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.
to half of the children’s caretakers who were offered testing refused.
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.
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.
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.
spite of the importance of testing at-risk children, little is known about the
acceptance of paediatric testing among children and their caregivers in
Academic Model Providing Access to Healthcare (AMPATH), a large clinical care
system, has enrolled over 113,000 HIV-infected adult and paediatric patients in
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
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
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.
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
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.
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.
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.
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.
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.
their findings, they note, also suggest less fear of stigma and discrimination
among caregivers of orphans.
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.
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
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.”