Background: Many HIV-infected infants and children die from HIV related causes without their HIV status being known or receiving HIV care. All HIV exposed infants should be tested by Dried Blood Spots (DBS)-PCR before or at 6 weeks of age. Testing is a crucial step to facilitate early access to antiretroviral treatment (ART). However, studies that assess the level of use and implementation of HIV DNA testing in Ethiopia are lacking. Objective: To investigate the rate of early infant diagnosis (EID), defined as having blood drawn for HIV DNA-PCR testing, and predictive factors of EID among infants born to HIV infected women. Method: A multicentre retrospective cohort study was conducted from April to June 2012 in three public hospitals and three health centers, in Northwest Ethiopia. Mother-infant pairs were followed from delivery until the time of the HIV diagnostic test. Data were captured using standardized forms. The time-to-diagnostic test was estimated using Kaplan-Meier estimators. Factors associated with EID were evaluated using logistic regression. Result: Of the 266 HIV-exposed infants identified from the health facilities, only 109 (41.0%) infants had early HIV DNA-PCR tests. The median age at the time of HIV diagnostic testing was 60 days (95% CI: 47 - 73 days), and the median turnaround time between blood draw for DNA-PCR testing to delivery of a test result to the respective health facility was 36 days (95% CI: 33 - 40 days). A total of 35 (13.2%) infants were diagnosed with HIV infection. The predictors of EID were the mother having prenatal care, maternal receipt of ART during pregnancy and place of birth. Conclusion: Three out of five HIV-infected women did not bring their infant for HIV testing during the recommended 6 week interval after birth. Special attention is required for infants born to HIV-infected women who did not receive ART or delivered at home or a private health facility to ensure early infant diagnosis, reduce loss to follow-up and prevent late initiation of ART for HIV-infected infants.
Worldwide, over 2 million children are infected with HIV, 90% of whom live in sub-Saharan Africa [
Globally, only 15% of HIV-exposed infants access early infant diagnosis (EID; i.e., within 45 days of birth) [
The WHO recommends that the HIV exposure status of infants be determined at the first contact with the health system, ideally before six weeks of age. All sites providing PMTCT and follow-up services for HIV-ex- posed infants must be able to collect samples for production of dried blood spots (DBS) for polymerase chain reaction (PCR) HIV DNA testing, even though the test will likely be processed elsewhere. Diagnosis of HIV- infected infants often occurs too late to allow early initiation of ART in many African countries [
Based on the single point estimate, Ethiopia has an estimated HIV prevalence of 2.4% with more than 1 million people living with HIV in 2010 [
The other element of PMTCT programmes is the uptake and adherence or follow-up of exposed infants. The provision of EID was started in Ethiopia under the PMTCT programme by the Ministry of Health and partners. The service is offered at all district hospitals and health centers providing PMTCT services free of charge in more than 300 centers including, government Hospitals and health centers. Unfortunately, free services are available in private health facilities. A testing algorithm for infants under 18 months was developed and implemented by the Federal government based on the WHO recommendation. Accordingly, all HIV exposed infants should be tested by DBS at 6 weeks of age and a confirmatory antibody test at 18 months (if a previous antibody test was negative and continued breastfeeding including the provision of provision of cotrimoxazole prophylaxis, and HIV-specific counseling and support [
The Ethiopian 2007/8 National PMTCT Guidelines [
The goal of EID is to identify HIV infected infants prior to the development of clinical disease to facilitate treatment and follow-up. For infants who are virologically negative, it provides an opportunity to plan and counsel on appropriate feeding to reduce the risk of infection whilst maintaining adequate nutrition. Throughout Africa, the diagnostic challenge of HIV exposure in infants is being addressed by scaling up virological testing using DBS for DNA-PCR [
This was a multicentre retrospective cohort study, which included 266 eligible mother-infant pairs. The study was supported by review of procedures at health facilities that provide PMTCT, infant diagnosis and clinical care and the regional central laboratory to identify the reasons for delay in DNA-PCR testing.
