Background

Children living with HIV who are not diagnosed in infancy often remain undiagnosed until they present with advanced disease. Provider-initiated testing and counselling (PITC) in health facilities is recommended for high-HIV-prevalence settings, but it is unclear whether this approach is sufficient to achieve universal coverage of HIV testing. We aimed to investigate the change in community burden of undiagnosed HIV infection among older children and adolescents following implementation of PITC in Harare, Zimbabwe.

Methods and findings

Over the course of 2 years (January 2013–January 2015), 7 primary health clinics (PHCs) in southwestern Harare implemented optimised, opt-out PITC for all attendees aged 6–15 years. In February 2015–December 2015, we conducted a representative cross-sectional survey of 8–17-year-olds living in the 7 communities served by the study PHCs, who would have had 2 years of exposure to PITC. Knowledge of HIV status was ascertained through a caregiver questionnaire, and anonymised HIV testing was carried out using oral mucosal transudate (OMT) tests. After 1 participant taking antiretroviral therapy was observed to have a false negative OMT result, from July 2015 urine samples were obtained from all participants providing OMTs and tested for antiretroviral drugs to confirm HIV status. Children who tested positive through PITC were identified from among survey participants using gender, birthdate, and location. Of 7,146 children in 4,251 eligible households, 5,486 (76.8%) children in 3,397 households agreed to participate in the survey, and 141 were HIV positive. HIV prevalence was 2.6% (95% CI 2.2%–3.1%), and over a third of participants with HIV were undiagnosed (37.7%; 95% CI 29.8%–46.2%). Similarly, among the subsample of 2,643 (48.2%) participants with a urine test result, 34.7% of those living with HIV were undiagnosed (95% CI 23.5%–47.9%). Based on extrapolation from the survey sample to the community, we estimated that PITC over 2 years identified between 18% and 42% of previously undiagnosed children in the community. The main limitation is that prevalence of undiagnosed HIV was defined using a combination of 3 measures (OMT, self-report, and urine test), none of which were perfect.

Conclusions

Facility-based approaches are inadequate in achieving universal coverage of HIV testing among older children and adolescents. Alternative, community-based approaches are required to meet the Joint United Nations Programme on HIV/AIDS (UNAIDS) target of diagnosing 90% of those living with HIV by 2020 in this age group.

中文翻译：

---

津巴布韦青少年在初级卫生保健提供者发起的 HIV 检测和咨询后未确诊 HIV 感染的社区负担：一项横断面调查

背景

在婴儿期未被诊断出的 HIV 感染儿童通常在出现晚期疾病之前仍未被诊断出来。对于 HIV 高发地区，建议在卫生设施中由提供者发起的检测和咨询 (PITC) 进行检测，但尚不清楚这种方法是否足以实现 HIV 检测的普遍覆盖。我们旨在调查在津巴布韦哈拉雷实施 PITC 后年龄较大儿童和青少年未确诊 HIV 感染的社区负担的变化。

方法和发现

在 2 年（2013 年 1 月至 2015 年 1 月）的过程中，哈拉雷西南部的 7 家初级保健诊所 (PHC) 为所有 6-15 岁的参与者实施了优化的、选择退出的 PITC。2015 年 2 月至 2015 年 12 月，我们对居住在研究 PHC 服务的 7 个社区的 8 至 17 岁儿童进行了具有代表性的横断面调查，这些人将有 2 年的 PITC 暴露史。通过看护人问卷确定对 HIV 状态的了解，并使用口腔黏膜渗出液 (OMT) 测试进行匿名 HIV 检测。在观察到 1 名接受抗逆转录病毒治疗的参与者的 OMT 结果为假阴性后，从 2015 年 7 月起，从所有提供 OMT 的参与者那里获取了尿液样本，并测试了抗逆转录病毒药物以确认 HIV 状态。使用性别、出生日期和地点从调查参与者中识别出通过 PITC 检测呈阳性的儿童。在 4,251 个符合条件的家庭的 7,146 名儿童中，3,397 个家庭的 5,486 名儿童（76.8%）同意参加调查，其中 141 名儿童艾滋病毒阳性。HIV 感染率为 2.6%（95% CI 2.2%–3.1%），超过三分之一的 HIV 感染者未确诊（37.7%；95% CI 29.8%–46.2%）。同样，在 2,643 名 (48.2%) 的尿检结果参与者的子样本中，34.7% 的 HIV 感染者未被诊断出来 (95% CI 23.5%–47.9%)。根据从调查样本到社区的推断，我们估计 PITC 在 2 年内识别出社区中 18% 至 42% 的先前未确诊儿童。

结论

以设施为基础的方法不足以实现对年龄较大的儿童和青少年进行艾滋病毒检测的普遍覆盖。需要以社区为基础的替代方法来实现联合国艾滋病毒/艾滋病联合规划署 (UNAIDS) 的目标，即到 2020 年在该年龄组中诊断出 90% 的艾滋病毒感染者。