Kankasa C, Carter RJ, Bulterys M, et al. Routine offering of HIV testing to hospitalized pediatric patients at university teaching hospital, Lusaka, Zambia: Acceptability and feasibility. J Aquir Immune Defic Syndr 2009;51:202-8.
To test the feasibility and acceptability of routine HIV counseling and testing among hospitalized pediatric patients in Lusaka, Zambia
This was an observational study of the acceptability and feasibility of a hospital-based HIV counseling and testing and early infant diagnosis program.
University Teaching Hospital (UTH), the tertiary referral center for urban and peri-urban communities in Lusaka, Zambia. The UTH has 450 pediatric inpatient beds and one admission ward, three general wards, specialty wards for malnutrition, isolation, diarrhea/rehydration, and fee-paying patients, and neonatal and pediatric intensive care units.
From January 1, 2006 through June 30, 2007, 17,003 children were admitted to UTH; 3997 (24%) were admitted more than once. Pediatric patients had a median age of 12 months (interquartile range: 0-24 months); 62.6% were younger than 18 months, and 52.6% were male. More children were admitted monthly during the rainy season when hospitalization rates increased secondary to diarrheal diseases (October to December 2006 and January to March 2007).
In September 2005, the inpatient testing program was piloted. Two counselors were deployed to the admission ward to provide individual counseling to parents and caregivers. Counselors obtained a venous blood sample from the child and ran HIV antibody testing once verbal permission was granted. The tests were performed in a renovated room within the admissions ward using a rapid test kit. Positive tests were confirmed. All children testing HIV positive were offered enrollment in care at the PCOE or at the local district clinic. Clinical and immunological staging was initiated during the hospitalization and cotrimoxazole was prescribed. In January 2006, after three months of piloting, the program was fully instituted. Two additional counselors were hired to provide services for all patients admitted to the admissions ward during weekday working hours and to children on other wards who had not been tested. With time, there was a shift from individualized to group pretest counseling. Furthermore, parents of children testing HIV positive were offered HIV testing and, if positive, were referred for HIV treatment services. In May 2006, EID testing became routinely available for hospitalized children <18 months of age who had tested positive by HIV antibody test using HIV DNA polymerase chain reaction (PCR).
The primary outcome was the proportion of children counseled and tested for HIV.
Of the 17,003 patients admitted during the study period, the HIV status of 15,670 (92%) was unknown, Of these, 13,239 (85%) received counseling and 11,571 (87%) counseled children were tested. Age and hospital ward were significantly associated with counseling, testing, and seropositive status. The highest counseling rates were found among children <12 months of age (86%) and among those admitted to the malnutrition (88%) and diarrhea/rehydration (92%) wards. Overall, 3373 children (29% of those tested) were HIV antibody positive with the highest rates among children <6 months of age (32.4%) and the lowest rates among children aged >5 years (23.4%); 69.6% of all children testing HIV antibody positive were <18 months of age. Females had a slightly higher seropositivity rate than males (31.3% vs. 27.0%; P=0.013); however, counseling and testing rates were not associated with gender. After adjusting for age, sex, and calendar quarter, children in the malnutrition (adjusted odds ratio 16.7, 95% confidence interval [CI]: 13.7-20.4) and diarrhea/rehydration wards (adjusted odds ratio 8.2; 95% CI: 6.6-10.2) were significantly more likely to test seropositive than children in general pediatric wards. The proportion of children counseled and tested increased from the beginning of the program to the last quarter: 79.9% and 76.0% in quarter one, January to March 2006; to 88.2% and 87.4% in quarter six, April to June 2007 (P<0.001), respectively. Seropositivity rates decreased over time from 35% during quarter one to 23% during the last quarter of testing (P<0.001). Of the 4099 eligible children who did not receive HIV antibody testing, 2431 (59.3%) received neither counseling nor testing, and 1668 (40.6%) were counseled but not tested. The most common reasons for not testing were child died (43.6%), parent refused (12.0%), and discharged early (9.6%). Many of the categories represent missed testing opportunities: early discharge, left against medical advice, and weekend admission. The majority of children in these categories received no counseling. In contrast, parental refusal and waiting for husband's permission represent situations where counseling was performed but the child was not tested. A total of 1276 hospitalized children <18 months of age had PCR tests between May 2006 and June 2007: 806 (63.2%) tested DNA PCR positive, 453 (35.5%) negative, 2 (0.5%) indeterminate, and 15 (1.3%) unavailable results. The proportion of eligible children who were tested increased from 44% when testing became available to 70% from April to June 2007. Older age was strongly associated with PCR positivity: more than 85% of 186 children between 12 and 18 months of age tested positive, whereas only 22% of 140 children <6 weeks of age were HIV positive (P<0.01).
The authors conclude that routine counseling and antibody testing of pediatric inpatients can identify large numbers of HIV-seropositive children in high prevalence settings, and the high rate of HIV infection in hospitalized infants and young children underscores the urgent need for early infant diagnostic capacity in high HIV-prevalence settings.
There is no quality rating tool for pre/post-evaluation studies such as this.
High acceptance of routine HIV testing and counseling with an option to refuse has been demonstrated in prevention of mother-to-child transmission programs.(1,2,3,4) A recent study in South Africa found that routine outpatient point of care testing resulted in five times as many adults newly identified as HIV infected compared with physician referral to an adjacent voluntary counseling site.(5) Similarly, at UTH, testing increased dramatically when it became routinely available on the wards, compared with the previous policy of sending children to an adjacent voluntary counseling and testing center.
Inpatient pediatric testing programs in settings of generalized HIV epidemics, such as Lusaka, appear to identify large numbers of infected infants and children. The addition of early infant diagnosis to differentiate infants with transient maternal antibody from those with actual infection is an important addition in this setting. Together HIV antibody testing and follow-on PCR testing for children aged <18 months appear from this study to be a highly feasible way to identify children in need of HIV care and antiretroviral treatment.
- Moses A, Zimba C, Kamanga E, et al. Prevention of mother-to-child transmission: program changes and the effect on uptake of the HIVNET 012 regimen in Malawi. AIDS 2008;22:83-7.
- Homsy J, Kalamya JN, Obonya J, et al. Routine intrapartum HIV counseling and testing for prevention of mother-to-child transmission of HIV in a rural Ugandan hospital. J Acquir Immune Defic Syndr 2006;42:149-54.
- Creek TL, Ntumy R, Seipone K, et al. Successful introduction of routine opt-out HIV testing in antenatal care in Botswana. J Acquir Immune Defic Syndr 2007;45:102-7.
- Sripipatana T, Spensley A, Miller A, et al. Site-specific interventions to improve prevention of mother-to-child transmission of human immunodeficiency virus. Am J Obstet Gynecol 2007;917:S107-12.
- Bassett IV, Giddy J, Nkera J, et al. Routine voluntary HIV testing in Durban, South Africa: the experience from an outpatient department. J Acquir Immune Defic Syndr 2007;46:181-6.