The study was conducted in Amhara region of Ethiopia in three government hospitals and three health centers: Metema Hospital, Gondar University Hospital, Debark Hospital, Woreta health center, Gondar health center and Addis Zemen health center. In this region, the estimated adult HIV prevalence is 2.2%. Only about 10% of deliveries occur in health facilities; 90% occur at home or non-health-related locations. The neonatal mortality rate was 54/1000 live births during the period of the study [
The data collection forms were tested for reliability, content and ease of use on a pilot sample of data. Infant HIV testing status by DNA-PCR was determined by review of the maternity and EID service register at the health centers/clinics or hospitals. Abstracted chart data included: date of birth, place of birth, date of first exposed infant clinic visit, date of blood collection, number of days from blood collection to receipt by the central laboratory, time from laboratory receipt to delivery of results at the clinic and infant follow-up for recipient of test result.
At each health facility, charts from HIV-exposed infants were routinely segregated allowing for ease of identification of eligible candidates. All HIV-exposed infants, who had at least one postpartum health center or hospital visit for HIV DNA-PCR testing, were included in the study. The HIV-exposed infants who had no HIV DBS testing or did not have the result recorded were excluded. We also reviewed respective HIV-infected mothers’ charts and abstracted relevant including: maternal socio-demographic, PMTCT interventions (including HAART and prophylaxis) including antenatal care, place of delivery, and maternal health conditions. On the exposed infant record sheet, both the DBS test and HIV antibody test results were recorded. HIV infection in this study was defined by either a positive HIV DNA-PCR test or a positive HIV antibody result recorded on the infant diagnosis chart. Note, Ethiopian national guidelines specify that infant HIV antibody testing should be done after 6 months of age, however, in some cases the data of antibody testing was not recorded in the database (all antibody tests were inferred to have been done according to guidelines). For some missing data in the health record, information was obtained during an in-depth interview (conducted by study personnel) using the case report forms. The interview was conducted at the time when women returned to the health facilities for a mother-to-mother support group (MSG) meeting.
Data abstraction was done by trained data collection assistants and the investigator. Data quality and completeness was checked for each data form. All mother/infant pairs were followed from the time of birth until the initial EID visit. Review of standard operating procedures at health facilities that provide PMTCT, infant diagnosis and clinical care and the regional central laboratory center was performed in order to identify the reasons for delay in DNA-PCR testing from the blood draw to the arrival of test result was done.
The study was reviewed and approved by the Ethical Review Board of the Institute of Public Health, at the University of Gondar for all the study ethical procedures. Permission was obtained from the medical director of each hospital and head of the health centers. Both written and verbal informed consent was obtained from the next of kin, caretakers, or guardians on behalf of the children enrolled in the study, and participants consent was documented on consent form attached with each questionnaire. Personal information remained confidential.
Data was coded, entered, cleaned and analyzed using the SPSS version 20.0 statistical package. Continuous data are presented using medians and interquartile ranges while categorical data are presented in frequencies and percentages. Early Infant Diagnosis (EID) was defined as infant access to or enrollment into HIV DNA-PCR testing before or at 6 weeks of birth.
EID (dichotomized) was analyzed using logistic regression to explore potential risk factors for not achieving early diagnosis. The models were adjusted for potential predictors including demographics, maternal age, ART status, residence, place of birth and maternal health condition. All variables in the univariate analysis with P value of less than 0.2 were entered into multivariable logistic regression models. The odds ratio and 95% confidence intervals were also constructed along with their corresponding P values. The Kaplan-Meier method was used to estimate time-to-infant diagnostic test (i.e. time from birth to first enrollment for HIV DNA-PCR testing using DBS).
