization of VCT services due to poor access, stigma and confidentiality of services. VCT use among men in Bukonzo West, Kasese district was low. In order to increase VCT use among men, the VCT programme needs to address HIV stigma and improve access and confidentiality of VCT services. Among the more promising interventions are the use of routine counselling and testing for HIV of patients seeking health care in health units, home based VCT programmes, and mainstreaming of HIV counselling and testing services in community development programmes.

Editors’ note: Kasese District in western Uganda had an HIV prevalence of 13.3% in 2005 at the time of this study and yet only 23.3% of the 780 men in this representative study population had ever had an HIV test and learned their results. Over half (61.8%) of the men believed that a couple could not have discordant HIV results. A combination of provider-initiated testing and counselling in health services, home-based offers of testing, and integration of testing services into community development programmes could remove many of the barriers to HIV testing raised by the participants of this study.

Thurstans S, Kerac M, Maleta K, Banda T, Nesbitt A. HIV prevalence in severely malnourished children admitted to nutrition rehabilitation units in Malawi: Geographical & seasonal variations A cross-sectional study A cross-sectional study. BMC Pediatr. 2008;8:22.

Severe malnutrition in childhood associated with HIV infection presents a serious humanitarian and public health challenge in Southern Africa. The aim of this study was to collect country wide data on HIV infection patterns in severely malnourished children to guide the development of integrated care in a resource limited setting. A cross sectional survey was conducted in 12 representative rural and urban nutrition rehabilitation units, from each of Malawi’s 3 regions. All children and their caretakers admitted to each nutrition rehabilitation unit over a two week period were offered HIV counselling and testing. Testing was carried out using two different rapid antibody tests, with PCR testing for discordant results. Children under 15 months were excluded, to avoid difficulties with interpretation of false positive rapid test results. The survey was conducted once in the dry/post-harvest season, and repeated in the rainy/hungry season. 570 children were eligible for study inclusion. Acceptability and uptake of HIV testing was high: 523 (91.7%) of carers consented for their children to take part; 368 (70.6%) themselves accepted testing. Overall HIV prevalence amongst children tested was 21.6% (95% confidence intervals, 18.2-25.5%). There was wide variation between individual nutrition rehabilitation units: 2.0-50.0%. Geographical prevalence variations were significant between the three regions (p<0.01) with the highest prevalence being in the south; Northern Region 23.1% (95%CI 14.3-34.0%), Central Region 10.9% (95%CI 7.5-15.3%) and Southern Region 36.9% (95%CI 14.3-34.0%). HIV prevalence was significantly higher in urban areas, 32.9% (95%CI 26.8-39.4%) than in rural 13.2% (95%CI 9.5-17.6%)(p<0.01). Nutrition rehabilitation unit HIV prevalence rates were lower in the rainy/hungry season 18.4% (95%CI 14.7-22.7%) than in the dry/post-harvest season 30.9% (95%CI 23.2-39.4%) (p<0.001%). There is a high prevalence of HIV infection in severely malnourished Malawian children attending nutrition rehabilitation units with children in urban areas most likely to be infected. Testing for HIV is accepted by carers in both urban and rural areas. Nutrition rehabilitation units could act as entry points to HIV treatment and support programmes for affected children and families. Recognition of the wide geographical variation in childhood HIV prevalence will ensure that limited resources are initially targeted to areas of highest need. These findings may have implications for the other countries with similar patterns of childhood illness and food insecurity.

Editors’ note: The five-fold difference in HIV prevalence between the highest rate nutrition rehabilitation units in the south and the lowest rate units in the central region has practical implications for efficient resource allocation. Southern units will need larger food allocations as kids stay longer in the programme and they will require more antiretroviral drugs, cotrimoxasole and antifungal agents. Paediatric HIV testing is clearly acceptable in Malawi nutrition rehabilitation units and should be promoted everywhere that access to effective prevention, treatment, and care services can be assured.

