Improving early identification of HIV-infected neonates with birth PCR testing in a large urban hospital in Johannesburg, South Africa: Successes and challenges

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Study Justification:
– Timely diagnosis of HIV-infected neonates is crucial to prevent early death.
– Birth PCR testing may improve early identification and access to care.
– This study aimed to assess the successes and challenges of implementing a birth HIV diagnosis program in Johannesburg, South Africa.
Highlights:
– Out of 30,591 women with live births, 22.4% were known to be HIV positive.
– An additional 1.4% of women were identified as HIV positive during postnatal testing.
– 89.9% of HIV-positive women agreed to data collection and consented to birth testing for their neonates.
– 97.4% of tested neonates were HIV negative, 1.4% were positive, and 0.9% revealed errors.
– The intrauterine transmission rate was 1.6%.
– 96% of infected infants were initiated on antiretroviral therapy with active outreach.
Recommendations:
– Strengthen efforts to identify HIV-positive pregnant women during antenatal care.
– Improve follow-up and repeat testing for neonates with indeterminate results.
– Enhance counseling services for HIV-positive women and their families.
– Increase efforts to ensure that neonates with negative results return to receive their test results.
Key Role Players:
– Healthcare providers: Obstetricians, pediatricians, nurses, and laboratory technicians.
– Counselors: Trained professionals to provide counseling services to HIV-positive women and their families.
– Quality control staff: Personnel responsible for ensuring accurate and reliable testing.
– Outreach workers: Individuals who actively track and follow up with HIV-positive women and their neonates.
Cost Items for Planning Recommendations:
– Additional staff for counseling services.
– Training programs for healthcare providers and counselors.
– Quality control measures and equipment.
– Outreach activities and personnel.
– Information and education materials for HIV-positive women and their families.
– Monitoring and evaluation of the program’s effectiveness.

Introduction: Timely diagnosis is necessary to avert early death in HIV-infected neonates. Birth PCR testing may improve early identification and facilitate access to care. We implemented a birth HIV diagnosis programme in Johannesburg, South Africa and present successes and challenges of the first two and a half years of operation. Methods: Between June 2014 and December 2016, we sought to identify all HIV-exposed births and offer newborn HIV PCR testing before discharge after delivery. The programme identified newly delivered women who had tested positive during pregnancy and provided post-partum HIV antibody testing for women without recent negative results. HIV-positive women were required to consent for neonatal birth testing and asked to return a week later to obtain their results. Neonatal venous blood was sampled and tested at the national laboratory using Roche COBAS® TaqMan® HIV-1 Qualitative Test (Version 2.0). Non-negative results triggered active follow-up for confirmatory testing and appropriate treatment. Results: Of 30,591 women with live births, 6864 (22.4%) were known to be HIV positive and an additional 221 women (1.4% of those tested) were identified during maternal postnatal testing. Of 7085 HIV-positive women, 6372 (89.9%) were interviewed and agreed to data collection, 6358 (99.8%) consented to birth testing for 6467 neonates and a blood sample was collected for 6377 (98.6%). If tested, 6210 (97.4%) tested negative, 91 (1.4%) positive, 57 (0.9%) revealed errors and 19 (0.3%) were indeterminate . Seven of the 19 neonates with indeterminate results and one with initial error result were found to be infected on subsequent testing yielding an intrauterine transmission rate of 1.6% (95% CI: 1.3-1.9). Sixteen (16%) of 99 infected infants were born to women (n = 221) identified during postnatal testing. With active outreach, 95/99 (96%) infected infants were initiated on antiretroviral therapy. Of 6261 neonates with negative results, 3251 (52%) returned to receive their test results. Conclusion: Our programme successfully achieved high coverage and uptake of birth PCR testing and was able, with active tracking, to start almost all identified HIV-infected neonates on antiretroviral therapy. Implementation required additional staff for counselling, quality control and outreach. Return for negative results was low and neonates with indeterminate results required multiple repeat tests.

