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Malawi: Routine test offer at immunisation clinics improves early infant HIV diagnosis
Carole Leach-Lemens, 2012-07-13 10:40:00
Integration of testing for early infant diagnosis (EID) was more acceptable and more feasible at a government immunisation clinic (IC), and the proportion of infants who received provider-initiated testing and counselling (PITC) was seven times higher than among those attending a government “under-five” clinic in Lilongwe, Malawi, researchers report in the advance online edition of the Journal of Acquired Immune Deficiency Syndromes.
In this prospective consecutive study of 877 and 880 children at an under-5s clinic and an immunisation clinic respectively, more than three times the proportion of HIV-exposed infants at the immunisation clinic returned for their polymerase chain reaction (PCR) results and then enrolled into care when compared with the under-5s clinic (78.6% compared to 25%, p<0.001).
Malawi has an HIV prevalence rate of 11%. In 2007, the government, wanting to improve infant HIV care, started using HIV-DNA PCR testing for early infant diagnosis.
The current early infant diagnosis programme recommends all HIV-infected mothers bring their infants at six weeks of age, whether well or not, for PCR and evaluation at an under-5s clinic. Yet over half of these HIV-exposed infants are never enrolled into the early infant diagnosis process and do not get a PCR test. If they do get a PCR test it is only after they become ill, usually HIV-related.
Of the 50% who do get a PCR at the under-5s clinic over two-thirds do not return for the results or enrol into care.
Given this situation there is a need for alternative early infant diagnosis entry points, note the authors. Integration of early infant diagnosis programming, they add, into a site used routinely by children and which could easily absorb an additional service makes the most sense.
Immunisation clinics see over 90% of all Malawian children, most of whom do not have acute illnesses. This would suggest immunisation clinics are ideal sites for early infant diagnosis.
While under-5s clinics offer care for sick children, immunisation and early infant diagnosis, the latter two are separate. Testing usually takes place at an under-5s clinic only when the children are brought in for PCR or are sick.
So the authors chose to compare the acceptability, feasibility and outcomes of a pilot programme integrating early infant diagnostic testing into an immunisation clinic compared to the current standard of early infant diagnostic testing at an under-5s clinic.
Routine provider-initiated testing and counselling registers were used to prospectively look at 1757 children offered PCR at the IC at Bwaila Hospital and at the U5C at Kamuzu Central Hospital beginning in February 2011. Both are busy government paediatric clinics serving a population of 750,000. Most care received is by self-referral.
The children were followed until disclosure of the PCR result or the missed appointment at which the diagnosis should have been given. In line with the Malawian early infant diagnosis protocol disclosure was set up four weeks after testing. However, for this study two additional weeks were allowed if the appointment was missed.
The immunisation clinic pilot PITC programme began in January 2011, while the under-5s clinic offered these services from June 2010. Both clinics are open Monday to Friday with similar staffing levels and use volunteer patient escorts. These escorts are parents of HIV-infected children and provide advocacy and administrative help and accompany the caregivers from the testing room to the HIV clinic for those newly identified as HIV-exposed or HIV-infected. For those older than six weeks of age cotrimoxazole prophylaxis is prescribed.
Children were eligible for PCR testing if younger than 12 months of age, if they had an HIV-infected mother and were not already enrolled in HIV care elsewhere.
HIV-exposed infants were defined as those younger than 12 months of age, with an HIV-infected mother but without a definitive negative PCR result, regardless of current breastfeeding status.
HIV-infected infants were defined as those older than 12 months of age who had tested HIV-antibody positive, or had a documented positive PCR result irrespective of their age.
84.2% compared to 11.4%, p<0.001 of the 880 and 877 of infants at the IC and U5C, respectively, received provider-initiated testing and counselling.
Even though staffing levels were similar at the clinics there is a striking difference in the numbers offered testing. Infants at the under-5s clinic are often sicker, need multiple services and the higher patient volume (171 compared to 52 patients per day at the IC) contributed to the difficulties of HIV testing within this setting, making the immunisation clinic a more suitable clinic setting for early infant diagnosis.
While there were no differences according to gender at the two clinics, those getting provider-initiated counselling and testing at the immunisation clinic were over 14 months younger (2.6 compared to 17 months, p<0.001), with a greater proportion identified as HIV-exposed (17.6% compared to 5.3%, p<0.001) and PCR eligible (7.9% compared to 3.5%, p<0.001).
More infants at the immunisation clinic than at the under-5s clinic accepted PCR testing (100% compared to 90.3%, p=0.03). They were also 2.5 months younger (3.1 compared to 5.6 months, p<0.001) with four times fewer testing PCR positive (7.1% compared to 32.1%, p<0.001. In addition higher proportions had received prevention of mother-to-child (PMTCT) interventions (85.7% compared to 40%, p<0.001).
Critical to the success of early infant diagnosis programmes is being able to identify all HIV-exposed infants as young as possible so they can get the most out of access to PCR testing, PMTCT interventions, breastfeeding counselling and cotrimoxazole prophylaxis.
Likewise, early identification of HIV-infected infants and early ART is critical to maximise their chances of survival.
In all settings, but especially in resource-poor settings where severe financial, human and logistical constraints are often prevalent, effectively targeting those who will benefit the most is the best use of expensive EID resources.
These findings, note the authors, show that provider-initiated testing and counselling at immunisation clinics compared to under-5s clinics is a better use of resources to achieve this.
The authors note these findings support those of a South African study showing similar acceptance rates of EID at immunisation clinics, suggesting “the integration of EID services and ICs would be acceptable throughout the southern Africa region.”
A limitation is this study only compares two urban clinics.
The authors in conclusion “recommend the integration of opt-out HIV testing and counselling at ICs for all eligible mothers and infants. Scaling up EID testing at ICs is likely to strengthen EID services in Malawi.”
Source:1