A total of 266 mother-infant pairs were included in the analysis. The majority of women, 224 (84%), were from urban areas, 48% had no formal education and 24% were divorced. The mean age of the women was 28 years (standard deviation: 5 years). Forty percent were already on HAART at the time of birth, but 22% of the mothers were diagnoses with HIV at or after the time of labor (
Of the 266 HIV-exposed infants identified from the 6 health facilities, only 109 (41%) successfully had blood taken for HIV DNA-PCR testing on or before 6 weeks after delivery. The mean age at infant diagnosis was 120 days (95% CI: 108 - 133 days) (
Among the 109 infants who had the DBS test for HIV by 6 weeks, 77 (71%) were born at the government hospital. A total of 58 (54%) of the mothers whose infant achieved early diagnosis knew their HIV status prior to the current pregnancy and 83% were enrolled in the adult HIV clinic prior to delivery. In addition, out of those who accessed EID, 82.5% of infants were given ARV prophylaxis at birth and 75.2% of the women had received ARV prophylaxis during labor.
Characteristics | Response | Frequency (percent) |
---|---|---|
Maternal age (years) | ≤20 | 15 (5.7%) |
21 - 30 | 185 (69.8%) | |
≥31 | 65 (24.5%) | |
Educational status (grades attended) | Uneducated | 125 (47.7%) |
Primary education (1 - 8) | 71 (27.2%) | |
Secondary education | 52 (19.8%) | |
College and above | 14 (5.3%) | |
Residence | Urban | 224 (84.2%) |
Rural | 42 (15.8%) | |
Occupation | Housewife (no outside work) | 120 (45.8%) |
Government employee | 23 (8.7%) | |
Daily laborer | 88 (33.6%) | |
Merchant | 17 (6.5%) | |
Local drinking seller | 14 (5.4%) | |
Marital status | Single | 19 (7.3%) |
Married | 149 (56.8%) | |
Divorced | 61 (23.3%) | |
Widowed | 24 (9.2%) | |
Separated | 9 (3.4%) | |
Parity | Primiparous | 67 (25.7%) |
multiparous | 194 (74.3%) | |
HIV infection identified | Before the current pregnancy | 110 (42.3%) |
During the current pregnancy | 94 (36.2%) | |
On labor/delivery | 26 (10.0%) | |
During postnatal | 30 (11.5%) | |
Maternal ARV during pregnancy | HAART | 105 (40.1%) |
Prophylaxis | 60 (22.9%) | |
none | 97 (37.0%) | |
ANC follow-up | Yes | 191 (75.7%) |
No | 61 (24.3%) | |
Place of delivery | Home | 103 (39.0%) |
Government institution | 134 (50.7%) | |
Private clinics/hospitals | 27 (10.3%) | |
Maternal ARV during labor | Yes | 146 (55.3%) |
No | 118 (44.7%) | |
Infant ARV at delivery | Yes | 159 (60.5%) |
No | 104 (39.5%) | |
Mothers health condition | Alive | 247 (92.8%) |
Died | 19 (7.2%) |
Steps in the HIV diagnosis process | Number (percent) |
---|---|
Number of infants with successful EID of HIV | 109/266 (41%) |
Number of infants lost to follow-up prior to receiving HIV test results | 89/266 (34%) |
Infants diagnosed positive for HIV | 37/266 (13.2%) |
Median age from birth to blood draw for HIV DNA-PCR test | 60 days [95% CI; 47 - 73] |
Median time from blood drawn to sample receipt by the central testing lab | 7 days [IQR: 4 - 13 days] |
Median time from sample arrival at the central lab to test performance | 20 days [IQR: 14 - 35 days] |
Median time between blood draw to result recipient by the respective health facility | 36 days [IQR: 25 - 49 days] |
The mean age from birth to recipient of HIV DNA-PCR test result | 159 days [IQR: 81 - 215 days] |
