Date Published: July 25, 2017
Publisher: Public Library of Science
Author(s): Victoria Simms, Ethel Dauya, Subathira Dakshina, Tsitsi Bandason, Grace McHugh, Shungu Munyati, Prosper Chonzi, Katharina Kranzer, Getrude Ncube, Collen Masimirembwa, Roslyn Thelingwani, Tsitsi Apollo, Richard Hayes, Helen A. Weiss, Rashida A. Ferrand, Alexander C. Tsai
Abstract: BackgroundChildren living with HIV who are not diagnosed in infancy often remain undiagnosed until they present with advanced disease. Provider-initiated testing and counselling (PITC) in health facilities is recommended for high-HIV-prevalence settings, but it is unclear whether this approach is sufficient to achieve universal coverage of HIV testing. We aimed to investigate the change in community burden of undiagnosed HIV infection among older children and adolescents following implementation of PITC in Harare, Zimbabwe.Methods and findingsOver the course of 2 years (January 2013–January 2015), 7 primary health clinics (PHCs) in southwestern Harare implemented optimised, opt-out PITC for all attendees aged 6–15 years. In February 2015–December 2015, we conducted a representative cross-sectional survey of 8–17-year-olds living in the 7 communities served by the study PHCs, who would have had 2 years of exposure to PITC. Knowledge of HIV status was ascertained through a caregiver questionnaire, and anonymised HIV testing was carried out using oral mucosal transudate (OMT) tests. After 1 participant taking antiretroviral therapy was observed to have a false negative OMT result, from July 2015 urine samples were obtained from all participants providing OMTs and tested for antiretroviral drugs to confirm HIV status. Children who tested positive through PITC were identified from among survey participants using gender, birthdate, and location. Of 7,146 children in 4,251 eligible households, 5,486 (76.8%) children in 3,397 households agreed to participate in the survey, and 141 were HIV positive. HIV prevalence was 2.6% (95% CI 2.2%–3.1%), and over a third of participants with HIV were undiagnosed (37.7%; 95% CI 29.8%–46.2%). Similarly, among the subsample of 2,643 (48.2%) participants with a urine test result, 34.7% of those living with HIV were undiagnosed (95% CI 23.5%–47.9%). Based on extrapolation from the survey sample to the community, we estimated that PITC over 2 years identified between 18% and 42% of previously undiagnosed children in the community. The main limitation is that prevalence of undiagnosed HIV was defined using a combination of 3 measures (OMT, self-report, and urine test), none of which were perfect.ConclusionsFacility-based approaches are inadequate in achieving universal coverage of HIV testing among older children and adolescents. Alternative, community-based approaches are required to meet the Joint United Nations Programme on HIV/AIDS (UNAIDS) target of diagnosing 90% of those living with HIV by 2020 in this age group.
Partial Text: Worldwide, an estimated 1.8 million children under the age of 15 years are living with HIV, 90% of them in sub-Saharan Africa . The incidence of HIV infection in infants has fallen substantially over the past decade because of the scale-up of interventions for prevention of mother-to-child HIV transmission (PMTCT), but coverage of PMTCT programmes remains suboptimal, with 150,000 infants infected worldwide in 2015 . Importantly, an estimated 51% of children living with HIV were not receiving antiretroviral therapy (ART) in 2015, mainly because of low rates of HIV testing and, hence, underdiagnosis .
Ethical approval for the study was obtained from the Medical Research Council of Zimbabwe (MRCZ/A/1676) and the Ethics Committees of Harare City Health Services, the Biomedical Research and Training Institute (BRTI) (AP 108/2012), and the London School of Hygiene and Tropical Medicine (6305).
One CEA was replaced because it was an undeveloped plot of land, and 6 were replaced because the Zimbabwe Central Statistics Office could not provide maps. Of the 150 selected CEAs, 130 (86.7%) were surveyed (S1 Table). Eighteen CEAs in 1 area were not surveyed within the time limit of the survey, and 2 contained police private accommodation, which the study team was not given permission to survey. The 18 missing CEAs were not known to be different from those included in the survey. Urine samples were collected in 71 (54.6%) CEAs, and analyses of this subset were weighted using inverse probability weighting to represent the whole population within the 6 communities that collected urine samples. The median number of households per CEA was 23.5 (IQR 18–29). The survey team visited 8,300 households, of which 668 were vacant, 138 refused enumeration, and 7,494 (90.3%) were enumerated, with 4,251 containing at least 1 child aged 8–17 years. Refusing households were evenly distributed by community and over time. In terms of demographic characteristics, there was no difference between children whose caregivers refused consent, or who did not assent, to the trial and those who participated.
This study demonstrates a substantial burden of undiagnosed HIV infection among older children and especially among adolescents. More than a third of children aged 8–17 years living with HIV in the community remained undiagnosed after 2 years of PITC.