Sebert Kuhlmann AK, Kraft JM, Galavotti C, Creek TL, Mooki M, Ntumy R. Radio role models for the prevention of mother-to-child transmission of HIV and HIV testing among pregnant women in Botswana. Health Promot Int. 2008 Apr 11 [Epub ahead of print]

Although Botswana supports a program for the prevention of mother-to-child-transmission of HIV (PMTCT), many women initially did not take advantage of the program. Using data from a 2003 survey of 504 pregnant and post-partum women, Sebert Kuhlmann and his colleagues assessed associations between exposure to a long-running radio serial drama that encourages use of the PMTCT program and HIV testing during pregnancy. Controlling for demographic, pregnancy and other variables, women who spontaneously named a PMTCT character in the serial drama as their favourite character were nearly twice as likely to test for HIV during pregnancy as those who did not. Additionally, multiparity, knowing a pregnant woman taking AZT, having a partner who tested, higher education and PMTCT knowledge were associated with HIV testing during pregnancy. Identification with characters in the radio serial drama is associated with testing during pregnancy. Coupled with other supporting elements, serial dramas could contribute to HIV prevention, treatment and care initiatives.

Editors’ note: This programme went further than public service announcements and counselling sessions to raise awareness of PMTCT services. It used two fundamental principles: modelling (showing people how to change) and reinforcement (supporting their efforts to change and to maintain healthy behaviours). The radio drama was the modelling component and may have helped some women to see HIV testing in pregnancy as a good choice supported by social norms. It is interesting to speculate whether this programme paved the way for broad acceptance of the introduction of a routine offer of antenatal testing in 2004.

Wringe A, Isingo R, Urassa M, Maiseli G, Manyalla R, Changalucha J, Mngara J, Kalluvya S, Zaba B. Uptake of HIV voluntary counselling and testing services in rural Tanzania: implications for effective HIV prevention and equitable access to treatment. Trop Med Int Health. 2008;13(3):319-27.

Wringe and colleagues aimed to describe the associations between socio-demographic, behavioural and clinical characteristics and the use of HIV voluntary counselling and testing (VCT) services among residents in a rural ward in Tanzania. Eight thousand nine hundred and seventy participants from a community-based cohort were interviewed, provided blood for research HIV testing, and were offered VCT. Univariate and multivariate logistic regression was used to identify socio-demographic, clinical, and behavioural factors associated with VCT use. Although 31% (1246/3980) of men and 24% (1195/4990) of women expressed an interest in the service, only 12% of men and 7% of women subsequently completed VCT. Socio-demographic factors, such as marital status, area of residence, religion and ethnicity influenced VCT completion among males and females in different ways, while self-perceived risk of HIV, prior knowledge of VCT, and sex with a high-risk partner emerged as important predictors of VCT completion among both sexes. Among males only, those infected with HIV for 5 years or less tended to self-select for VCT compared to HIV-negatives (adjusted odds ratio = 1.43; 95% CI: 0.99-2.14). This contributed to a higher proportion of HIV-positive males knowing their status compared to HIV-positive females.  In this setting, a disproportionate number of HIV-positive women are failing to learn their status, which has implications for equitable access to onward referral for care and treatment services. Evidence that some high-risk behaviours may prompt VCT use is encouraging, although further interventions are required to improve knowledge about HIV risk and the benefits of VCT. Targeted interventions are also needed to promote VCT uptake among married women and rural residents.

Editors´note: Both the proportion of people interested in learning their HIV serostatus and the proportion of people who actually got tested are very low for a country with a sizeable HIV epidemic. It is likely that fear of stigma and discrimination had remained an important barrier to HIV testing during this study, since the Tanzanian government had already announced on radio and in newspapers that it intended to start providing free antiretroviral treatment though major hospitals.

Pai NP, Barick R, Tulsky JP, Shivkumar PV, Cohan D, Kalantri S, Pai M, Klein MB, Chhabra S. Impact of round-the-clock, rapid oral fluid HIV testing of women in labor in rural India. PLoS Med. 2008;5(5):e92.