The multivariate logistic regression analysis of factors associated with EID demonstrated that mothers who were on HAART or had received PMTCT prophylaxis during pregnancy were more likely to successfully complete EID compared to those without these factors (odds ratios 3.4 and 3.7 respectively). Compared to being
Factors | Infant HIV DNA-PCR at or before 45 days | Odds Ratio (OR) (95% C.I) | P-Value | ||
---|---|---|---|---|---|
Yes | No | Unadjusted OR | Adjusted OR | ||
Prenatal care (ANC) | |||||
Yes | 92 (89.3%) | 11 (10.7%) | 4.2 (2.0 - 8.6) | 1.7 (0.7 - 4.3) | 0.154 |
No | 99 (66.4%) | 50 (33.6%) | 1.0 | ||
ARV during pregnancy | |||||
HAART | 56 (52.4%) | 49 (31.6%) | 5.0 (2.6 - 9.5) | 3.4 (1.5 - 7.3) | 0.002 |
Prophylaxis | 33 (30.8%) | 27 (17.5%) | 5.4 (2.6 - 11.0) | 3.7 (1.5 - 8.7) | |
None | 18 (16.8%) | 79 (50.9%) | 1.0 | 1.0 | |
Place of birth | |||||
Home | 25 (22.9%) | 78 (50.4%) | 1.0 | 1.0 | <0.001 |
Private clinic | 7 (6.5%) | 20 (12.9%) | 1.1 (0.4 - 2.8) | 0.5 (0.2 - 1.7) | |
Government health facility | 77 (70.6%) | 57 (36.7%) | 4.2 (2.4 - 7.4) | 2.9 (1.6 - 5.5) | |
Time mother get HIV diagnosed | |||||
Before pregnancy | 58 (53.7%) | 52 (34.2%) | 7.2 (2.3 - 22.2) | * | <0.001 |
During pregnancy | 40 (37.0%) | 54 (35.5%) | 4.8 (1.5 - 14.8) | ||
At labor/birth | 6 (5.6%) | 20 (13.2%) | 1.9 (0.5 - 7.8) | ||
Postnatal | 4 (3.7%) | 26 (17.1%) | 1.0 | ||
Mother prophylaxis at labor | |||||
Yes | 82 (75.2%) | 64 (41.3) | 4.32 (2.52 - 7.45) | * | <0.001 |
No | 27 (24.8%) | 91 (58.7%) | 1.0 | ||
Infant prophylaxis at birth | |||||
Yes | 90 (82.6%) | 69 (44.8%) | 5.83 (3.2 - 10.5) | * | <0.001 |
No | 19 (17.4%) | 85 (55.2%) | 1.0 |
CI = Confidence interval; ANC = Antenatal Care; OR = Odds Ratio; * = variables not entered in the multivariable model due to significant correlation with other variables.
born at home, infants delivered at a government facility were almost three times more likely to have early infant diagnosis (odds ratio: 3.0, 95% CI: 1.6 - 5.5). Three significant variables from the univariate analysis were excluded due to multiple colinearity (
The median time from birth to sample collection for HIV DNA-PCR (infant HIV diagnosis) was 60 days (95% CI: 47 - 73); (
Our study highlights the problem of delayed initiation and completion of HIV testing for infants born to HIV- infected mothers in northern Ethiopia. In fact, the infants at highest risk for HIV transmission, defined by their
mothers not receiving any form of ARV prevention or treatment during pregnancy, had the greatest time to collection of HIV DNA test specimens (
Overall, only 41% of infants had samples collected for HIV DNA-PCR testing at or before 6 weeks of life, the benchmark for achieving EID. The median time between blood draw for DBS to result recipient by the respective health facility was 36 days (IQR: 25 - 49 days). These findings are consistent with other studies from Kenya and Mozambique [
The dynamics between place of delivery and PMTCT interventions are major challenges to early infant diagnosis. Mothers who delivered at government health institutions had the highest rate of early HIV DNA-PCR testing compared to deliveries which took place at home. Most mothers who gave birth at home did not receive ARV prophylaxis during labor and the infants were not given ARV prophylaxis immediately on delivery. In addition, mothers who delivered at private health facilities were less likely to bring their infants for early HIV testing.
