The Effectiveness of Routine Opt-Out HIV Testing for Children in Harare, Zimbabwe

Journal of Acquired Immune Deficiency Syndromes, Volume 71, No. 1, Year 2016

Interprétation

Objective: HIV testing is the entry point to access HIV care. For HIV-infected children who survive infancy undiagnosed, diagnosis usually occurs on presentation to health care services. We investigated the effectiveness of routine opt-out HIV testing (ROOT) compared with conventional opt-in provider-initiated testing and counseling (PITC) for children attending primary care clinics. Methods: After an evaluation of PITC services for children aged 6-15 years in 6 primary health care facilities in Harare, Zimbabwe, ROOT was introduced through a combination of interventions. The change in the proportion of eligible children offered and receiving HIV tests, reasons for not testing, and yield of HIV-positive diagnoses were compared between the 2 HIV testing strategies. Adjusted risk ratios for having an HIV test in the ROOT compared with the PITC period were calculated. Results: There were 2831 and 7842 children eligible for HIV testing before and after the introduction of ROOT. The proportion of eligible children offered testing increased from 76% to 93% and test uptake improved from 71% to 95% in the ROOT compared with the PITC period. The yield of HIV diagnoses increased from 2.9% to 4.5%, and a child attending the clinics post intervention had a 1.99 increased adjusted risk (95% CI: 1.85 to 2.14) of receiving an HIV test in the ROOT period compared with the preintervention period. Conclusion: ROOT increased the proportion of children undergoing HIV testing, resulting in an overall increased yield of positive diagnoses, compared with PITC. ROOT provides an effective approach to reduce missed HIV diagnosis in this age group. An evaluation of PITC for children aged between 6 and 15 years was performed in 6 primary health care clinics (PHCs) in high-density suburbs in Harare, Zimbabwe, between mid-January and mid-May 2013. Each clinic serves 1 suburb and provides comprehensive outpatient primary care, including acute care, maternal and child health services and HIV care services, as well as antenatal, delivery, and postnatal services. Clinical care is provided by nurses, with visits by a doctor on a weekly basis. PITC in all health care facilities has been part of the National Guidelines since 2007. HIV testing in PHCs is usually performed by lay counselors who have undergone certified training in HIV counseling and testing. Activities were initiated in mid-May 2013 in preparation for the introduction of ROOT. These activities were supported by the municipal health authorities and clinic management teams. A 1-day meeting was held for senior nursing personnel (the nurses in charge at each clinic and the district nursing officers) to understand the challenges of providing HIV testing to children in the primary care environment and to discuss the changes that would be required to implement ROOT. This was followed by a 5-day training course at each clinic site for clinic nurses and lay counselors, who are responsible for performing the bulk of the HIV testing. The training focused specifically on issues relating to testing children, including counseling of children and guardians, frameworks for consent and guardianship, the burden of HIV among older children, and the benefits of early treatment. Specifically, HCW were trained on how to implement an opt-out testing model. Further training was not provided during the course of the study. A mentorship program in pediatric HIV was established to provide HCW with ongoing support. An additional lay counselor was deployed at each clinic, whose main task was to perform HIV testing in children when routine clinic staff was unavailable. In addition, a buffer supply of HIV testing kits was made available to ensure an uninterrupted supply. The kits and additional staff were funded by the study for the duration of the study period. The outcomes of ROOT were evaluated over a period of 17 months. The implementation of ROOT involved several activities over a period of 2 months (mid-May to mid-July 2013). Thus, full implementation of ROOT was only in place from mid-July 2013 onward. The period mid-January to mid-February 2013 was labeled February 2013, mid-February to mid-March 2013 was labeled March 2013 and so forth. ROOT was performed for every child aged 6–15 years, attending the PHC for any reason, unless the child had a documented HIV test result from the past 6 months, was already registered in an HIV care service, or was attending without a caregiver (unless an emancipated minor). HIV testing was performed unless the caregiver or the child specifically declined permission, as per national guidelines.20 A caregiver was defined as someone aged 18 years or older and responsible for the day-to-day care of the child. Emancipated minors were defined as those who were married, living with a sexual partner, or who had children gave independent consent. ROOT was not performed in children who were moribund or required immediate hospitalization. The standard HIV testing algorithm recommended by the national guidelines was used; a rapid HIV antibody testing kit (Abbott Determine) was used with all positive tests confirmed by a second rapid antibody test (SD Bioline). A discrepant test result was resolved using a third tie-breaker test (INSTI). Ethical approval for the study was obtained from the Medical Research Council of Zimbabwe and the Ethics Committees of Harare City Health Services, the Biomedical Research and Training Institute, and the London School of Hygiene and Tropical Medicine. Data on socio-demographics of the child and guardian, the number of attendances of children aged 6–15 years, the number of tests offered and accepted, and reasons why testing did not occur were collected prospectively as previously described.19 Data were analyzed using STATA version 12.0 (StataCorp, College Station, TX). The proportion of children being offered and accepting testing, the yield of HIV-positive diagnoses (defined as the number of children testing positive among all children eligible for testing), and reasons for not being tested for HIV were compared before and after the introduction of ROOT. The proportions not tested due to a particular reason were calculated and stratified by PITC and ROOT period using the total number of children eligible during a period as a denominator. Modified Poisson regression was used to calculate the risk of being tested before and after the intervention, controlling for child and guardian age and sex, as well as client factors likely to raise the suspicion of HIV infection including orphanhood, skin conditions, previous hospitalization, and self-reported poor health in the last 3 months.