Testing pregnant women for HIV at the time of labour and delivery is the last opportunity for prevention of mother-to-child HIV transmission measures, particularly in settings where women do not receive adequate antenatal care. However, HIV testing and counselling of pregnant women in labour is a challenge, especially in resource-constrained settings. In India, many rural women present for delivery without any prior antenatal care. Those who do get antenatal care are not always tested for HIV, because of deficiencies in the provision of HIV testing and counselling services. In this context, we investigated the impact of introducing round-the-clock, rapid, point-of-care HIV testing and counselling in a busy labour ward at a tertiary care hospital in rural India. After they provided written informed consent, women admitted to the labour ward of a rural teaching hospital in India were offered two rapid tests on oral fluid and finger-stick specimens (OraQuick Rapid HIV-1/HIV-2 tests, OraSure Technologies). Simultaneously, venous blood was drawn for conventional HIV ELISA testing. Western blot tests were performed for confirmatory testing if women were positive by both rapid tests and dual ELISA, or where test results were discordant. Round-the-clock (24 h, 7 d/wk) abbreviated prepartum and extended postpartum counselling sessions were offered as part of the testing strategy. HIV-positive women were administered prevention of mother-to-child HIV transmission interventions. Of 1,252 eligible women (age range 18 y to 38 y) approached for consent over a 9 month period in 2006, 1,222 (98%) accepted HIV testing in the labour ward. Of these, 1,003 (82%) women presented with either no reports or incomplete reports of prior HIV testing results at the time of admission to the labour ward. Of 1,222 women, 15 were diagnosed as HIV-positive (on the basis of two rapid tests, dual ELISA and Western blot), yielding a seroprevalence of 1.23% (95% confidence interval [CI] 0.61%-1.8%). Of the 15 HIV test-positive women, four (27%) had presented with reported HIV status, and 11 (73%) new cases of HIV infection were detected due to rapid testing in the labour room. Thus, 11 HIV-positive women received prevention of mother-to-child transmission interventions on account of round-the-clock rapid HIV testing and counselling in the labour room. While both OraQuick tests (oral and finger-stick) were 100% specific, one false-negative result was documented (with both oral fluid and finger-stick specimens). Of the 15 HIV-infected women who delivered, 13 infants were HIV seronegative at birth and at 1 and 4 mo after delivery; two HIV-positive infants died within a month of delivery. In a busy rural labour ward setting in India, Pai and colleagues demonstrated that it is feasible to introduce a program of round-the-clock rapid HIV testing, including prepartum and extended postpartum counselling sessions. Their data suggest that the availability of round-the-clock rapid HIV testing resulted in successful documentation of HIV serostatus in a large proportion (82%) of rural women who were unaware of their HIV status when admitted to the labour room. In addition, 11 (73%) of a total of 15 HIV-positive women received prevention of mother-to-child transmission interventions because of round-the-clock rapid testing in the labour ward. These findings are relevant for prevention of mother-to-child transmission programs in developing countries.

Editors´note: Despite the fact that labour is not an ideal time to make a decision about learning one’s serostatus, offering HIV testing during labour is the last chance for women who have had no antenatal care or were not given the opportunity to be tested during pregnancy. Acceptance was high in this study, with HIV prevalence of 1.23% mirroring the 1% anticipated in recent antenatal sentinel surveillance. Studies of cost-effectiveness may be needed to convince policy makers in some resource-constrained settings that this “catch up” approach for women of unknown HIV status has merit.

Zhang Q, Wang L, Jiang Y, Fang L, Pan P, Gong S, Yao J, Tang YW, Vermund SH, Jia Y. Early infant HIV-1 diagnosis suitable for resource-limited settings with multiple circulating subtypes: Nested, 3-monoplex DNA PCR on dried blood spots. J Clin Microbiol. 2007; 46(2):721-6.

Early infant diagnosis of HIV-1 infection is complicated by the persistence of maternal antibodies and by diverse HIV-1 subtypes. Zhang and colleagues developed a nested, 3-monoplex HIV-1 DNA polymerase chain reaction (N3M-PCR) assay to detect diverse HIV-1 subtypes in infants born to infected mothers. They optimized the test for use with dried blood spot samples for ease of storage and transport from rural China to central laboratories. Six pairs of primers were designed targeting env, gag, and pol genomes run in three reactions with an analytical sensitivity of 10 copies DNA per reaction to cover nine HIV-1 subtypes A, B, C, D, F, G, CRF01_AE, CRF08_BC, and CRF07_BC. Assay performance was evaluated on 347 dried blood spot specimens from 151 exposed infants in four diverse provinces of China with multiple circulating subtypes. Results were compared with HIV antibody enzyme immunoassay and Western blot confirmation in the infants at >/=18 months of age, or convincing clinical and epidemiologic data for deceased infants. Sensitivity of the N3M-PCR assay was 30.0% (3/10) for infants at 48 hours after birth, 91.7% (11/12) at 1-2 months, and 93.7% (15/16) at 3-6 months of age. Specificity was 100% (94/94) at all three time points. The polymerase chain reaction reproducibility in the three DNA regions was 100% for samples at 48 hours after birth, 96.7% at 1-2 months, and 100% at 3-6 months of age. The HIV-1 DNA N3M-PCR assay on dried blood spots offers a simple and affordable approach for early infant HIV-1 diagnosis in regions with diverse HIV-1 circulating subtypes.

