Routine opt-out HIV testing reduces missed diagnoses in children

The effectiveness of routine opt-out HIV testing for children in Harare, Zimbabwe.

Ferrand RA, Meghji J, Kidia K, Dauya E, Bandason T, Mujuru H, Ncube G, Mungofa S, Kranzer K. J Acquir Immune Defic Syndr. 2015 Oct 12. [Epub ahead of print]

Objective: HIV testing is the entry point to access HIV care. For HIV-infected children who survive infancy undiagnosed, diagnosis usually occurs on presentation to health care services. We investigated the effectiveness of routine opt-out HIV testing (ROOT) compared to conventional opt-in provider-initiated testing and counselling (PITC) for children attending primary care clinics.

Methods: Following an evaluation of PITC services for children aged 6 to 15 years in six primary health care facilities in Harare, Zimbabwe, ROOT was introduced through a combination of interventions. The change in the proportion of eligible children offered and receiving HIV tests, reasons for not testing, and yield of HIV positive diagnoses were compared between the two HIV testing strategies. Adjusted risk ratios for having an HIV test in the ROOT compared to the PITC period were calculated.

Results: There were 2831 and 7842 children eligible for HIV testing before and after the introduction of ROOT. The proportion of eligible children offered testing increased from 76% to 93% and test uptake improved from 71% to 95% in the ROOT compared to the PITC period. The yield of HIV diagnoses increased from 2.9% to 4.5%, and a child attending the clinics post intervention had a 1.99 increased adjusted risk (95% CI 1.85-2.14) of receiving an HIV test in the ROOT period compared to the pre-intervention period.

Conclusion: ROOT increased the proportion of children undergoing HIV-testing, resulting in an overall increased yield of positive diagnoses, compared to PITC. ROOT provides an effective approach to reduce missed HIV diagnosis in this age-group.

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Editor’s notes: The policy and practice of HIV testing in high HIV prevalence settings has evolved over the years, from a more cautious approach in the early years of the HIV epidemic to a more proactive one with the scale up of antiretroviral therapy (ART). Despite a marked increase in HIV testing following the introduction of provider-initiated testing and counselling (PITC) in clinical settings, coverage remains suboptimal. Routine opt-out testing (ROOT) describes a strategy of HIV testing as part of the routine clinical ‘work-up’, unless a person explicitly refuses to test. To date, ROOT has been confined to specialist clinical services, such as prevention of mother-to-child HIV transmission programmes, sexual health clinics and tuberculosis services.

This study in primary care facilities in Harare compared the effectiveness of ROOT with PITC in children aged six to 15 years, a group for whom opportunities to receive HIV testing have been limited. The authors found that a 22% increase in the proportion of eligible children offered testing following the introduction of ROOT; a 34% increase in the proportion of HIV test uptake; and a 55% increase in proportion of children testing HIV positive (yield).  Importantly, the increase in proportion of children to whom testing was offered, test uptake and yield compared to opt-in PITC was sustained over the 1.5 years follow-up period. Factors postulated to have resulted in improved testing and uptake included the removal of the decision of whether to test from the guardian and healthcare worker and decreased stigma associated with opt-out testing. The authors also acknowledge that investment in training and human resource capacity likely contributed to improvements seen. Further, as stated by the authors, HIV testing must be accompanied by effective strategies to ensure linkage to care in order to improve health outcomes in this population.

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