Superior Uptake and Outcomes of Early Infant Diagnosis of HIV Services at an Immunization Clinic Versus an “Under-Five” General Pediatric Clinic in Malawi
ABSTRACT Although the Malawian government recommends HIV-exposed infants receive early infant diagnosis (EID) of HIV at "under-five" pediatric clinics (U5Cs), most never enroll. Therefore, we evaluated the integration of EID testing into an immunization clinic (IC) compared with the current standard of EID testing at an U5C.
Prospective observational study.
Using routine provider-initiated HIV testing and counseling (PITC) registers, we prospectively studied 1757 children offered PITC at a government IC and U5C. Infants tested by HIV DNA polymerase chain reaction (PCR) were followed until PCR result disclosure or defaulting.
We sampled 877 and 880 consecutive PITC recipients at U5C and IC, respectively. Overall, a 7-fold greater proportion received PITC at IC (84.2% vs. 11.4%, P < 0.001). PITC recipients at IC were more than 14 months younger (2.6 vs. 17.0, P < 0.001), with greater proportions HIV exposed (17.6% vs. 5.3%, P < 0.001) and PCR eligible (7.9% vs. 3.5%, P < 0.001). A higher percentage of IC infants accepted PCR testing (100.0% vs. 90.3%, P = 0.03). Additionally, IC PCR recipients were 2.5 months younger (3.1 vs. 5.6, P < 0.001) with 4 times less testing PCR positive (7.1% vs. 32.1%, P < 0.001). Importantly, a more than 3-fold greater proportion of HIV-exposed infants at IC returned for their PCR result and enrolled into care (78.6% vs. 25.0%, P < 0.001).
Compared with an U5C, integrating EID testing into an IC is more acceptable, more feasible, enrolls more infants into EID at younger ages, and would likely strengthen Malawi's EID services if expanded.
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ABSTRACT: OBJECTIVE:: Determine how routine inpatient provider-initiated HIV testing differs from traditional community-based client-initiated testing with respect to clinical characteristics of children identified and outcomes of outpatient HIV care. DESIGN:: Prospective observational cohort. METHODS:: Routine clinical data were collected from children identified as HIV-infected by either testing modality in Lilongwe, Malawi in 2008. After one year of outpatient HIV care at the Baylor College of Medicine Clinical Center of Excellence, outcomes were assessed. RESULTS:: Of 742 newly-identified HIV-infected children enrolling into outpatient HIV care, 20.9% were identified by routine inpatient HIV testing. Compared to community-identified children, hospital-identified patients were younger (median 25.0 vs 53.5 months), with more severe disease (22.2% vs 7.8% WHO stage IV). Of 466 children with known outcomes, 15.0% died within the first year of HIV care; median time to death was 15.0 weeks for community-identified children vs 6.0 weeks for hospital-identified children. The strongest predictors of early mortality were severe malnutrition (hazard ratio, 4.3; 95% confidence interval, 2.2 - 8.3), moderate malnutrition (hazard ratio, 3.2; confidence interval, 1.6 - 6.6), age <12 months (hazard ratio, 3.2; 95% confidence interval, 1.4 - 7.2), age 12-24 months (hazard ratio, 2.5; 95% confidence interval, 1.1 - 5.7), and WHO stage IV (hazard ratio, 2.2; 95% confidence interval, 1.1 - 4.6). After controlling for other variables, hospital identification did not independently predict mortality. CONCLUSIONS:: Routine inpatient HIV testing identifies a subset of younger HIV-infected children with more severe, rapidly-progressing disease that traditional community-based testing modalities are currently missing.JAIDS Journal of Acquired Immune Deficiency Syndromes 01/2013; 63(1). DOI:10.1097/QAI.0b013e318288aad6 · 4.39 Impact Factor
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ABSTRACT: Early infant diagnosis (EID) of HIV infection is an important service to reduce paediatric morbidity and mortality related to HIV/AIDS. Although South Africa has a national EID programme based on PCR testing, there are no population-wide data on the linkage of infants testing HIV PCR-positive to HIV care and treatment services. We conducted a retrospective analysis of all public sector laboratory data from across the Western Cape province between 2005 and 2011. We linked positive HIV PCR results to subsequent HIV viral load testing to determine the proportion of infants who were successfully linked to HIV care. A total of 83 698 unique infant HIV PCR tests were documented, of which 6322 (8%) were PCR positive. The proportion of PCR-positive children declined from 12% in 2005 to 3% in 2011. Of the children testing PCR-positive, 4105 (65%) had subsequent viral load testing indicating successful linkage to care. The proportion of successfully linked infants increased from 54% in 2005 to 71% in 2010, while the median delay in days to successful linkage decreased from 146 days in 2005 to 33 days in 2010. From 2005 to 2011 there has been a reduction in the proportion of children testing HIV PCR-positive, and an increase in the proportion of infected infants successfully linked to HIV care and treatment, in this setting. However a large proportion of infected infants remain unlinked to antiretroviral therapy services and there is a clear need for interventions to further strengthen EID programmes.PLoS ONE 02/2013; 8(2):e55308. DOI:10.1371/journal.pone.0055308 · 3.53 Impact Factor
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ABSTRACT: To reach virtual elimination of pediatric HIV, programs for the prevention of mother-to-child HIV transmission (PMTCT) must expand coverage and achieve long-term retention of mothers and infants. Although PMTCT have been traditionally aligned with maternal, newborn, and child health (MNCH) services, novel approaches are needed to address the increasing demands of evolving global PMTCT policies. PMTCT-MNCH integration has improved the uptake and timely initiation of antiretroviral therapy (ART) among treatment-eligible pregnant women in public health settings. Postpartum engagement of HIV-infected mothers and HIV-exposed infants has been insufficient, although alignment of visits to the childhood immunization schedule and establishment of integrated mother-infant clinics may increase retention. Evidence also suggests that the integration of maternal HIV testing into childhood immunization clinics can significantly increase the identification of at-risk HIV-exposed infants previously missed by traditional PMTCT models. Targeted service integration models can improve PMTCT uptake. However, as global PMTCT policy shifts to universal provision of maternal ART during pregnancy (i.e., Option B/B+), these findings must be reexamined in the context of increased service demand and systems burden. Intensive evaluation is needed to ensure quality clinical care is maintained both for PMTCT and for underpinning MNCH services.Current opinion in HIV and AIDS 07/2013; DOI:10.1097/COH.0b013e3283637f7a · 4.39 Impact Factor