Editors’ note: The numbers of samples tested in this study in China are small but the results are very encouraging. This polymerase chain reaction (PCR) test is detecting the virus, not antibody, and its performance is judged against the presence of antibodies after 18 months of age. Test sensitivity is good by one month when the test is missing up to 10% of infected infants and test specificity is excellent (no false positive results) from 48 hours of life on. Dried blood spots (DBS) require minimal storage facilities because they are stable at room temperature for prolonged periods and can be safely and easily shipped for centralised testing with economies of scale. As for the DBS-ELISA of Patton et al (below), further testing of the DBS-PCR for infant diagnosis is now needed on a larger scale.

The diagnostic accuracy of the modified p24 Ag assay on paediatric dried blood spots was evaluated. Samples analyzed within 6 weeks of collection yielded no false positive results (specificity 100%) and few false negative results (sensitivity 96.5%-98.3%). Laboratory services with limited resources should assess this option for routine infant diagnosis.

Editors’ note: In this South African study, dried blood spot specimens from 147 six-week old babies born to HIV-seropositive mothers and 99 children known to be infected (median age 20 months) were tested with good sensitivity and excellent specificity. Dried blood spots were obtained from capillary blood obtained by heel stick. The test was an ultra sensitive 24 antigen ELISA and specimens were collected on two types of filter paper. Storage with a desiccant conserved test sensitivity. As with the DBS-PCR of Zhang et al (above), testing should proceed in other settings with larger numbers to validate these findings.

Chomba E, Allen S, Kanweka W, Tichacek A, Cox G, Shutes E, Zulu I, Kancheya N, Sinkala M, Stephenson R, Haworth A. Evolution of Couples’ Voluntary Counseling and Testing for HIV in Lusaka, Zambia. J Acquir Immune Defic Syndr 2008; 47(1):108-15.

Chomba and colleagues describe promotional strategies for couples’ voluntary HIV counselling and testing and demographic risk factors for couples in Lusaka, Zambia, where an estimated two thirds of new infections occur in cohabiting couples. Couples’ voluntary HIV counselling and testing attendance as a function of promotional strategies is described over a 6-year period. Cross-sectional analyses of risk factors associated with HIV in men, women, and couples are presented. Community workers recruited from couples seeking voluntary HIV counselling and testing promoted testing in their communities. Attendance dropped when community worker outreach ended, despite continued mass media advertisements. In Lusaka, 51% of 8500 cohabiting couples who sought HIV testing were concordant negative for HIV and 26% concordant positive; 23% of couples were serodiscordant (that is, had 1 HIV-positive partner/1 HIV-negative partner), with 11% HIV-positive man/HIV-negative woman and 12% HIV-negative man/HIV-positive woman. HIV infection was associated with men’s age 30 to 39, women’s age 25 to 34, duration of union <3 years, and number of children <2. Even among couples with only 1-2 or no risk factors, HIV prevalence was 45% and 29%, respectively. Many married African adult couples do not have high-risk profiles, nor do they realize that one of the partners may have HIV. Active and sustained promotion is needed to encourage all couples to be jointly tested and counselled.

Editors’ note: This study highlights the importance of knowing your epidemic and tailoring effective responses to it. In mature HIV epidemics such as this one, as much as two-thirds of all HIV transmission is occurring within cohabiting couples. Serodiscordant couples have an HIV prevalence of 50% in their marital bed of which they may be unaware. Community mobilisation to create new social norms around knowledge of serostatus and the advantages of joint testing can provide couples with the opportunity to learn how they can prevent HIV from entering, or being transmitted within, their couple, while linking those already infected to treatment and support services. This study focused on couples seeking testing but home-based testing outreach in the community can achieve very high uptake with few negative social consequences if communities are engaged in the design, conduct, and evaluation of such programmes.

