Oga, Maxime Aimé MSc*; Ndondoki, Camille MD†; Brou, Hermann PhD*; Salmon, Amadou MSc*; Bosse-Amani, Clarisse MD*; Timite-Konan, Marguerite Pr*‡; Leroy, Valériane MD, PhD†
The UNAIDS world report on the global AIDS epidemic 2010 indicated for the first time that new infections and AIDS-related deaths among children decreased because of the increasing use of services for prevention of mother-to-child transmission of HIV (PMTCT) and access to antiretroviral treatment (ART) by children. Thus, an estimated 370,000 children were newly infected with HIV in 2009, a drop of 24% from 5 years earlier.1 Despite this significant progress, the operational context of HIV care still needs to be improved in Africa to reach more ambitious targets.
Without ART, high levels of early mortality are observed among HIV-infected children, up to 50% before their second birthday.2 Thus, in 2010, the World Health Organization guidelines recommended universal early ART for all HIV-infected children aged less than 24 months, irrespective of their clinical status or symptomatology.3-5 However, children continue to have less access to ART than adults (28% coverage in children compared with 37% in adults).1 Moreover, it occurs often too late, the median age of ART initiation being 5 years.6-9 To improve earlier access to pediatric ART among HIV-infected children in resource-limited settings, it is crucial first to enhance public health strategies for early infant diagnosis (EID).
Although adult HIV counselling and testing (CT) practices have been rapidly scaled-up in low-income countries in the ART era, routine offering of HIV CT to pediatric patients often occurs too late.1 EID targeted to both children exposed and not exposed to PMTCT interventions is indeed an important operational challenge in Africa.10 EID requires investment in key areas such as training and support for providers, improvement of laboratory tools and referral networks. The feasibility of this public health strategy is therefore highly conditioned by at least 3 parameters: (1) the availability of technical platforms and virological tools for EID, (2) the family acceptability, but also (3) the skills, attitudes, and practices of health care workers (HCW) toward HIV EID to guarantee a timely refferal.
The ANRS 12165 Pedi-test project aimed to evaluate the social and family acceptability of routinely HIV pediatric CT as the entry point of a family screening strategy offered in immunization clinics and pediatric consultations among children aged <6 months, in Abidjan, Côte d'Ivoire.11 Throughout this initiative, we first assessed the baseline attitudes and practices of HCWs toward HIV routine CT offered to infants in pediatric health services.
Study Design and Patients
The ANRS 12165 PEDI-TEST study was a cross-sectional evaluation of family acceptance of routine HIV pediatric CT as the entry point for a family screening strategy that has been reported elsewhere.11 It was conducted in 4 community health facilities in Abidjan, Côte d'Ivoire. Since 2004, these health centres have been providing a comprehensive HIV/AIDS care and treatment package, including voluntary counselling and testing for HIV services, PMTCT services, and ART for children and adults.
We performed a baseline cross-sectional survey among all HCWs of the 4 sites working in immunization, weighing, or pediatric care services with a target of 120 eligible professionals.
One standardized, structured, self-administered anonymous questionnaire was used to collect information on HCWs attitudes and practices toward infant HIV CT. After an information session on the purposes of the study, HCWs were asked about their sociodemographic characteristics, prior experience with infant HIV testing, their attitude toward testing, their role and daily activities related to the practice of testing and for infant care, their perception about the difficulties encountered, and their training needs.
All staff who accepted to answer the questionnaire were included in the analysis. First, baseline characteristics of HCWs were described. Then, we analyzed and compared their attitudes and practices toward infant HIV testing according first to their type of activity then to the training they had received.
Frequency distributions and expressed as percentages. Associations between categorical variables were assessed using Pearson χ2 test. Statistical analysis was performed using SAS 9.1.
The study was approved by the Ivoirian ethical committee (March 2008). The anonymity and the voluntary consent of participants were respected.