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One potential innovation to improve access to maternal health based on the provided information is the implementation of a mobile health (mHealth) application for tracking and follow-up. This application could be used to send reminders and notifications to HIV-positive women and their families regarding the importance of neonatal birth testing and returning for test results. It could also provide educational resources and support for adherence to antiretroviral therapy. Additionally, the mHealth application could facilitate communication between healthcare providers and patients, allowing for virtual consultations and reducing the need for in-person visits. This innovation could help improve access to maternal health by increasing engagement and adherence among HIV-positive women and their families, ultimately leading to better health outcomes for neonates.
AI Innovations Description
The recommendation to improve access to maternal health based on the provided description is to implement a birth HIV diagnosis program. This program aims to improve early identification of HIV-infected neonates and facilitate access to care. The program involves offering newborn HIV PCR testing before discharge after delivery. The steps involved in the program include:

1. Identifying all HIV-exposed births: The program seeks to identify all births where the mother is known to be HIV positive or where the mother’s HIV status is unknown.

2. Offering newborn HIV PCR testing: Newborns of HIV-positive mothers or mothers with unknown HIV status are offered HIV PCR testing before they are discharged from the hospital.

3. Post-partum HIV antibody testing: For women without recent negative HIV test results, post-partum HIV antibody testing is provided to determine their HIV status.

4. Consent for neonatal birth testing: HIV-positive women are required to provide consent for their newborns to undergo HIV PCR testing.

5. Follow-up for confirmatory testing and treatment: Non-negative results from the newborn HIV PCR testing trigger active follow-up for confirmatory testing and appropriate treatment.

The program’s successes include achieving high coverage and uptake of birth PCR testing, starting almost all identified HIV-infected neonates on antiretroviral therapy, and implementing active outreach to ensure follow-up and treatment. However, challenges include low return rates for negative results and the need for multiple repeat tests for neonates with indeterminate results.

Implementing this recommendation would require additional staff for counseling, quality control, and outreach. By implementing a birth HIV diagnosis program, early identification of HIV-infected neonates can be improved, leading to better access to care and potentially reducing early deaths in this population.
AI Innovations Methodology
Based on the provided description, here are some potential recommendations to improve access to maternal health:

1. Strengthening Antenatal Care: Enhance antenatal care services to ensure early identification of HIV-positive pregnant women and provide them with appropriate counseling and support.

2. Birth PCR Testing Expansion: Expand the implementation of birth PCR testing to more healthcare facilities, especially in areas with high HIV prevalence, to improve early identification of HIV-infected neonates.

3. Streamlined Testing Process: Simplify the process of neonatal HIV PCR testing by integrating it into routine newborn care, ensuring that all newborns are tested before discharge from the hospital.

4. Improved Communication and Follow-up: Enhance communication and follow-up mechanisms to ensure that HIV-positive women receive their newborns’ test results promptly and are linked to appropriate care and treatment services.

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

1. Data Collection: Gather data on the current access to maternal health services, including the number of HIV-positive pregnant women identified, the percentage of newborns tested, and the outcomes of the testing process.

2. Baseline Analysis: Analyze the collected data to establish a baseline for access to maternal health services and identify any existing challenges or gaps.

3. Intervention Design: Design the interventions based on the identified recommendations, taking into account the specific context and resources available.

4. Simulation Modeling: Develop a simulation model that incorporates the interventions and their potential impact on improving access to maternal health. This model could consider factors such as the number of additional healthcare facilities implementing birth PCR testing, the expected increase in the percentage of newborns tested, and the projected reduction in the transmission rate of HIV from mother to child.

5. Impact Assessment: Use the simulation model to assess the potential impact of the interventions on improving access to maternal health. This could include estimating the number of additional HIV-positive neonates identified, the percentage of infected infants initiated on antiretroviral therapy, and the overall improvement in maternal and neonatal health outcomes.

6. Sensitivity Analysis: Conduct sensitivity analysis to test the robustness of the simulation model by varying key parameters and assumptions. This will help evaluate the potential variability in the impact of the interventions under different scenarios.

7. Recommendations and Implementation: Based on the simulation results, provide recommendations for implementing the interventions and monitor their progress over time. Continuously evaluate and adjust the interventions as needed to ensure sustained improvements in access to maternal health.

It is important to note that the methodology described above is a general framework and may need to be adapted based on the specific context and available data.

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