HIV testing of infants at immunisation clinics in Kwazulu-Natal

A poster from Nigel Rollins and coworkers in Kwazulu-Natal (KZN), South Africa presented results from an acceptability and feasibility study of routine HIV testing of infants attending immunisation clinics in a setting with high HIV prevalence.

Although universal treatment of infants <12 months is now recommended in WHO guidelines, routine postnatal testing of infants is uncommon and many HIV-infected children are not identified early enough to benefit from this recommendation.

In this study, all mothers bringing their infants for immunisation at 6, 10 or 14 weeks of age to three primary healthcare sites in KZN were offered HIV testing. Heel pricks were performed and blood collected on filter paper. If HIV antibodies were detected the dried blood spots (DBS) were tested for HIV by DNA PCR.

If the infant was infected, mothers were referred to routine HIV services after counselling that they would also be expected to be HIV-positive.

The investigators reported that between November 2007 and February 2008, 646 mothers were offered HIV testing for their infants. Of this group, 584 (90.4%, 95% CI 87.8%-92.5%) consented and 332 (56.8%, 95% CI 52%-60.9%) returned to collect the results.

They found that women who self reported their own HIV-positive status were more likely to return for results than those who reported themselves to be HIV-negative, p=0.001.

HIV antibodies were present in 247/584 (42.3%) of infant DBS and 54/247 (21.9%) had positive DNA PCR results (54/584, 9.2% of all infants tested). Among the women reporting themselves to be HIV-negative, 7.2% of infants had HIV antibodies detected. The mother-to-child-transmission rate for these infants was 38%.

The investigators found that, in this study, HIV testing at immunisation clinics was acceptable and feasible. Over half of the infected infants were identified which, they noted, contrasts sharply with the experience of PMTCT programmes in which routine testing of infants is achieved in only 8% of HIV-exposed infants.

Comment

Routine testing at immunisation clinics, in settings with high HIV prevalence, offers a feasible entry point into care for infants before 12 months of age.

As the investigators mention, although WHO guidelines recommend early diagnosis and treatment, only 8% of infants born to pregnant women with HIV are tested before they are two months old. Most studies report that children start ART when they are about 5 years old when they already have severe immunodeficiency and when they are identified through health facilities due to clinical symptoms. In these circumstances, mortality in the first few months of treatment is high.

Since estimations suggest that as many as 89% of HIV-infected children will have died before they are 5 years old in sub-Saharan African, currently the overwhelming majority of children who could benefit from WHO recommendations are neither being tested nor treated.

Rollins et al. Universal HIV testing of infants at immunization clinics in high HIV prevalence settings: Acceptable, feasible, and potential for high returns. 16th CROI, February 2008, Montreal, Canada. Poster abstract 899b.
http://www.retroconference.org/2009/Abstracts/36509.htm