Missed opportunities for early infant diagnosis in South Africa

Missed opportunities for early infant HIV diagnosis: results of a national study in South Africa.

Woldesenbet SA, Jackson D, Goga AE, Crowley S, Doherty T, Mogashoa MM, Dinh TH, Sherman GG. J Acquir Immune Defic Syndr. 2015 Mar 1;68(3):e26-32. doi: 10.1097/QAI.0000000000000460.

Background: Services to diagnose early infant HIV infection should be offered at the 6-week immunization visit. Despite high 6-week immunization attendance, the coverage of early infant diagnosis (EID) is low in many sub-Saharan countries. We explored reasons for such missed opportunities at 6-week immunization visits.

Methods: We used data from 2 cross-sectional surveys conducted in 2010 in South Africa. A national assessment was undertaken among randomly selected public facilities (n = 625) to ascertain procedures for EID. A subsample of these facilities (n = 565) was revisited to assess the HIV status of 4- to 8-week-old infants receiving 6-week immunization. We examined potential missed opportunities for EID. We used logistic regression to assess factors influencing maternal intention to report for EID at 6-week immunization visits.

Results: EID services were available in >95% of facilities and 72% of immunization service points (ISPs). The majority (68%) of ISPs provide EID for infants with reported or documented (on infant's Road-to-Health Chart/booklet-iRtHC) HIV exposure. Only 9% of ISPs offered provider-initiated counseling and testing for infants of undocumented/unknown HIV exposure. Interviews with self-reported HIV-positive mothers at ISPs revealed that only 55% had their HIV status documented on their iRtHC and 35% intended to request EID during 6-week immunization. Maternal nonreporting for EID was associated with fear of discrimination, poor adherence to antiretrovirals, and inadequate knowledge about mother-to-child HIV transmission.

Conclusions: Missed opportunities for EID were attributed to poor documentation of HIV status on iRtHC, inadequate maternal knowledge about mother-to-child HIV transmission, fear of discrimination, and the lack of provider-initiated counseling and testing service for undocumented, unknown, or undeclared HIV-exposed infants.

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Editor’s notes: Early infant diagnosis (EID) in HIV-exposed infants is important for a number of reasons. Most importantly, it allows early identification and antiretroviral treatment of HIV-positive infants, resulting in markedly reduced morbidity and mortality. It also allows objective assessment of the effectiveness of prevention efforts to eliminate mother-to-child transmission. 

In South Africa, EID services are widely available at immunization service points in public primary healthcare facilities, with 68% offering focussed testing of HIV-exposed infants. This strategy relies on maternal reporting or documentation of maternal HIV status on the “infant’s road to health chart” (iRtHC). This study found that neither the iRtHC nor the maternal reporting were used effectively for conveying HIV exposure status of infants to health workers responsible for EID. Nearly half, 45%, of mothers self-reporting HIV-positive status, had no documentation of their positive status on the iRtHC. In addition, very few healthcare facilities offered provider-initiated counselling and testing for infants of unknown HIV exposure status.

HIV-positive mothers were less likely to disclose their HIV status at six-week immunisation visits if they had limited knowledge of risk of transmission to their child, had missed doses of maternal or infant antiretroviral therapy or reported fear of discrimination and stigma. These results suggest that improving EID requires improving identification of HIV-exposed infants at the six-week immunisation visit and improving maternal education about infant testing during antenatal care. Other strategies include reducing stigma and discrimination through community-level educational campaigns, improving privacy at immunisation facilities and improving provider-initiated counselling and testing of all infants with undocumented or unknown HIV status.

Africa
South Africa
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