Prost and colleagues explore the feasibility and acceptability of translating a successful voluntary counselling and testing service model from Kenya to African communities in London. The authors conducted a qualitative study with focus group discussions and a structured workshop with key informants. Five focus group discussions were conducted in London with 42 participants from 14 African countries between August 2006 and January 2007. A workshop was held with 28 key informants. Transcripts from the group discussions and workshop were analysed for recurrent themes. Participants indicated that a community-based HIV voluntary counselling and testing service would be acceptable to African communities in London, but also identified barriers to uptake: HIV-related stigma, concerns about confidentiality, and doubts about the ability of community-based services to maintain professional standards of care. Workshop participants highlighted three key requirements to ensure feasibility: (a) efficient referrals to sexual health services for the newly diagnosed; (b) a locally appropriate testing algorithm and quality assurance scheme; (c) a training programme for voluntary counselling and testing counsellors. In conclusion, offering a community-based voluntary counselling and testing with rapid HIV tests appears feasible within a UK context and acceptable to African communities in London, provided that clients’ confidentiality is ensured and appropriate support is given to the newly diagnosed. However, the persistence of concerns related to HIV-related stigma among African communities suggests that routine opt-out testing in healthcare settings may also constitute an effective approach to reducing the proportion of late diagnoses in this group. HIV service models and programmes from Africa constitute a valuable knowledge base for innovative interventions in other settings, including developed countries.

Editors’ note: Provider-initiated testing and counselling can reduce the proportion of late diagnoses among African communities in cities such as London but it does not address the issue of HIV-related stigma. Research such as this, working with communities to identify barriers and facilitators of feasibility and acceptance, is key to ensuring that community-based testing increases knowledge of serostatus in a supportive environment.

Chersich MF, Luchters SM, Othigo MJ, Yard E, Mandaliya K, Temmerman M. HIV testing and counselling for women attending child health clinics: an opportunity for entry to prevent mother-to-child transmission and HIV treatment. Int J STD AIDS. 2008 Jan;19(1):42-6.

This study assessed the potential for HIV testing at child health clinics to increase knowledge of HIV status, and entry to infant feeding counselling and HIV treatment. At a provincial hospital in Mombasa, Kenya, HIV testing and counselling were offered to women bringing their child for immunization or acute care services. Most women said HIV testing should be offered in these clinics (472/493, 95.7%), with many citing the benefits of regular testing and entry to prevent mother-to-child transmission. Of 500 women, 416 (83.4%) received test results, 97.6% on the same day. After 50 participants, point-of-care testing replaced laboratory-based rapid testing. Uptake increased 2.6 times with point-of-care testing (95% confidence interval = 1.4-5.1; P = 0.003). Of 124 women who had not accessed HIV testing during pregnancy, 98 tested in the study (79.0%). Measured by uptake and attitudes, HIV testing in child health clinics is acceptable. This could optimize entry into HIV treatment, infant feeding counselling and family planning services.

Editors’ note: One in four women in this study had not accessed HIV testing during pregnancy, limiting their access to antenatal, perinatal, and post-partum HIV prevention services. Offering HIV testing for mother and father at well-baby clinics and paediatric acute care services can identify babies that have been exposed to HIV infection for cotrimoxazole prophylaxis and assist parents with unmet needs for family planning, an important component (prong 2) of prevention of mother-to-child transmission programmes. If current trials of antiretroviral prophylaxis during breastfeeding prove it is effective, there will be yet another benefit of post-partum HIV testing and counselling.

Ersoy N, Akpinar A. Attitudes about prenatal HIV testing in Turkey. Nurs Ethics. 2008 Mar;15(2):222-33.

The aim of this study was to assess the attitudes of Turkish pregnant women and antenatal health care providers towards prenatal HIV testing. A self-administered questionnaire was used. The relationships between the different groups’ knowledge and attitudes were analysed by using the chi-squared statistic. A total of 494 pregnant women and 181 care providers participated. Forty-four per cent of the pregnant women thought that prenatal HIV testing should be mandatory, and 84% of the health care providers thought it should be performed routinely or be mandatory. The majority of the pregnant women (74%) and half of the care providers agreed that the test results should be disclosed first to the pregnant woman. The study results also revealed that most of the prenatal care providers would not protect pregnant women’s autonomy and privacy, contrary to the pregnant women’s own preferences. It is essential to establish national prenatal HIV testing policies in order to prevent unethical practices and ensure satisfaction for pregnant women and health care providers.

