of testing for early infant diagnosis was acceptable and feasible at a government immunisation clinic (IC); the proportion of
infants who received provider-initiated testing and counselling (PITC) was
seven times higher at this sort of clinic than for those attending a government 'under-five' clinic in Lilongwe, Malawi, researchers report in the advance online edition of
the Journal of Acquired Immune Deficiency
this prospective consecutive study of 877 and 880 children at an under-five
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, compared to those attending the under-five 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.
current early infant diagnosis programme recommends all HIV-infected mothers
bring their infants at six weeks of age, whether well or not, for PCR testing and
evaluation at an under-five 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
the 50% who do get a PCR at the under-five clinic, more than two-thirds do not return
for the results or enrol into care.
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.
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
under-five clinics offer care for sick children and provide immunisation and early infant
diagnosis, the latter two are separate. Testing usually takes place at an under-five
clinic only when the children are brought in for PCR testing or are sick.
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-five clinic.
provider-initiated testing and counselling registers were used to prospectively
look at 1757 children, all offered PCR testing at either the immunisation clinic at Bwaila
Hospital or the under-five clinic 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.
children were followed until disclosure of the PCR test 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
immunisation clinic pilot programme began in January 2011, while the
under-five 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, who provide advocacy and
administrative help, and accompany caregivers from the testing room to the
HIV clinic for those newly identified as HIV-exposed or HIV-infected. For infants older than six weeks of age, cotrimoxazole prophylaxis is prescribed.
were eligible for PCR testing if younger than 12 months of age, if they had an
HIV-infected mother, and if they were not already enrolled in HIV care elsewhere.
infants were defined as those younger than 12 months of age, with an HIV-infected
mother and without a definitive negative PCR result, regardless of current
infants were defined as those older than 12 months of age who had tested
HIV-antibody positive, or who had a documented positive PCR result, irrespective of
During the study, 84.2%
and 11.4% respectively (p<0.001) of the 880 and 877 of infants attending the immunisation clinic and the under-five clinic received provider-initiated testing and counselling.
though staffing levels were similar at the clinics, there is a striking
difference in the numbers offered testing. Infants at the under-five clinic are
often sicker and need multiple services. The higher patient volume (171
a day, compared to 52 patients per day at the immunisation clinic) contributed to the difficulties of
HIV testing within this setting, making the immunisation clinic a more suitable
clinic setting for early infant diagnosis.
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).
carers at the immunisation clinic than at the under-five clinic accepted PCR
testing for their infants (100% compared to 90.3%, p=0.03). The children were 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
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
early identification of HIV-infected infants and early ART is critical to maximising
their chances of survival.
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 makes the best use of expensive early-infant-diagnosis resources.
findings, note the authors, show that provider-initiated testing and counselling at immunisation clinics, compared to
under-five clinics, is a better use of resources.
authors note these findings support those of a South African study showing
similar acceptance rates of early infect diagnosis (EID) at immunisation clinics, suggesting “the integration of EID services and ICs would be
acceptable throughout the southern Africa
limitation to this research is that this study only compares two urban clinics.
In conclusion, the
authors “recommend the integration of opt-out HIV testing and
counselling at ICs [immunisation clinics] for all eligible mothers and infants. Scaling up EID testing
at ICs is likely to strengthen EID services in Malawi”.