Thirty seven percent of women in this study failed to take any form of ARV to prevent HIV transmission to their infants and the lack of ARV use was associated with delays in bringing the infant for early HIV diagnosis. Thus, not only would there be greater chance for HIV transmission, but infected infants would not be recognized and treated early; the combination would ultimately result in greater infant HIV morbidity and mortality. Fortunately, educational status, residence and marital status did not remain statistically significant association with
Delays | Contributing factors |
---|---|
Delay one* | Mothers delay in early return or not bringing the infants |
Delay two# | Delay in sending the sample for DBS-PCR, Delay of the courier/postage system. Reported reasons: limit number (minimum number of samples) for courier, poor cooperation of postal offices, and loss of samples on the way of transport and the need to resend the sample twice. |
Delay three# | Delay in laboratory processing in the regional laboratory center, Delay in resending the result or delay of the courier/postage system. Reported reasons: light interruption at the central/regional laboratory, DBS testing Lab chemicals use processing (under sampling), oversampling/overloading. |
Delay four* | Delay of the mothers/caregivers in returning to receive the test result, delay in the health professional early enrolling the infants into care. Reasons reported: lack of reminding the mothers as most mothers forget the appointment, loss of the mothers and/or death of the mothers/parents. |
*Clients delay; #Health system delay.
EID, but prenatal care improved rates of EID. These findings corroborates those studies from Mozambique [
This study is limited by the retrospective, chart review nature of the design. In addition, the diagnosis of HIV infection of the infants was based both on HIV DNA-PCR and HIV antibody tests as recorded in the infants chart. However we were not able to verify that the date of antibody test was more than six months after birth and had to presume that the infant HIV antibody tests were done according to guidelines. Despite the limitations, these results emphasize the importance of conducting future prospective studies.
Three of five HIV-infected women did not bring their children for early infant HIV diagnosis. In addition to delays in blood collection, infant HIV diagnosis was further delayed by sample transportation, processing and result delivery. Both patient and health service factors require attention.
The main factors associated with delay in early infant diagnosis were location of delivery as well as lack of prenatal care and maternal use of ARV intervention. The first step to rectify these problems would be to increase maternal HIV testing during pregnancy which would then enable referral to PMTCT programs. Special attention should be given to strengthen services for women who choose to deliver at home. The finding that rates of EID were lower in women delivering at private clinics was surprising and should be addressed by greater HIV training for health care providers both during their primary health educational programs and as part of ongoing post- graduate education. Our group has emphasized augmenting the HIV-specific content of the curricula of undergraduate and postgraduate training of medical and ancillary healthcare providers as part of our UCSD PEPFAR program, but clearly more work is needed. Further, integrated maternal HIV testing, maternal ARV access and infant prophylaxis with postpartum advice for infant testing would increase rates of early infant diagnosis.
Medical records could be used to track lack of maternal follow-up in order to further reduce missing HIV diagnoses. Scheduling EID appointments to coincide with routine visits, i.e. first infant vaccination could eliminate the need for additional visits. In addition, reduction in test turnaround time, from sample collection, to laboratory, to the return of test results, is urgently required. Alternative methods to deliver test results to the clinic should be considered, such as use of email and telephone, instead of depending only on couriers.
We would like to thank the district health offices and health centers/hospitals for allowing us to conduct the study and access data, and the University of Gondar for ethical review. We are grateful to the study participants, data collection assistants and the hospital and health centers data managers.
This work was supported in part by University of Gondar Institute of Public Health and a grant from the HIV Research Trust and NIAID grants: AI 064086 (K24 to RH); AI 069432 (UCSD ACTU); and AI 36214 (CFAR Clinical Investigation and Biostatistics Core).
The authors declare that there are no competing interests.
BK: conceived and proposed the study, was involved in data collection and analyzed and drafted the manuscript. AG: revised the proposal and study design and was involved in initial data analysis. RH, SJ and SS: were involved in data cleaning, analysis and fully revised and edited the final manuscript.