Editors’ note: These discrepancies in the attitudes of prenatal care providers and pregnant women are striking and underscore the importance of Turkey moving now to establish a national policy and programming framework for client-initiated and provider-initiated HIV testing. Protecting the autonomy and privacy of pregnant women, preventing discrimination and stigmatisation of those found to be HIV-positive, providing treatment and care, and agreeing on choices for serostatus disclosure are among the key elements of such a framework.

Ncama BP. Acceptance and disclosure of HIV status through an integrated community/home-based care program in South Africa. Int Nurs Rev 2007;54(4):391-7.

This was a comparative study of acceptance and disclosure of the HIV status among people living with HIV (PLHIV) served by an integrated community/home-based care programme and those who are not in any home-based care programme. One of the major challenges in HIV care in developing countries is acceptance and disclosure of a positive HIV status by PLHIV. Denial and non-disclosure of HIV status hinders prevention efforts as well as access to treatment, care and support for these people. Quantitative data were collected in 2004 from a group of PLHIV served by the integrated community/home-based care programme and a group that was not receiving any community/home-based care. Data were compared between the two groups in terms of acceptance and disclosure of HIV status. The integrated community/home-based care programme was effective in improving acceptance and disclosure of the HIV-positive status by PLHIV. People living with HIV in the integrated community/home-based care programme did not find disclosure of their status difficult, and had disclosed their positive HIV status to more people than those who were not in any programme. PLHIV in the integrated community/home-based care programme not only disclosed their positive HIV status within their family network and households, but also disclosed to the community in general, sports group, religious groups and other social networks. Ncama and colleagues conclude that community/home-based care programmes can serve as catalysts for acceptance and disclosure of a positive HIV status by people living with HIV.

Editors’ note: Home-based care services such as this one can foster an individual’s acceptance of his/her HIV status. Disclosure of one’s HIV status, which is linked to acceptance of an HIV-positive diagnosis, is the first step in accessing family and community support. The more that people can come to terms with and disclose their HIV status, the more likely it is that their community’s awareness, openness, and understanding about HIV will increase, particularly in the context of access to care and treatment for those in need.

De Baets AJ, Sifovo S, Parsons R, Pazvakavambwa IE. HIV disclosure and discussions about grief with Shona children: A comparison between health care workers and community members in Eastern Zimbabwe. Soc Sci Med 2008; 66: 479-491.

Research in HIV-related counselling for African children has concentrated on urban tertiary hospitals, but most children have their first health care encounter at a rural primary health care centre. This study investigated perceptions about the acceptability of disclosing the parents’ or child’s HIV status to a child and talking about grief with children, as well as the preferred time, type, and setting for HIV disclosure. An anonymous survey was taken from 64 primary health care workers and 131 community members from rural Eastern Zimbabwe. The results expressed a high need and desire for such communications and should be interpreted against a background of high perceived confidence to talk about grief with adults and a high degree of familiarity with child bereavement and foster care. The participants preferred that partial disclosure occurs from the age of 10.8 (+/-4.2) years and full disclosure from the age of 14.4 (+/-4.5) years.  Compared to community members, health care workers were significantly more open to full disclosure and disclosure at a younger age but were slightly less open to discussing grief. The different preferred combinations of persons to initiate such communications included a health care worker in up to 56% of the responses and a family member in up to 52%. The most commonly preferred family members were father’s sister (up to 37%) and grandmother (up to 40%) rather than the partner (up to 15%). Southern African family dynamics may hinder a mother initiating HIV disclosure and discussions about grief, even though she is traditionally present during HIV diagnosis, counselling, and health education. A more culturally adapted approach than the standard Western ‘couple approach’ may thus be required.  Consequently, counselling training models may need to be adapted. Further research into empowering mothers to involve significant members from the extended family may be highly beneficial.

Editors’ note: The high acceptability of disclosure to children of their own and/or their parents’ serostatus and the perceived need for open communication about grief seen in this study contrasts with assumptions that there is great stigma in rural communities. Accommodating cultural sensitivities means that health care workers should ask the parents to bring the most appropriate family member to attend the child’s counselling sessions, unless parents prefer to initiate HIV disclosure and discussions about grief with their own children without any assistance – one third preferred this option in this study.