Résumé de l’IA

Study Justification:

The study aimed to evaluate the effectiveness of routine opt-out HIV testing (ROOT) compared to conventional opt-in provider-initiated testing and counseling (PITC) for children attending primary care clinics in Harare, Zimbabwe. The justification for the study was to address the issue of missed HIV diagnoses in HIV-infected children who survive infancy undiagnosed. The study aimed to determine if ROOT could increase the proportion of children undergoing HIV testing and improve the yield of positive diagnoses compared to PITC.

Highlights:

– The introduction of ROOT increased the proportion of eligible children offered testing from 76% to 93%.
– Test uptake improved from 71% to 95% in the ROOT period compared to the PITC period.
– The yield of HIV diagnoses increased from 2.9% to 4.5%.
– Children attending the clinics post-intervention had a 1.99 increased adjusted risk of receiving an HIV test in the ROOT period compared to the pre-intervention period.

Recommendations:

– Implement routine opt-out HIV testing (ROOT) as the standard testing strategy for children attending primary care clinics.
– Provide training for healthcare workers on how to implement an opt-out testing model, including counseling of children and guardians, frameworks for consent and guardianship, and the benefits of early treatment.
– Establish a mentorship program in pediatric HIV to provide ongoing support for healthcare workers.
– Deploy additional lay counselors at each clinic to perform HIV testing in children when routine clinic staff is unavailable.
– Ensure an uninterrupted supply of HIV testing kits by maintaining a buffer supply.

Key Role Players:

– Senior nursing personnel
– District nursing officers
– Clinic nurses
– Lay counselors
– Municipal health authorities
– Clinic management teams

Cost Items for Planning Recommendations:

– Training courses for clinic nurses and lay counselors
– Additional lay counselors’ salaries
– HIV testing kits and supplies
– Mentorship program in pediatric HIV
– Administrative and logistical support for implementation
Please note that the provided information is a summary of the study and may not include all details. For a comprehensive understanding, it is recommended to refer to the original publication in the Journal of Acquired Immune Deficiency Syndromes, Volume 71, No. 1, Year 2016.

Force de la preuve

The strength of evidence for this abstract is 8 out of 10.
The evidence in the abstract is strong, as it presents clear data and results. However, to improve the evidence, the abstract could include more information on the study design, sample size, and statistical methods used.

