Routine Offering of HIV Testing to Hospitalized Pediatric Patients at University Teaching Hospital,
Abstract and Introduction
Objectives: The difficulties diagnosing infants and children with HIV infection have been cited as barriers to increasing the number of children receiving antiretroviral therapy worldwide.
Design: We implemented routine HIV antibody counseling and testing for pediatric patients hospitalized at the University Teaching Hospital, a national reference center, in Lusaka, Zambia. We also introduced HIV DNA polymerase chain reaction (PCR) testing for early infant diagnosis.
Methods: Caregivers/parents of children admitted to the hospital wards were routinely offered HIV counseling and testing for their children. HIV antibody positive (HIV+) children <18 months of age were tested with PCR for HIV DNA.
Results: From January 1, 2006, to June 30, 2007, among 15,670 children with unknown HIV status, 13,239 (84.5%) received counseling and 11,571 (87.4%) of those counseled were tested. Overall, 3373 (29.2%) of those tested were seropositive. Seropositivity was associated with younger age: 69.6% of those testing HIV antibody positive were <18 months of age. The proportion of counseled children who were tested increased each quarter from 76.0% in January to March 2006 to 88.2% in April to June 2007 (P < 0.001). From April 2006 to June 2007, 1276 PCR tests were done; 806 (63.2%) were positive. The rate of PCR positivity increased with age from 22% in children <6 weeks of age to 61% at 3-6 months and to 85% at 12-18 months (P < 0.001).
Conclusions: Routine counseling and antibody testing of pediatric inpatients can identify large numbers of HIV-seropositive children in high prevalence settings. The high rate of HIV infection in hospitalized infants and young children also underscores the urgent need for early infant diagnostic capacity in high prevalence settings.
Recent efforts to provide antiretroviral therapy (ART) to HIV-infected individuals in resource-limited countries have met with considerable success. More than 2.1 million individuals in sub-Saharan Africa were reported to have initiated ART by December 2007. These successes have been predominantly limited to adults: efforts to treat HIV-infected children have been less robust. By the end of 2007, an estimated 2.5 million children worldwide were living with HIV, but only 200,000 children were receiving ART.
Multiple barriers to pediatric ART have been delineated. Pediatric formulations are more costly than adult medications and require precise dosing based on weight or body surface area. Pediatric fixed-dose combination tablets only recently became available. Pediatric expertise is often limited, with few health care providers trained to care for children with complex conditions. And, in the context of large numbers of adults with HIV, few governments have prioritized the needs of children.
Identifying and diagnosing HIV-infected children have also posed formidable barriers to engaging children in care. Prevention of mother-to-child transmission (PMTCT) programs offer opportunities to identify HIV-exposed infants, but the scale-up of PMTCT programs has been eclipsed by efforts to roll-out ART, and routine infant follow-up has been difficult to achieve. Furthermore, until recently, there has been limited guidance on pediatric HIV testing policies and a reliance on risk-based offering of testing. The rapid rate of pediatric disease progression and overlap of symptoms with other diseases have shown this approach to be inadequate to prevent HIV-related mortality. Finally, the complexity of diagnosing HIV infection in infants and young children often precludes early ART initiation. Special virologic tests such as RNA or DNA polymerase chain reaction (PCR) are required to determine if an HIV-exposed infant is infected.
In Zambia, with the rapid scale-up of HIV services, 11,602 children were receiving ART at the end of 2007. At the University Teaching Hospital of Zambia (UTH), the national reference hospital in Lusaka Zambia, there are more than 10,000 pediatric admissions annually. Because HIV-exposed and HIV-infected children are at high risk for infectious and nutritional complications, we hypothesized that routinely offering HIV antibody testing to all hospitalized children would identify large numbers of HIV-positive children. In January 2006, we initiated a program to routinely offer counseling and HIV antibody testing with same day results for all children hospitalized at UTH. We present the results for the first 18 months of activity and results of an early infant diagnosis (EID) program using DNA PCR initiated in May 2006.