Rollins N, Mzolo S, Moodley T, Esterhuizen T, van Rooyen H. Universal HIV testing of infants at immunization clinics: an acceptable and feasible approach for early infant diagnosis in high HIV prevalence settings. AIDS. 2009;23:1851-1857.
The World Health Organization (WHO) recommends early initiation of antiretroviral therapy (ART) in infants with HIV infection.(1) However, postnatal HIV testing of infants is uncommon.(2) In South Africa, anonymous HIV testing of infants has identified high rates of undiagnosed infections.(3) Although the WHO has developed an algorithm for HIV testing of infants at six weeks, this method has limited sensitivity.(4)
To determine the acceptability and feasibility of HIV testing of infants presented for immunization
Three primary care clinics in KwaZulu Natal, South Africa
Non-randomized, single-arm intervention
Infants attending any of the first three immunizations (given at 6, 10, and 14 weeks of age)
Percentage of infants tested, percentage of mothers returning for infant test results, percentage of infants who have test results positive for HIV antibodies and HIV DNA by polymerase chain reaction (PCR).
All mothers attending any of the first three infant immunization clinics were offered infant HIV testing. Written informed consent was required for testing. Blood was collected by heel stick, placed onto filter paper and dried, and samples were sent weekly for testing. Antibody-positive blood was confirmed using DNA PCR. Mothers were scheduled to return for results two weeks after testing. Women could elect to receive test results at the next immunization clinic. Women whose infants were antibody positive but who were unaware of their own infection were counseled on the meaning of the result and given confirmatory testing. Exit interviews were offered to all women, including those who declined infant testing.
Between November 2007 and February 2008, 646 mothers and infants attended the immunization clinics and were invited to participate. The mothers' mean age was 24.8 years and the infants' mean age was 7.7 weeks. There were 584 (90.4%) women who consented to infant testing. Ninety-eight percent of mothers reported previously testing for HIV and nearly all had received their results. Forty percent (n=233) of the mothers self-reported HIV infection and 266 reported taking nevirapine during labor. Two hundred thirty-three of the infants of the 233 (71%) mothers who reported having HIV infection received nevirapine. Of the 584 mothers who consented to infant testing, 332 (57%) returned for results (160 at the scheduled visit). Of the infants tested, 247 (42%) were antibody positive, 54 (22%) of whom were DNA positive. Equivocal results occurred in 20 of the blood specimens. Overall, 9% of the infants tested were HIV infected. Of the women who reported that they were HIV negative at the time of infant testing, 7% had infants who were antibody positive. Seventy-eight percent of the mothers felt comfortable having testing offered for their infants. Among women who declined testing, the most common reasons stated were that they could not decide and that they needed to talk about it more. Confirmation of status and opportunity for antiretroviral therapy were the most common reasons cited for testing. The most frequently cited disadvantages of testing were that it was frightening and offered too quickly and that it would reveal their own and their infants serostatus.
HIV screening of infants at immunization clinics is feasible and relatively acceptable even when written consent is required.
Although this study was not randomized and included only a single arm, it was designed and conducted well. Furthermore, it tested a practical approach to remedy a serious problem. Therefore, although it does not meet the standards for a well-designed interventional trial, it is a high quality and important study.
This study demonstrates the benefit of integrating HIV testing into medical care settings. Infants presenting for immunizations offer an opportunity for HIV testing that should not be overlooked. In this study, written consent for testing was required and acceptance rates were high. A move to opt-out, as currently is done in prevention of mother-to-child transmission programs and other high-risk settings, should be encouraged.
- World Health Organization. Report of the WHO Technical Reference Group. Paediatric HIV/ART Care Guidelines Group Meeting; 10-11 April 2008; WHO Headquarters, Geneva. Geneva:WHO;2008:4.
- UNICEF. Children and AIDS. Third Stocktaking Report 2008. New York, USA: UNICEF; 2008.
- Rollins N, Little K, Mzolo S, Horwood C, Newell ML. Surveillance of mother-to-child transmission prevention programmes at immunization clinics: the case for universal screening. AIDS 2007;21:1341-7
- Horwood C, Liebeschuetz S, Blaauw D, Cassol S, Qazi S. Diagnosis of paediatric HIV infection in a primary healthcare setting with a clinical algorithm. Bull World Health Organ 2003;81:858-66.