An early infant HIV risk score for targeted HIV testing at birth

  • Pediatrics, Volume 143, No. 6, Year 2019

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Study Justification:
– Early HIV testing is crucial for successful treatment in young infants.
– Universal testing is expensive, and alternative strategies are needed.
– This study aimed to examine the feasibility of using early infant HIV risk scores for targeted PCR testing and early HIV diagnosis.
Study Highlights:
– A total of 1,759 participants were enrolled from August 2014 to December 2016.
– Mothers without antenatal care were more likely to deliver newborns who tested positive for HIV.
– A significant number of mothers had high HIV viral load, and a considerable proportion of infants were preterm or had low birth weight.
– Symptomatic newborns frequently tested positive for HIV.
– The HIV PCR positivity rate was 2.2%.
– Three different risk models for HIV acquisition were developed, with varying predictive probabilities.
– However, using these risk scores, 20% to 24% of infected newborns would be missed compared to universal testing.
Study Recommendations:
– Targeted newborn testing should include access to maternal viral load.
– Risk models that consider parameters such as maternal antiretroviral therapy history, birth weight, gestational age, and symptoms can guide targeted testing.
– However, universal PCR testing at birth is currently recommended within the South African prevention of mother-to-child transmission of HIV context.
Key Role Players:
– Researchers and scientists involved in HIV/AIDS research and prevention
– Healthcare providers and clinicians specializing in pediatric HIV care
– Policy makers and government officials responsible for healthcare planning and funding
– Non-governmental organizations (NGOs) working in HIV/AIDS prevention and treatment
Cost Items for Planning Recommendations:
– Development and implementation of risk scoring algorithms
– Training and education for healthcare providers on targeted testing strategies
– Access to maternal viral load testing
– PCR testing kits and laboratory equipment
– Data collection and analysis
– Public awareness campaigns on the importance of early HIV testing in infants
– Monitoring and evaluation of the targeted testing program

The strength of evidence for this abstract is 7 out of 10.
The evidence in the abstract is moderately strong, but there are some limitations. The study used logistic regression models to quantify associations between HIV infection and various parameters, and derived risk scores to guide targeted HIV testing at birth. The study enrolled a large cohort of newborns exposed to HIV, which adds to the strength of the evidence. However, there are some limitations to consider. The study only examined associations and did not establish causation. Additionally, the study was conducted in the South African context, so the findings may not be generalizable to other settings. To improve the strength of the evidence, future studies could consider conducting a randomized controlled trial to establish causation and include a more diverse population to enhance generalizability.

BACKGROUND: Early HIV testing is needed for treatment success in young infants, but universal testing is expensive. In this study, we examined the feasibility of early infant HIV risk scores for targeted polymerase chain reaction (PCR) testing and early HIV diagnosis. METHODS: A cross-sectional cohort of newborns exposed to HIV was enrolled and PCR tested within 72 hours. We quantified associations between HIV infection and clinical and laboratory maternal-infant parameters by logistic regression models and determined sensitivity and specificity for derived risk scores. RESULTS: From August 2014 to December 2016, 1759 participants were enrolled. Mothers without antenatal care (5.7% [97 of 1688]) were more likely to deliver newborns who are PCR-positive (P = .0005). A total of 1 in 5 mothers (217 of 990; 21.9%) had HIV viral load (VL) .1000 copies per µL. A total of 432 of 1655 (26.1%) infants were preterm. Low birth weight was documented in 398 of 1598 (24.55%) and 13 of 31 (40.63%) newborns who are PCR-negative and -positive, respectively (P = .0329). A total of 204 of 1689 (12.08%) were growth restricted or small for gestational age, and 6 of 37 (16.22%) were PCR-positive. Symptomatic newborns frequently tested positive (P = .0042). The HIV PCR positivity rate was 2.2% (37 of 1703). Two-risk (combined 3-drug antiretroviral therapy [cART] duration, VL), 3-risk (cART duration, VL, symptomatic newborn), and 4-risk (cART duration, VL, symptomatic, small for gestational age newborn) models for HIV acquisition had predictive probability of 0.28, 0.498, and 0.57, respectively; this could guide targeted birth testing. However, using the 3- and 4-risk scores (probability 0.02 and 0.04), 20% and 24% will be missed compared with universal testing. CONCLUSIONS: Targeted newborn testing requires access to maternal VL. Even if risk models include parameters such as maternal cART history, birth weight, weeks’ gestation, and symptoms, 1 in 5 newborns who are infected will not be targeted. At present, we support universal PCR testing at birth within the South African prevention of mother-to-child transmission of HIV context.