Characteristics of Study Participants
From March to April 2008, 105 of the 120 HCWs were interviewed, a response rate of 88%. Among them, 27% were physicians, 24% nurses or midwives, 31% caregivers, social workers, or counsellors, and 19% had other duties (Table 1). Their median age was 36 years (range: 21-54 years) and 65% were women, 57% worked in a pediatric care service and 43% in the immunization and well-baby clinics. The average length of professional experience in the health facility was 5.8 years and 47% of HCWs had worked there for >5 years. Past training in HIV CT, sex, age, and professional experience varied acoording to the type of activity (pediatric care versus immunization service) (Table 1). Regarding the specific training ion HIV/AIDS on HIV/AIDS, 89% of the HCWs were already trained, 61% of them through workshops. For those trained, the training topics had been HIV CT (67%), PMTCT (82%), and HIV care (54%). Among immunization staff (n = 45), none of them had been trained in HIV CT versus 26% in pediatric care services (n = 60, P < 0001).
Attitudes and Practices of HCWs Toward HIV EID
Only 39% of HCWs had already been dealing with EID, 27% of whom found it difficult to discuss, 40% difficult to perform technically, 43% difficult to announce if the result was positive, and 23% difficult to take care of children if they were HIV infected. However, 81% of HCWs declared no difficulties in offering an HIV test and 96% thought that it was important to offer HIV EID. Three-quarters of HCWs suggested that any staff should offer EID, but 15% thought it was the role of physicians only.
Eight of 10 HCWs declared they would accept HIV screening for their own child. Faced with a child suspected of HIV infection only 61% of HCWs declared they would offer HIV CT to the whole family. Two-thirds of the respondents declared they would like to be more involved in HIV EID activities and 71% felt a need to be trained specifically for this activity.
Eighty percent (80%) of staff had already offered an HIV test to someone, 42% to a child, 78% to an adult and 63% to a pregnant woman. Nearly 80% of the health workers declared that they had never performed HIV testing without patient's consent.
In the pediatric care units, 61% of the HCW worked had a practice related to HIV EID, 79% of whom performed pretest and post-test counselling, 34% blood collection, and 68% announced test results. About two-thirds of these HCWs referred patients elsewhere for the proposal of an HIV test. However, no staff declared having referred patients to a traditional medical practitioner.
Sixty-eight percent of pediatric care staff versus 82% of immunization staff thought that HCWs should offer HIV EID, but 22% thought that it is the role of physicians only, versus 7% of immunization staff (P = 0.01) (Table 2). Close to 50% of pediatric staff versus 73% of immunization staff thought that HIV EID should be routinely offered by immunization services (P = 0.03). Faced with a suspected HIV-infected child, 54% of pediatric care staff and 71% of immunization staff would give HIV CT to the whole family (P = 0.012).
In their daily work, 22% of immunization staff and 48% of pediatric care staff had already been faced with HIV early diagnosis in children less than 6 months (P = 0.01).
The referral of HIV-infected patients to other organisations (nongovernmental organizations, associations, etc…) was also dependant of the activity performed: 84% of pediatric care staff referred HIV-infected children versus 54% in weighing or immunization services (P = 0.001); in addition, 12% of pediatric care staff declared that he (she) had performed or prescribed an HIV test at least once to a patient without his consent versus none in the immunization clinics (P = 0.05).
There was no statistical difference between physicians, nurses, and midwives or other staff in attitudes toward infant HIV testing according to their initial training. Although 14% of physicians faced with a child suspected to be HIV infected would suggest to perform the HIV test only to the child, 8% of nurses or midwives and no social workers and counsellors would do so. Similarly, 75% of social workers and counsellors would offer the HIV test to the whole family versus only 46% of physicians (P = 0.01) (Table 3).
Finally more than 1 physician of 10 declared having prescribed an HIV test to a patient without his (her) formal consent versus 4% of nurses or midwives and 3% of social workers (P = 0.74).