Abstrait

An evaluation of PITC for children aged between 6 and 15 years was performed in 6 primary health care clinics (PHCs) in high-density suburbs in Harare, Zimbabwe, between mid-January and mid-May 2013. Each clinic serves 1 suburb and provides comprehensive outpatient primary care, including acute care, maternal and child health services and HIV care services, as well as antenatal, delivery, and postnatal services. Clinical care is provided by nurses, with visits by a doctor on a weekly basis. PITC in all health care facilities has been part of the National Guidelines since 2007. HIV testing in PHCs is usually performed by lay counselors who have undergone certified training in HIV counseling and testing. Activities were initiated in mid-May 2013 in preparation for the introduction of ROOT. These activities were supported by the municipal health authorities and clinic management teams. A 1-day meeting was held for senior nursing personnel (the nurses in charge at each clinic and the district nursing officers) to understand the challenges of providing HIV testing to children in the primary care environment and to discuss the changes that would be required to implement ROOT. This was followed by a 5-day training course at each clinic site for clinic nurses and lay counselors, who are responsible for performing the bulk of the HIV testing. The training focused specifically on issues relating to testing children, including counseling of children and guardians, frameworks for consent and guardianship, the burden of HIV among older children, and the benefits of early treatment. Specifically, HCW were trained on how to implement an opt-out testing model. Further training was not provided during the course of the study. A mentorship program in pediatric HIV was established to provide HCW with ongoing support. An additional lay counselor was deployed at each clinic, whose main task was to perform HIV testing in children when routine clinic staff was unavailable. In addition, a buffer supply of HIV testing kits was made available to ensure an uninterrupted supply. The kits and additional staff were funded by the study for the duration of the study period. The outcomes of ROOT were evaluated over a period of 17 months. The implementation of ROOT involved several activities over a period of 2 months (mid-May to mid-July 2013). Thus, full implementation of ROOT was only in place from mid-July 2013 onward. The period mid-January to mid-February 2013 was labeled February 2013, mid-February to mid-March 2013 was labeled March 2013 and so forth. ROOT was performed for every child aged 6–15 years, attending the PHC for any reason, unless the child had a documented HIV test result from the past 6 months, was already registered in an HIV care service, or was attending without a caregiver (unless an emancipated minor). HIV testing was performed unless the caregiver or the child specifically declined permission, as per national guidelines.20 A caregiver was defined as someone aged 18 years or older and responsible for the day-to-day care of the child. Emancipated minors were defined as those who were married, living with a sexual partner, or who had children gave independent consent. ROOT was not performed in children who were moribund or required immediate hospitalization. The standard HIV testing algorithm recommended by the national guidelines was used; a rapid HIV antibody testing kit (Abbott Determine) was used with all positive tests confirmed by a second rapid antibody test (SD Bioline). A discrepant test result was resolved using a third tie-breaker test (INSTI). Ethical approval for the study was obtained from the Medical Research Council of Zimbabwe and the Ethics Committees of Harare City Health Services, the Biomedical Research and Training Institute, and the London School of Hygiene and Tropical Medicine. Data on socio-demographics of the child and guardian, the number of attendances of children aged 6–15 years, the number of tests offered and accepted, and reasons why testing did not occur were collected prospectively as previously described.19 Data were analyzed using STATA version 12.0 (StataCorp, College Station, TX). The proportion of children being offered and accepting testing, the yield of HIV-positive diagnoses (defined as the number of children testing positive among all children eligible for testing), and reasons for not being tested for HIV were compared before and after the introduction of ROOT. The proportions not tested due to a particular reason were calculated and stratified by PITC and ROOT period using the total number of children eligible during a period as a denominator. Modified Poisson regression was used to calculate the risk of being tested before and after the intervention, controlling for child and guardian age and sex, as well as client factors likely to raise the suspicion of HIV infection including orphanhood, skin conditions, previous hospitalization, and self-reported poor health in the last 3 months.

Matériaux

N/A

Innovations

Based on the provided information, here are some potential innovations that can be used to improve access to maternal health:

1. Implement routine opt-out HIV testing: This approach involves automatically offering HIV testing to all pregnant women as a standard part of prenatal care, unless they specifically decline. This can help identify HIV-positive women early in their pregnancy and ensure they receive appropriate care and treatment.

2. Strengthen training and support for healthcare workers: Providing comprehensive training on maternal health, including prenatal care, childbirth, and postnatal care, can help healthcare workers deliver high-quality services. Ongoing mentorship programs and support can also enhance their skills and knowledge.

3. Improve access to maternal health services in primary care clinics: Enhancing the capacity of primary care clinics to provide comprehensive maternal health services, including antenatal, delivery, and postnatal care, can increase access for pregnant women. This can involve ensuring an adequate supply of healthcare providers, equipment, and essential supplies.

4. Increase community awareness and education: Conducting community outreach programs to raise awareness about the importance of maternal health and the available services can help overcome barriers to access. This can include providing information on prenatal care, safe childbirth practices, and postnatal care.

5. Strengthen referral systems: Developing effective referral systems between primary care clinics and higher-level healthcare facilities can ensure that pregnant women with complications receive timely and appropriate care. This can involve establishing clear protocols for referrals and improving communication channels between healthcare providers.

6. Utilize technology for remote consultations: Implementing telemedicine or mobile health solutions can enable pregnant women in remote or underserved areas to access maternal health services. This can involve virtual consultations with healthcare providers, remote monitoring of vital signs, and the provision of educational resources through mobile applications.

7. Address socio-economic barriers: Addressing socio-economic factors that hinder access to maternal health services, such as poverty, transportation, and cultural beliefs, is crucial. This can involve providing financial assistance for healthcare costs, improving transportation infrastructure, and engaging with communities to address cultural barriers.

It’s important to note that these recommendations are based on the provided information and may need to be tailored to the specific context and resources available in Zimbabwe.

AI Innovations Description

Based on the information provided, the recommendation to improve access to maternal health is to implement routine opt-out HIV testing for children attending primary care clinics. This approach, compared to conventional opt-in provider-initiated testing and counseling (PITC), has been shown to be more effective in increasing the proportion of eligible children offered and receiving HIV tests, improving test uptake, and increasing the yield of HIV-positive diagnoses.

