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A cohort design was used to determine uptake and drop out of 213 HIV-exposed infants eligible for Early Infant Diagnosis (EID) of HIV. To explore service providers and care givers knowledge, attitudes and perceptions of the EID process, observations and in-depth interviews were conducted. 145 (68%) infants enrolled after 2 months of age. 139 (65%) dropped out before follow up to 18 months old. 60 (43%) drop outs occurred within 2 months of enrolment. Maternal factors associated with infant drop out were maternal loss to follow up (48 [68%] vs. 8 [20%], P.001) and younger maternal age (27.2 vs. 30.1 years, P = 0.033). Service providers and caregivers had inadequate training, knowledge and understanding of EID. Poverty and lack of social support were challenges in accessing EID services. EID should be more closely aligned within PMTCT services, integrated with routine mother and child health (MCH) activities and its implementation more closely monitored. © 2011. The Author (s).
EID was introduced in Kenya under the prevention of mother to child transmission (PMTCT) programme by the Ministry of Health in 2006. The service is offered free of charge in more than 190 centers including private health centers, government clinics and public health care institutions [10]. A testing algorithm for infants under 18 months was developed and implemented by the National AIDS and Sexually transmitted disease Control Programme (NASCOP). It recommends that all HIV exposed infants should be tested by PCR at 6 weeks of age (or at first contact), by an antibody test at 12 months (if PCR negative) and a confirmatory antibody test at 18 months (if a previous antibody test was negative and continued breastfeeding). In August 2008, in view of data suggesting poor infant outcomes [15], national policy changed to offer ART to all infants with HIV infection confirmed by PCR. The study was conducted at the HIV clinic in Kilifi District Hospital. Kilifi District is predominantly rural and is located along the Kenyan coast. DBS samples are collected and couriered as a weekly batch to a central laboratory in Nairobi, approximately 560 km away, for analysis. Detailed sample collection, transport, analysis and feedback of results have been previously described [10]. Data on clinic registration follow up visits, treatment and blood test results were prospectively recorded on a computer database for all clients attending the clinic. We included data from all HIV-exposed infants enrolling for care in the clinic between August 2006 (when EID was initiated) and August 2008 (when the algorithm changed to promptly initiate ART for any positive PCR test). To fully assess completion, we excluded infants who had not reached 18 months of age by August 2008. We also assessed infant-caregiver couples for mothers/caregivers who had ever enrolled for care at the clinic. For qualitative research, we recruited i) caregivers of infants still in follow up in the clinic, identified from the database and purposively sampled on their next routine visit over a 4 week period, and ii) service providers including nurses, counselors and clinical officers involved with implementing EID. We used an observational study design involving mixed methodology. A historic cohort study was used to determine uptake and drop out. We examined data on enrolment and follow up since 2006 using a dynamic model to illustrate intake, drop out and completion at different ages of entry (in 2 month strata). Continuous data are presented using medians and interquartile ranges while categorical data are presented in frequencies and percentages. To determine factors related to drop out in both infants and their mothers, we used the Kruskal–Wallis rank sum test and Pearson’s χ2 test as appropriate. Analysis was performed using STATA version 9.0 (Stata Corp., TX, USA). This was complemented by a qualitative descriptive study to determine knowledge, attitudes and perceptions of service providers and caregivers regarding the early infant testing process. Qualitative data collection comprised six non-participatory observations of the early infant testing and care process, in-depth interviews with ten caregivers (all mothers) and six service providers (two PMTCT counselors, two clinic nurses, a nutritionist and a clinical officer) directly involved in provision of EID services. Experienced female interviewers fluent in the local languages, Swahili and Giriama, conducted the interviews and transcribed the recordings. Two investigators separately identified the main themes. The resulting findings were presented back to the clinic staff to elicit further information, and validation. Data were grouped using an access framework considering three dimensions of accessibility: availability (physical access), acceptability (cultural access) and affordability (financial access) [16]. The study was approved by the Kenya National Scientific Steering Committee and the National Ethics Review Committee. Verbal consent was sought for the observations and written informed consent was obtained for the interviews.
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