Universal HIV Screening at Postnatal Points of Care: Which Public Health Approach for Early Infant Diagnosis in Côte d’Ivoire?

Background:Universal HIV pediatric screening offered at postnatal points of care (PPOC) is an entry point for early infant diagnosis (EID). We assessed the parents’ acceptability of this approach in Abidjan, Côte d’Ivoire.Methods:In this cross-sectional study, trained counselors offered systematic HIV screening to all children aged 6-26 weeks attending PPOC in three community health centers with existing access to HAART during 2008, as well as their parents/caregivers. HIV-testing acceptability was measured for parents and children; rapid HIV tests were used for parents. Both parents’ consent was required according to the Ivorian Ethical Committee to perform a HIV test on HIV-exposed children. Free HIV care was offered to those who were diagnosed HIV-infected.Findings:We provided 3,013 HIV tests for infants and their 2,986 mothers. While 1,731 mothers (58%) accepted the principle of EID, only 447 infants had formal parental consent 15%; 95% confidence interval (CI): [14%-16%]. Overall, 1,817 mothers (61%) accepted to test for HIV, of whom 81 were HIV-infected (4.5%; 95% CI: [3.5%-5.4%]). Among the 81 HIV-exposed children, 42 (52%) had provided parental consent and were tested: five were HIV-infected (11.9%; 95% CI: [2.1%-21.7%]). Only 46 fathers (2%) came to diagnose their child. Parental acceptance of EID was strongly correlated with prenatal self-reported HIV status: HIV-infected mothers were six times more likely to provide EID parental acceptance than mothers reporting unknown or negative prenatal HIV status (aOR: 5.9; 95% CI: [3.3-10.6], p = 0.0001).Conclusions:Although the principle of EID was moderately accepted by mothers, fathers’ acceptance rate remained very low. Routine HIV screening of all infants was inefficient for EID at a community level in Abidjan in 2008. Our results suggest the need of focusing on increasing the PMTCT coverage, involving fathers and tracing children issued from PMTCT programs in low HIV prevalence countries. © 2013 Ndondoki et al. The study was approved by the Ivoirian Ethical Committee (March 2008). The National Ethics Committee, in reference to the law of the civil code n°70–453 of 3 August 1970 on minorities in Cote d’Ivoire, specified that “HIV-testing and care for children who are enrolled in any clinical research study must be conditioned by mutual and written informed consent of both their father and mother.” The PEDI-TEST ANRS 12165 Study was a cross-sectional evaluation of both health care workers and family- acceptability of routine HIV pediatric counseling and testing (CT) as the entry point of a family screening strategy. The study was conducted at three community health facilities (General Hospital of Bonoua, Urban Health Facility of Koumassi and Urban Health Facility of Abobo Avocatier) in Abidjan, Côte d’Ivoire. The study on health care workers acceptability towards routine infant HIV testing was reported elsewhere [24]. Since 2004, those health centers offer comprehensive HIV/AIDS care and treatment program, including HIV voluntary counseling and testing services, PMTCT services, and antiretroviral treatment for children and adults infected by HIV. Any child aged 6–26 weeks attending postnatal care at any pediatric service (immunization, weighing and consultation) in either three centers, was eligible for this study with four sequential contacts over a three-month period. Their parents/caregivers (mother, father, caregiver or legal guardian) were also eligible for this survey. At the first contact, trained counselors offered systematic early infant diagnosis to index children and an HIV CT to their mother/parents/caregiver. Counselors translated and explained the study information sheet in mother -tongue to illiterate women. The process of the HIV testing method, return appointments, and provision of results was explained by trained counselors to each caregiver who agreed to participate in the study. An HIV serology was first performed for mothers who accepted their own test. Each mother was encouraged to discuss infant testing with the child’s father or legal guardian before formal acceptance of EID. Mothers returned at home with the study information sheet and the consent form, in order to present them to their partner or the child’s legal guardian. At the second contact two weeks later, the mother’s result was disclosed to her with confidentiality, if she was tested. We collected the parental consent for EID independently of the HIV mother’s status. Then, we performed an HIV testing for all HIV exposed infants for those whose both parents (or legal guardian) had given written informed consent, as required by the Ivoirian Ethical Committee. Children whose mother was either tested HIV-positive at the first contact or HIV-unknown first had a serology before HIV PCR testing. Children whose mother was tested as HIV-uninfected at the first contact were not tested at all, assuming that at this age (<6 months), the nosocomial risk of HIV infection by contaminated injections was low in this context. Real-time PCR was performed only in HIV-exposed infants (defined by a positive rapid test) [25], while adults underwent rapid HIV testing using two parallel assays (Determine®+Genie II®). The child's PCR result was disclosed with confidentiality to parents at the third contact (four weeks after the test), and children diagnosed HIV-infected were referred to the pediatric HIV care program. At the pediatric HIV centre (the fourth contact), free HIV care was offered. All family transport costs were supported by the project. Standardized structured questionnaires were used at the first contact, to collect information on mother's acceptability of EID, then on parents'/caregivers' acceptability of HIV testing for both their infants and themselves. Parents/caregivers were asked about their socio-demographic characteristics, prior experiences with HIV testing and PMTCT services, how they felt about the option of infant testing, and reasons for accepting or declining infant testing. Sub-samples of parents who refused and accepted infant HIV testing were interviewed at each pediatric health center by a public health sociologist, using a semi-directive grid tool to further understand the local interpretation of the acceptability of HIV testing in children, the mother's perceptions of EID, the reasons for accepting or refusing HIV testing for their infant, and the constraints and difficulties related to HIV early infant diagnosis. All children whose parents/caregivers received a proposal for a pediatric HIV CT were included in the analysis. First, descriptive baseline characteristics of children and caregivers were analyzed. Next, five outcomes were analyzed: 1) maternal acceptance of infant HIV-testing (defined as the formal mother's consent only; 2) adequate parent's acceptance of infant HIV testing (requiring both parents' signed informed consent: acceptance was deduced from the number of returned informed signed consent); 3) mother's and 4) father's formal acceptance of their own HIV testing; 5) parent/caregiver acceptance of the notification (defined as the proportion of caregivers who returned for infant test results, among those HIV tested). These proportions were expressed as percentages and reported with their 95% confidence intervals. Simple frequency distributions were calculated for responses collected from questionnaires. Associations between categorical variables were assessed using Pearson χ2 test. Univariate and multivariate logistic regression was performed to explore the correlates of first the “maternal acceptance”, then “both parents acceptance”, of infant HIV testing. Independent variables were clinical centre, mother's religion, ability to write, way of live, self-reported prenatal screening, self-reported prenatal status and the disclosure of their HIV status to their partners. A subset of 2962 children with completed mothers' informative records was used to perform this. For the adjusted analysis, we excluded variables with p-value>20% in univariate analysis. The final model was obtained using a backward-stepwise strategy with consideration for interaction and cofounding. The criterion for the statistical significance was set at an α of 0.05. Statistical analysis was performed using SAS 9.1 (TS1M3). The qualitative analysis of parental interviews was done thematically by an inductive approach.