To implement routine opt-out HIV testing, the following steps can be taken:

1. Conduct a comprehensive evaluation of the current HIV testing services for children in primary care clinics to identify areas for improvement.
2. Introduce a combination of interventions to support the implementation of routine opt-out HIV testing, including training for clinic nurses and lay counselors on issues related to testing children, such as counseling techniques, consent and guardianship frameworks, and the benefits of early treatment.
3. Establish a mentorship program in pediatric HIV to provide ongoing support to healthcare workers.
4. Deploy additional staff, such as lay counselors, to perform HIV testing in children when routine clinic staff is unavailable.
5. Ensure an uninterrupted supply of HIV testing kits by maintaining a buffer supply.
6. Implement the routine opt-out HIV testing model for every child aged 6-15 years attending the primary care clinic, unless they meet specific exclusion criteria (e.g., recent HIV test, already registered in an HIV care service).
7. Use the recommended HIV testing algorithm, including rapid HIV antibody testing kits and confirmatory tests for positive results.
8. Collect data on the proportion of children offered and accepting testing, the yield of HIV-positive diagnoses, and reasons for not being tested before and after the introduction of routine opt-out HIV testing.
9. Analyze the data to assess the impact of routine opt-out HIV testing on access to HIV testing and diagnosis in children.
10. Continuously monitor and evaluate the implementation of routine opt-out HIV testing to identify any further improvements or adjustments needed.

By implementing routine opt-out HIV testing, healthcare facilities can improve access to maternal health by ensuring that more children are tested for HIV, leading to early diagnosis and timely initiation of treatment. This can contribute to reducing missed HIV diagnoses and improving overall maternal and child health outcomes.

AI Innovations Methodology

Based on the provided information, here are some potential recommendations to improve access to maternal health:

1. Implement routine opt-out HIV testing: Following the success of routine opt-out HIV testing for children in Harare, Zimbabwe, this approach can be expanded to include pregnant women attending antenatal care clinics. By making HIV testing a routine part of prenatal care and offering it to all pregnant women unless they specifically decline, more women can be tested and diagnosed early, leading to improved access to HIV care and prevention of mother-to-child transmission.

2. Strengthen training and support for healthcare workers: Providing comprehensive training for healthcare workers on maternal health issues, including antenatal care, delivery, and postnatal care, can improve their knowledge and skills in providing quality care to pregnant women. Additionally, establishing mentorship programs and ongoing support can help healthcare workers stay updated on best practices and address any challenges they may face in delivering maternal health services.

3. Increase availability of maternal health services: Ensuring that primary healthcare clinics have adequate resources, including staff, equipment, and supplies, is crucial for improving access to maternal health. This can involve hiring additional healthcare workers, providing necessary equipment and testing kits, and ensuring a consistent supply of essential medicines and supplies.

To simulate the impact of these recommendations on improving access to maternal health, a methodology could be developed as follows:

1. Define the indicators: Identify key indicators that measure access to maternal health, such as the proportion of pregnant women receiving antenatal care, the proportion of women tested for HIV during pregnancy, the proportion of women receiving skilled birth attendance, and the proportion of women receiving postnatal care.

2. Collect baseline data: Gather data on the current status of these indicators in the target population or region. This can be done through surveys, interviews, or analysis of existing data sources.

3. Introduce the recommendations: Implement the recommended interventions, such as routine opt-out HIV testing, training and support for healthcare workers, and improving the availability of maternal health services.

4. Monitor and collect data: Continuously monitor the implementation of the recommendations and collect data on the selected indicators. This can involve regular data collection from healthcare facilities, surveys of pregnant women, or analysis of existing health information systems.

5. Analyze the data: Compare the data collected after the implementation of the recommendations with the baseline data to assess the impact of the interventions on the selected indicators. This can be done using statistical analysis techniques to determine any significant changes or improvements.

6. Evaluate the results: Assess the findings to determine the effectiveness of the recommendations in improving access to maternal health. This can involve analyzing the data, conducting qualitative interviews or focus groups with healthcare providers and pregnant women, and considering any contextual factors that may have influenced the results.

By following this methodology, it is possible to simulate the impact of the recommendations on improving access to maternal health and evaluate their effectiveness in the specific context.

Auteur

Dima Health

Statistics:

Citations: 18

Identifiers:

DOI: 10.1097/QAI.0000000000000867

ISSN: 15254135

Research Areas:

Community Interventions, Health System and Policy, Infectious Diseases, Maternal Access, Maternal and Child Health, Quality of Care, Sexual and Reproductive Health, Social Determinants

Study Countries:

Zimbabwe

Study Design:

randomised-control-trial

Study Approach:

Quantitative

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