Menu
Menu
Menu
Menu
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.
N/A
