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The Acceptability and Feasibility of Routine Pediatric HIV Testing in an Outpatient Clinic in Durban, South Africa

Ramirez-Avila, Lynn MD, MSc*†‡; Noubary, Farzad PhD‡§; Pansegrouw, Deirdre MBChB; Sithole, Siphesihle; Giddy, Janet MBChB, DipPHC(Ed), MFamMed; Losina, Elena PhD‡§‖**††‡‡; Walensky, Rochelle P. MD, MPH‡§ ‡‡§§¶¶; Bassett, Ingrid V. MD, MPH‡§ ‡‡¶¶

Pediatric Infectious Disease Journal:
doi: 10.1097/INF.0b013e31829ba34b
HIV Reports

Background: Limited access to HIV testing of children impedes early diagnosis and access to antiretroviral therapy. Our objective was to evaluate the feasibility and acceptability of routine pediatric HIV testing in an urban, fee-for-service, outpatient clinic in Durban, South Africa.

Methods: We assessed the number of patients (0–15 years) who underwent HIV testing upon physician referral during a baseline period. We then established a routine, voluntary HIV testing study for pediatric patients, regardless of symptoms. Parents/caretakers were offered free rapid fingerstick HIV testing of their child. For patients <18 months, the biological mother was offered HIV testing and HIV DNA polymerase chain reaction was used to confirm the infant’s status. The primary outcome was the HIV testing yield, defined as the average number of positive tests per month during the routine compared with the baseline period.

Results: Over a 5-month baseline testing period, 931 pediatric patients registered for outpatient care. Of the 124 (13%) patients who underwent testing on physician referral, 21 (17%, 95% confidence interval: 11–25%) were HIV infected. During a 13-month routine testing period, 2790 patients registered for care and 2106 (75%) were approached for participation. Of these, 1234 were eligible and 771 (62%) enrolled. Among those eligible, 637 (52%, 95% confidence interval: 49–54%) accepted testing of their child or themselves (biological mothers of infants <18 months). There was an increase in the average number of HIV tests during the routine compared with the baseline HIV testing periods (49 versus 25 tests/month, P = 0.001) but no difference in the HIV testing yield during the testing periods (3 versus 4 positive HIV tests/month, P = 0.06). However, during the routine testing period, HIV prevalence remains extraordinarily high with 39 (6%, 95% confidence interval: 4–8%) newly diagnosed HIV-infected children (median 7 years, 56% female).

Conclusions: Targeted and symptom-based testing referral identifies an equivalent number of HIV-infected children as routine HIV testing. Routine HIV testing identifies a high burden of HIV and is a feasible and moderately acceptable strategy in an outpatient clinic in a high prevalence area.

Author Information

From the *Division of Infectious Diseases, Children’s Hospital Boston, Boston, MA; Division of Pediatric Infectious Disease, UCLA School of Medicine, Los Angeles, CA; Medical Practice Evaluation Center; §Division of General Medicine, Massachusetts General Hospital, Boston, MA; McCord Hospital, Durban, KwaZulu Natal, South Africa; Department of Orthopedic Surgery; **Division of Rheumatology, Brigham and Women’s Hospital; ††Department of Biostatistics, Boston University, Boston; ‡‡Center for AIDS Research, Harvard Medical School, Cambridge; §§Division of Infectious Disease, Brigham and Women’s Hospital; and ¶¶Division of Infectious Diseases, Massachusetts General Hospital, Boston, MA.

Accepted for publication May 3, 2013.

L.R.-A., D.P. and I.V.B. conceived and designed the study; L.R.-A. and S.S. collected and assembled the data; L.R.-A., F.N. and E.L. analyzed the results; L.R.-A., F.N., J.G., E.L., R.P.W. and I.V.B. interpreted the data; L.R.-A. and I.V.B drafted the article; and L.R.-A., F.N., D.P., J.G., E.L., R.P.W. and I.V.B. critically reviewed the article for intellectual content.

Supported by the Boston Children’s Hospital Aerosmith Endowment Grant (L.R.-A.), the Harvard Global Health Institute (L.R.-A.), National Institute of Child Health and Human Development T32 HD 055148-02 (L.R.-A.), National Institute of Allergy and Infectious Diseases (NIAID) T32 AI 007433 (L.R.-A.), NIAID P30 AI060354 (Harvard University Center for AIDS Research) (L.R.-A.), National Institute of Mental Health R01 MH090326 (I.V.B.), R01 MH073445 (R.P.W.), Harvard University Program on AIDS and the Claflin Distinguished Scholar Award of the Massachusetts General Hospital (I.V.B.).

The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health. The authors have no other funding or conflicts of interest to disclose.

Address for correspondence: Lynn Ramirez-Avila, MD, MSc, Division of Pediatric Infectious Diseases, 10833 Le Conte Ave, 22-442 MDCC, Los Angeles, CA 90095. E-mail:

© 2013 by Lippincott Williams & Wilkins, Inc.