Our study took place in Abidjan, Côte d'Ivoire, and assessed the baseline attitudes and practices of HCW toward HIV CT as a service that should be routinely offered to any infant in pediatric primary health care services. Our results can be viewed as reasonably representative because of the high response rate and the relative uniformity of the public health system in the city. The use of a standardised semiquantitative and self-administered questionnaire to be completed by each staff member within each health facility allowed us to minimize information bias. However, our quantitative study design did not allow us to explore in-depth some of the issues identified. Despite these limitations, this survey allowed us to identify interesting facts, attitudes, and practices of HWCs toward routine EID in 2008. Few studies have explored this topic so far, especially EID in Africa.12-14 To our knowledge, our study is the first one reported in West Africa.
In 2008, HIV CT among infants was not uncommon in both the pediatric wards and immunization services. But very few health workers had received specific training to do so and particularly primary HCWs compared with physicians. Health staff was generally favourable to EID, but 80% found it difficult, the main difficulties being the announcement of a positive HIV test result. Less than two-thirds of pediatric staff had worked already on an activity related to HIV EID. Although almost all HCWs perceived the importance of HIV testing among children, less than 70% felt able to offer it to a child <6 months old. Insufficient training and skills of health workers on HIV testing seemed to be one of the obstacles to the implementation of routine HIV EID in this group of HCWs. With this respect, our results were similar to those observed in Uganda, where the main reason of underoffering HIV testing was a lack of knowledge and skills on HIV among health staff.12 In South Africa, negative staff attitudes, missed testing opportunities in health care facilities, and provider difficulties with pediatric counselling and venipuncture seemed as main facility-related barriers to the EID.14 In Burkina Faso, the main difficulty of health staff was the announcement of the HIV tests result to pregnant women.15 In Botswana, providers of HIV services reported also discomfort with their knowledge and skills although 84% believed HIV testing should be routinely offered.16
All HCWs interviewed were generally favourable to EID. Although we did not report any significant differences regarding attitudes toward HIV EID by initial training, inadequate practices were more frequently described among physicians compared to other HCWs. Indeed, midwives and counsellors would offer significantly more HIV testing for the whole family if the child was suspected to be infected than physicians. In addition, 10% of physicians reported to perform an HIV test without consent although it was reported by less than 4% of nurses and counsellors. Altogether, we highlighted that the proposal of HIV testing was significantly associated with the type of activity and the initial training, suggesting that EID is still viewed as a vertical program. Although we were not able to further investigate the reasons behind these improper practices, we hypothesized that the were not due to a lack of training but rather to the fact that physicians are generally overloaded and thus are not the best HIV CT providers. In Vietnam, the fragmentation of the health care system into specialized vertical pillars, including a vertical program for HIV/AIDS seemed as a major obstacle to provide a continuum of care between PMTCT and HIV care in children.17 One of the solutions to enhance an appropriate proposal for EID could thus be the delegation of HIV CT activities to lay counsellors and the decentralization of CT services to the primary care level.18 Indeed, this task shifting resulted in an increased access to HIV services with good program outcomes despite staff shortages in Malawi.19
In conclusion, our survey on attitudes and practices highlighted that in Abidjan, awareness of HCWs on the issue of pediatric HIV screening and the delegation of this task to the primary care level particularly to nursing staff and counsellors is a priority to improve appropriate access to EID with early ART for HIV-infected children. This is likely to be true in many other areas of West Africa.
We would like to warmly thank all the children and their families involved in this survey, the PEDITEST ANRS 12165 Study Group in Abidjan, Côte d'Ivoire. Special thanks to the directors of the Urban Health Facility of Abobo Avocatier and the General Hospitals of Bonoua, Koumassi and Port Bouet. Special thanks to S. Desmonde (ISPED) and L Quinty (ANRS). We are deeply grateful to all members of the HIV associations, and to the PACCI and ACONDA teams involved in the care of HIV/AIDS in Abidjan. Each of these people has, since the beginning of the crisis, courageously continued to serve the sick, wounded, displaced, and refugees - all victims of the war, and to bring them medicine, food, water, support and humanity.
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