Implementing services for Early Infant Diagnosis (EID) of HIV: a comparative descriptive analysis of national programs in four countries

Abstract

Background: There is a significant increase in survival for HIV-infected children who have early access to diagnosis and treatment. The goal of this multi-country review was to examine when and where HIV-exposed infants and children are being diagnosed, and whether the EID service is being maximally utilized to improve health outcomes for HIV-exposed children.

Methods: In four countries across Africa and Asia existing documents and data were reviewed and key informant interviews were conducted. EID testing data was gathered from the central testing laboratories and was then complemented by health facility level data extraction which took place using a standardized and validated questionnaire

Results: In the four countries reviewed from 2006 to 2009 EID sample volumes rose dramatically to an average of >100 samples per quarter in Cambodia and Senegal, >7,000 samples per quarter in Uganda, and >2,000 samples per quarter in Namibia. Geographic coverage of sites also rapidly expanded to 525 sites in Uganda, 205 in Namibia, 48 in Senegal, and 26 in Cambodia in 2009. However, only a small proportion of testing was done at lower-level health facilities: in Uganda Health Center IIs and IIIs comprised 47% of the EID collection sites, but only 11% of the total tests, and in Namibia 15% of EID sites collected >93% of all samples. In all countries except for Namibia, more than 50% of the EID testing was done after 2 months of age. Few sites had robust referral mechanisms between EID and ART. In a sub-sample of children, we noted significant attrition of infants along the continuum of care post testing. Only 22% (Senegal), 37% (Uganda), and 38% (Cambodia) of infants testing positive by PCR were subsequently initiated onto treatment. In Namibia, which had almost universal EID coverage, more than 70% of PCR-positive infants initiated ART in 2008.

Conclusions: While EID testing has expanded dramatically, a large proportion of PCR- positive infants are initiated on treatment. As EID services continue to scale-up, more programmatic attention and support is needed to retain HIV-exposed infants in care and ensure that those testing positive initiate treatment in a timely manner. Namibia's experience demonstrates that it is feasible for a rural, low-income country to achieve high national coverage of infant testing and treatment.

Figure 1

Infant Diagnosis Service Delivery Continuum. Note: At the time of the reviews, WHO guidance recommended that all children under 12 months testing positive by PCR be initiated onto ART. 2010 WHO guidance now recommends that all children under 24 months of age that test PCR-positive should be initiated onto treatment.

Figure 2

Samples tested for EID over time for the national programs.

Figure 3

Utilization of EID by level of health care delivery system. Top: Availability and uptake of EID by level of health care delivery system in Uganda. Bottom: Number of samples from Hospitals vs. Health Centers in Namibia from 2006-2009.

Figure 4

Time of EID test stratified by age categories (2006-2009).

Figure 5

Outcomes for HIV positive Infants at Reviewed Sites in Uganda.

Figure 6

Initiation of Infants Testing PCR-positive on ART in Namibia. Data are from the 25 review sites in Namibia and represent the proportion of known PCR-positive infants who were enrolled in HIV care services that initiated antiretroviral therapy <6 m after enrolling in care, >6 m after enrolling, or not at all.