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：

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在以医疗机构为基础的医疗人员发起的艾滋病毒检测和咨询后，津巴布韦青少年的未确诊艾滋病毒感染的社区负担：一项横断面调查

背景

未被诊断为婴儿期的HIV感染儿童通常直到他们患有晚期疾病才被诊断。对于高艾滋病毒感染率的环境，建议在卫生机构中由提供者启动检测和咨询（PITC），但尚不清楚这种方法是否足以实现艾滋病毒检测的普遍覆盖。我们的目的是调查在津巴布韦哈拉雷实施PITC之后，年龄较大的儿童和青少年中未确诊的HIV感染社区负担的变化。

方法和发现

在过去的2年中（2013年1月至2015年1月），哈拉雷西南部的7家初级卫生诊所（PHC）对所有6至15岁的参与者实施了优化的选择退出PITC。2015年2月至2015年12月，我们对居住在研究PHC服务的7个社区中的8-17岁儿童进行了代表性横断面调查，他们可能会接触PITC 2年。通过看护者问卷确定对艾滋病毒状况的了解，并使用口腔粘膜渗出液（OMT）进行匿名的艾滋病毒检测。在观察到一名接受抗逆转录病毒疗法的参与者的OMT假结果为假后，从2015年7月开始，从所有提供OMT的参与者中获取尿液样本，并进行抗逆转录病毒药物测试以确认HIV状况。通过性别，出生日期和位置从参与调查的参与者中识别出通过PITC测试呈阳性的儿童。在4,251个合格家庭中的7,146名儿童中，3,397户中的5,486名儿童（76.8％）同意参加该调查，其中141名艾滋病毒呈阳性。HIV患病率为2.6％（95％CI为2.2％–3.1％），三分之一以上的HIV参与者未被诊断（37.7％； 95％CI为29.8％–46.2％）。同样，在2643名（48.2％）参与者的尿液检查结果子样本中，有34.7％的HIV感染者未被诊断（95％CI为23.5％–47.9％）。根据从调查样本到社区的推断，我们估计PITC在2年内发现了社区中先前未诊断出的儿童的18％至42％。

结论

基于设施的方法不足以在年龄较大的儿童和青少年中实现艾滋病毒检测的普遍覆盖。为了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，该年龄组要诊断90％的艾滋病毒感染者，需要采取基于社区的替代方法。