Home-based testing improves HIV diagnosis rate among children

Home-based voluntary HIV counselling and testing (HCT) provided an opportunity to identify 60 new paediatric HIV cases among 1300 high-risk children between the ages of 18 months and 13 years of age in a single community in rural western Kenya between June 2008 and June 2009, researchers reported in a retrospective analysis published in the advance online edition of the Journal of Acquired Immune Deficiency Syndromes.

However, close to half of the children’s caretakers who were offered testing refused.

The likelihood of children getting tested was greatest where information about the mother’s suspected or confirmed HIV infection was available; if the parents were not in the household; if they were grandchildren of the head of household; or if the father was not in the household.

Timely treatment of HIV infection requires early diagnosis. This is particularly important for children. Without treatment approximately 50 percent will die before the age of two.

In sub-Saharan Africa and other resource-limited settings where HIV-incidence among children is high early diagnosis is critical to achieve the best treatment outcomes.

However, in spite of the importance of testing at-risk children, little is known about the acceptance of paediatric testing among children and their caregivers in sub-Saharan Africa.

The Academic Model Providing Access to Healthcare (AMPATH), a large clinical care system, has enrolled over 113,000 HIV-infected adult and paediatric patients in western Kenya.

Home-based voluntary counselling and testing, (community-based or population-based HIV-testing) can identify children early in the course of the disease so they can get treated early.

In 2007 AMPATH started HCT in western Kenya. This comprises: giving a rapid, in-home HIV test for adults and children over the age of 18 months, immediate availability of the test results, post-test counselling and referral as appropriate, during one household visit

HCT was rolled out in the Turbo Division of the Uasin Gishu District of the Rift Valley Province in 2008. This division, with an AMPATH clinic caring for 5340 patients including 989 children, is considered ethnically and socio-economically representative of many rural divisions in western Kenya.

All consenting adult household members over the age of 13 were eligible for testing. Children 18 months to 13 years of age were offered HCT if their mother was known to be dead, her living status unknown, known to be HIV-infected or of unknown HIV status. The goal was to identify children at high risk for HIV-infection.

In contrast to 95% of adults who agreed to be tested, caregivers refused testing for almost half (995-43%) of all children (2,289) at high risk for HIV-infection. Of the 57% tested 60 (4.6%) were identified as HIV-positive.

The likelihood of being tested was greater for children with HIV-infected mothers, OR 3.20, 95% CI: 1.64-6.23; not having parents living with them, OR 1.50, 95% CI: 1.40-1.63; were grandchildren of the head of household (compared to the child of the head of household, other relatives or non-biological heads of household), OR 4.02, 95% CI: 3.06-5.28; or if their father was not in the household OR 1.41, 95% CI: 1.24-1.56.

These findings, the authors note, highlight the mother’s HIV and living status as key indicators of a child’s HIV risk in regard to a caregiver’s willingness to agree to testing as well as HIV prevalence. Nonetheless, many children of HIV-infected mothers were not tested. This led the authors to estimate that 46 (2%) more at-risk children could have been identified as HIV-infected.  

Children aged 5-12 were more likely to be tested than those under five. The authors offer a number of potential reasons: the children may have more signs of illness, the risk of sexually transmitting HIV and the belief that older children were better able to handle a diagnosis. In addition they note with increased antenatal HIV testing there is a possibility that younger children had already been tested.

Fear of stigma and discrimination could also have played a key role in refusal of testing, the authors note. Only high-risk children were offered testing. The family or caregivers may not have wished to be singled out. Or, they did not wish their own status to be known to their children. Not having easy access to care could also have played a role.

However, their findings, they note, also suggest less fear of stigma and discrimination among caregivers of orphans.

These findings highlight the need to investigate why caregivers accept or refuse testing. Missed opportunities and interventions to increase paediatric testing can be identified and treatment outcomes improved. 

Limitations included, according to the authors,

• The child’s eligibility was based solely on the mother’s status. While useful the child’s own health status was not taken into account. Unlike adults in the household all children were not tested.
• Testing of children under18 months of age was not offered. These children needed a non rapid DNA PCR test to distinguish between maternal and child antibodies that could not be done in the home.
• Data collected was quantitative from a brief home visit.
• The study was limited to a specific geographical and cultural area so was not generalisable. However, the findings nonetheless point to the importance of understanding a caregiver’s reasoning for accepting or refusing testing. So that the best use of scale-up of paediatric HIV testing using community-based methods is made.

The authors conclude that “home-based voluntary counselling and testing provides an opportunity to identify HIV among high-risk children.” And add “Further investigation is needed to identify and overcome barriers to testing uptake.”

Reference

Vreeman RC et al. Acceptance of HIV testing for children ages 18 months to 13 years identified through voluntary, home-based HIV counselling and testing in western Kenya. Journal of Acquired Immune Deficiency Syndromes, advance online publication, August 13, 2010. (Link to abstract and full-text publication).