Over 3000 children diagnosed with HIV in Lusaka after hospital introduces opt-out HIV testing

Implementing a policy of routine opt-out HIV testing led to the diagnosis of 3000 HIV infections in children admitted to hospital in Lusaka over an 18-month period, investigators report in a study published in the online edition of the Journal of Acquired Immune Deficiency Syndromes.

“Increased HIV testing has been proposed as an important component of HIV prevention and a pathway to support universal access to antiretroviral therapy”, write the investigators. “This is particularly important for infants where the rate of disease progression is extremely rapid, the risk of early death is high, and antiretroviral therapy can decrease mortality significantly in the first year of life”, they add.

In an attempt to increase the number of diagnosed HIV-positive children in Lusaka, Zambia, investigators at the University Teaching Hospital implemented a policy of offering routine HIV counselling and testing to all children admitted as inpatients.

HIV prevalence amongst women attending antenatal services in Zambia is 25% and an estimated 28,000 infants are born each year in the country with HIV infection. The investigators therefore hypothesised that routinely offering HIV testing would identify large numbers of HIV-infected children.

A total of 15,670 children of unknown HIV status were admitted to the hospital as in-patients between January 2006 and June 2007. Of these, 13,239 parents/caregivers (85%) received counselling for testing of their child and 11,571 children (87%) had an HIV test.

In all, 3373 (29%) of children tested HIV-positive. Almost a third of children under six months of age were HIV-positive, as were 23% of children aged five and over. Nevertheless, two-thirds (69%) of children testing positive were under 18 months of age.

Children admitted to the malnutrition ward had the highest prevalence of HIV infection (36%). After adjusting for possible confounding factors, the investigators found that children admitted to the malnutrition ward (adjusted odds ratio [AOR], 16.7; 95% CI: 13.7-20.4) and the diarrhoea/rehydration ward (AOR, 8.2; 95% CI: 13.7-20.4) were significantly more likely to test HIV-positive than children admitted to other wards.

Approximately 4100 eligible children were not tested for HIV and 1668 (41%) received counselling but were not subsequently tested for the infection. The most common reason for not testing were the death of the child (44%), the refusal of the parent (12%) and early discharge (10%).

“Many of the categories represent missed testing opportunities: early discharge, absconded, and weekend admission. The majority of children in these categories received no counselling. In contrast, parental refusal and waiting for husband’s permission represent situations where counselling was performed, but the child was not tested”, note the authors.

As well as diagnosing over 3000 children, the investigators note secondary benefits of their programme of routine testing. “Parents and caregivers were offered HIV testing and, later in the programme, CD4 cell testing. HIV-positive adults were referred for care.” The investigators also write that parents were encouraged to bring other children in for HIV testing.

“We successfully implemented a routine HIV counselling and testing programme for hospitalized paediatric patients”, conclude the investigators, “we propose that this programme is particularly relevant in settings with generalised HIV epidemics and should be replicated as a highly feasible way to identify children in need of HIV care and antiretroviral treatment.”