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Innovation Recommendation: Implementing an Early Infant HIV Risk Score for Targeted HIV Testing at Birth

Description: This study explores the feasibility of using an early infant HIV risk score to determine which newborns should undergo targeted polymerase chain reaction (PCR) testing for early HIV diagnosis. The goal is to improve access to maternal health by identifying infants at higher risk of HIV infection and providing them with timely testing and treatment.

Key Findings:
– Mothers without antenatal care were more likely to deliver newborns who tested positive for HIV.
– A significant number of mothers had high HIV viral load, indicating a higher risk of transmission to their infants.
– Preterm birth, low birth weight, growth restriction, and symptomatic newborns were also associated with a higher likelihood of HIV infection.
– Different risk models incorporating factors such as antiretroviral therapy duration, viral load, symptoms, and small for gestational age newborns were developed to predict HIV acquisition.

Recommendation:
– While the risk models showed promise in identifying infants at higher risk of HIV infection, using them alone would miss a significant number of infected newborns compared to universal testing.
– Therefore, the recommendation is to continue with universal PCR testing at birth within the South African prevention of mother-to-child transmission of HIV context.
– However, it is important to ensure access to maternal viral load testing, as it is a crucial parameter in determining the risk of HIV transmission to the newborn.

By implementing this recommendation, healthcare providers can continue to ensure that all newborns have access to early HIV testing and appropriate treatment, while also exploring the potential of risk scoring models to further improve targeted testing in the future.
AI Innovations Description
The recommendation to improve access to maternal health is the development and implementation of an early infant HIV risk score for targeted HIV testing at birth. This recommendation is based on a study that examined the feasibility of using risk scores to identify newborns who are at a higher risk of HIV infection and would benefit from early PCR testing.

The study found that certain factors, such as lack of antenatal care, high HIV viral load in mothers, preterm birth, low birth weight, growth restriction or small for gestational age, and symptomatic newborns, were associated with an increased risk of HIV infection in newborns. By combining these factors into a risk score model, it was possible to predict the probability of HIV acquisition in newborns.

However, the study also found that even with the use of risk scores, a significant number of infected newborns would be missed compared to universal testing. Therefore, the recommendation supports universal PCR testing at birth within the context of preventing mother-to-child transmission of HIV in South Africa.

In summary, the recommendation is to develop and implement an early infant HIV risk score for targeted HIV testing at birth, while also maintaining universal PCR testing to ensure that all newborns have access to early HIV diagnosis and treatment.
AI Innovations Methodology
One potential innovation to improve access to maternal health is the development of an early infant HIV risk score for targeted HIV testing at birth. This innovation aims to identify newborns who are at a higher risk of HIV infection and prioritize them for early testing, while reducing the need for universal testing which can be expensive.

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

1. Data Collection: Collect data on a cross-sectional cohort of newborns exposed to HIV, including clinical and laboratory maternal-infant parameters such as antenatal care, HIV viral load, birth weight, gestational age, and symptoms.

2. Logistic Regression Analysis: Use logistic regression models to quantify the associations between HIV infection and the collected parameters. This analysis will help identify the parameters that are most strongly associated with HIV infection in newborns.

3. Risk Score Development: Based on the logistic regression analysis, develop a risk score system that assigns a score to each newborn based on their individual parameters. The risk score should reflect the probability of HIV infection.

4. Sensitivity and Specificity Analysis: Determine the sensitivity and specificity of the derived risk scores. This analysis will assess how accurately the risk scores can identify newborns who are at a higher risk of HIV infection.

5. Comparison with Universal Testing: Compare the performance of the risk scores with universal testing. Calculate the percentage of newborns who would be missed by using the risk scores compared to universal testing.

6. Evaluation and Recommendations: Evaluate the performance of the risk scores and assess their impact on improving access to maternal health. Based on the results, make recommendations on the implementation of targeted HIV testing at birth using the risk scores.

It is important to note that this methodology is a general outline and the specific details may vary depending on the available data and resources. Additionally, further research and validation would be necessary to ensure the accuracy and effectiveness of the risk score system before implementing it in practice.

Statistics:
Citations: 4
Authors: 5
Identifiers:
DOI: 10.1542/peds.2018-3834
ISSN: 00314005
Research Areas:
Community Interventions, Health System and Policy, Infectious Diseases, Maternal Access, Maternal and Child Health
Study Countries:
South Africa
Study Design:
Cohort Study, Cross Sectional Study
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