Date Published: July 20, 2010
Publisher: Public Library of Science
Author(s): Scott Kellerman, Shaffiq Essajee
Abstract: Scott Kellerman and Shaffiq Essajee argue that the time has come to increase access to HIV testing for children, especially in sub-Saharan Africa.
Partial Text: In many African countries, HIV has reversed previously recorded declines in child mortality. Worldwide, children account for 18% of HIV-related deaths and 15% of HIV infections each year –, an estimated 2.3 million children are infected, and 730,000 urgently need antiretroviral therapy (ART), which only about 275,000 currently receive. The mortality of untreated pediatric patients is very high in the first 2 years of life, and reaches 80% by age 5 . While the number of children under age 15 in low- and middle-income countries receiving ART rose dramatically between 2005 and 2007 (Figure 1), it is nonetheless evident that those children currently on treatment still represent only a small proportion of those who need it. Coverage will need to be greatly expanded if the global community’s goal of providing ART to 80% of children in need by 2010 is to be met .
Current approaches to testing infants and children center on PMTCT programs. New approaches should build on the considerable success realized by PMTCT while its shortcomings are recognized. Routine testing of newborns may be an appropriate approach to identify infants missed by PMTCT programs, particularly in countries with high prevalence, while more targeted testing of infants and children at greater risk may be more cost effective for lower-prevalence countries. Regardless of the approach, there are significant challenges to testing children for HIV. In infants younger than 18 months, the persistence of maternal antibodies, the lack of appropriate laboratory facilities for PCR testing, the cost of assays, and the need to repeat PCRs in infants who are exposed to infected breast milk , make it difficult to implement infant diagnosis programs. WHO estimates that, in 2007, only 8% of infants known to be HIV-exposed were tested for HIV within the first 2 months of life . Waiting for infants to develop symptoms or become old enough to test using standard rapid tests is not ideal but has become the norm in many places, resulting in children tested late in the course of their infection, when ART may be less effective.
Two groups of strategies that may be useful for case finding of children missed by PMTCT are presented here. First-tier strategies use existing systems to incorporate pediatric HIV testing into established entry points to care, whereas second-tier strategies require the development of new programs or systems to actively seek out and diagnose infected children and link them to care (Figure 2). First-tier approaches include variations of provider or program-initiated testing such as testing newborns when they present for immunizations—which may prove cost-effective in countries with high HIV prevalence. In such hyperendemic settings, an initial rapid test could be used as a screen to test mothers or their newborns, with a subsequent PCR for infants who test positive or whose mothers are positive. While such screening is potentially expensive, higher prevalence rates, and thus higher rates of diagnosis, may justify the increased costs. One study of routine testing in immunization clinics found that testing was well accepted and identified a large number of exposed children with an overall seropositivity rate of 10% . In lower-prevalence settings, connecting the offer of testing to points of care where the concentration of infected children is likely to be higher such as pediatric inpatient wards, nutrition rehabilitation units, and tuberculosis clinics may be effective. In one recent report, 80% of parents accepted testing in pediatric inpatient wards, yielding a seroprevalence rate of 29% . In Zambia, children admitted to the malnutrition ward were found to have high HIV prevalence rates (Marc Bulterys, personal communication). Medical settings, while an obvious point of contact, are not the only venues through which to reach affected children. Community organizations, especially those serving orphans or adults living with HIV, can also be important partners in expanding access to pediatric testing.
Many of the strategies proposed here have been tried and evaluated; however, implementing them in a coordinated fashion in resource-limited settings requires new investments. Provider-initiated testing in pediatric wards, routine testing of newborns and infants in immunization clinics, and door-to-door and family testing have all been attempted in sub-Saharan Africa. What is needed now is a more coordinated effort at the national level to ensure that infected children known to be exposed to HIV and those missed by PMTCT are identified and linked to care. Although challenging, especially when one weighs the parents’ right to confidentiality against the child’s right to care, a standardized approach to childhood testing is feasible. Indeed, in the US many states perform mandatory testing of newborns, allowing the clinician to offer postnatal ARV prophylaxis to the index case, comprehensive HIV care to the mother, and early treatment to the infected child, with resultant near-elimination of pediatric HIV mortality and mother-to-child transmission . Finally, while the costs of establishing routine pediatric testing are not insignificant, they pale in comparison to the societal costs of delayed diagnosis and increased child mortality. Given the challenges of scaling up ART treatment services in resource-limited settings, we believe the targeted approaches described above may be a cost-effective, first strategy to decreasing the pediatric treatment gap in many countries and as with other prevention efforts, should be based on the local epidemiology of the epidemic. It is clear that new approaches and a coordinated response to testing children are necessary to close this gap. The global public health community should make this an urgent priority. Anything less is unacceptable.