Rethinking the challenges of paediatric HIV diagnosis
Authors: Annette H Sohn, Linda-Gail Bekker
Journal: The Lancet HIV (2020)

Diagnosing infants and children with HIV was supposed to have been made easier. Several contact points now exist that create opportunities to complete the paediatric diagnosis process, including routine postnatal care visits and childhood vaccinations. However, achieving early infant diagnosis in the first few months of life has remained one of the lowest global HIV programme metrics. In 2019, antiretrovirals were delivered to 85% of pregnant women living with HIV worldwide, but only 60% of their infants were diagnosed at an age early enough to reduce the high rates of morbidity and mortality from perinatally acquired HIV.1Violari A Cotton MF Gibb DM et al.Early antiretroviral therapy and mortality among HIV-infected infants.N Engl J Med. 2008; 359: 2233-2244Crossref PubMed Scopus (987) Google Scholar Chido Dziva Chikwari and colleagues2Dziva Chikwari C Simms V Kranzer K et al.Comparison of index-linked HIV testing for children and adolescents in health facility and community-based settings in Zimbabwe: findings from the interventional B-GAP study.Lancet HIV. 2020; (published online Nov 13.)https://doi.org/10.1016/S2352-3018(20)30267-8Summary Full Text Full Text PDF PubMed Scopus (1) Google Scholar sought to address this perennial challenge in their study, Bridging the Gap in HIV testing and care for children in Zimbabwe (B-GAP), on the uptake of facility-based and community-based index-linked HIV testing. The research team developed the study after an extensive formal stakeholder engagement process to optimise the identification and testing of children and adolescents (age 2–18 years) at risk of having undiagnosed HIV.3Dziva Chikwari C Simms V Dringus S et al.Evaluating the effectiveness and cost-effectiveness of health facility-based and community-based index-linked HIV testing strategies for children: protocol for the B-GAP study in Zimbabwe.BMJ Open. 2019; 9e029428Crossref PubMed Scopus (3) Google Scholar Their strategy was to focus on households with caregivers living with HIV and in HIV care in both urban and rural settings, as the index patients of the programme. Families were offered three ways for their children to be tested: at a formal primary health-care facility by a health-care provider; in their homes by a community health worker; or in their homes by the caregivers themselves using an oral fluid test. The option to change the method of testing was available throughout the study. Even in the context of this thoughtfully implemented study with a well resourced and experienced research team, only 1789 (62·3%) of the 2870 eligible index patients had at least one child in their household tested for HIV. The main challenge in two-thirds of cases was not being able to make contact with the children and adolescents, regardless of where or how the testing was to take place. The investigators identified factors associated with increased rates of acceptance and completion of testing that will be useful in guiding future efforts. Most notably, families were more likely to have their child tested if they chose a community-based option. However, their 0·6% testing yield (39 children testing positive of 6062 eligible children) by index-linked testing was lower than expected in comparison with other studies. This outcome might reflect bias in their tested population or the cumulative effect of increasingly successful maternal HIV prevention interventions in the country. However, these results should not take away from the linkage of 36 (92%) children who tested positive for HIV in the study to HIV care, representing a triple dividend of healthier adolescents who will become adults and future parents. Furthermore, we should take note that the median age of children testing positive was 11 years (IQR 8–15), which shows that the majority were adolescents with perinatally acquired HIV who were previously missed by the health care system.4Kariminia A Law M Davies MA et al.Mortality and losses to follow-up among adolescents living with HIV in the IeDEA global cohort collaboration.J Int AIDS Soc. 2018; 21e25215Crossref PubMed Scopus (16) Google Scholar The B-GAP study shows that a differentiated HIV testing approach and task-shifting model (between health-care providers, lay health workers, and caregivers) can be successfully used to diagnose children and adolescents who were lost in the traditional health-care system. In addition, to reach UNAIDS targets for paediatric HIV testing and care,5UNAIDSProgress towards the Start Free, Stay Free, AIDS Free targets. 2020 report.https://www.unaids.org/sites/default/files/media_asset/start-free-stay-free-aids-free-2020-progress-report_en.pdfDate: 2020Date accessed: September 15, 2020Google Scholar we can and should allow for increased patient-driven flexibilities at several decision points. As informed by the study findings, we must become more comfortable as health-care providers, implementers, and policy makers with what is essentially self-testing in the context of paediatric HIV, in which a caregiver can administer a HIV test to their child in their home. The findings of Dziva Chikwari and colleagues are valuable clues to closing the gaps in the global paediatric prevention and treatment cascade. Untested HIV-exposed children and adolescents represent some of the hardest to reach at-risk populations in low-income and middle-income country settings.6Essajee S Bhairavabhotla R Penazzato M et al.Scale-up of early infant HIV diagnosis and improving access to pediatric HIV care in global plan countries: past and future perspectives.J Acquir Immune Defic Syndr. 2017; 75: 51-58Crossref Scopus (19) Google Scholar The B-GAP study reminds us that any intervention to improve paediatric HIV testing needs to appreciate the complex dynamics around parent-to-child HIV transmission, the consequences of orphanhood, and the financial burdens associated with accessing health care. To achieve an AIDS-free future for children, we must work from both ends of the paediatric age spectrum; by focusing on early infant diagnosis around the perinatal period, and by redoubling our efforts to find older children and adolescents who have been hidden from the usual HIV testing approaches for far too long. AHS has received grant funding to her institution from ViiV Healthcare. L-GB declares no competing interests. Comparison of index-linked HIV testing for children and adolescents in health facility and community settings in Zimbabwe: findings from the interventional B-GAP studyThe HIV yield of index-linked testing was low compared with blanket testing approaches in similar settings. Index-linked HIV testing can improve testing uptake among children, although strategies that improve testing uptake in older children are needed. Community based testing by lay workers is a feasible strategy that can be used to improve uptake of HTS among children and adolescents. Full-Text PDF Open Access