Barriers to Provider-Initiated Testing and Counselling for Children in a High HIV Prevalence Setting: A Mixed Methods Study

PLoS Medicine, May 2014

Rashida Ferrand and colleagues combine quantitative and qualitative methods to investigate HIV prevalence among older children receiving primary care in Harare, Zimbabwe, and reasons why providers did not pursue testing. Please see later in the article for the Editors' Summary

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Barriers to Provider-Initiated Testing and Counselling for Children in a High HIV Prevalence Setting: A Mixed Methods Study

et al. (2014) Barriers to Provider-Initiated Testing and Counselling for Children in a High HIV Prevalence Setting: A Mixed Methods Study. PLoS Med 11(5): e1001649. doi:10.1371/journal.pmed.1001649 Barriers to Provider-Initiated Testing and Counselling for Children in a High HIV Prevalence Setting: A Mixed Methods Study Katharina Kranzer 0 Jamilah Meghji 0 Tsitsi Bandason 0 Ethel Dauya 0 Stanley Mungofa 0 Joanna Busza 0 Karin Hatzold 0 Khameer Kidia 0 Hilda Mujuru 0 Rashida A. Ferrand 0 Lynne Meryl Mofenson, National Institute of Child Health and Human Development, United States of America 0 1 Department of Infectious Disease Epidemiology, London School of Hygiene & Tropical Medicine , London , United Kingdom , 2 Biomedical Research and Training Institute , Harare , Zimbabwe , 3 Harare City Health Department , Harare , Zimbabwe , 4 Department of Population Health, London School of Hygiene & Tropical Medicine , London , United Kingdom , 5 Population Services International , Harare , Zimbabwe , 6 Department of Paediatrics, University of Zimbabwe , Harare , Zimbabwe , 7 Clinical Research Department, London School of Hygiene & Tropical Medicine , London , United Kingdom Background: There is a substantial burden of HIV infection among older children in sub-Saharan Africa, the majority of whom are diagnosed after presentation with advanced disease. We investigated the provision and uptake of providerinitiated HIV testing and counselling (PITC) among children in primary health care facilities, and explored health care worker (HCW) perspectives on providing HIV testing to children. Methods and Findings: Children aged 6 to 15 y attending six primary care clinics in Harare, Zimbabwe, were offered PITC, with guardian consent and child assent. The reasons why testing did not occur in eligible children were recorded, and factors associated with HCWs offering and children/guardians refusing HIV testing were investigated using multivariable logistic regression. Semi-structured interviews were conducted with clinic nurses and counsellors to explore these factors. Among 2,831 eligible children, 2,151 (76%) were offered PITC, of whom 1,534 (54.2%) consented to HIV testing. The main reasons HCWs gave for not offering PITC were the perceived unsuitability of the accompanying guardian to provide consent for HIV testing on behalf of the child and lack of availability of staff or HIV testing kits. Children who were asymptomatic, older, or attending with a male or a younger guardian had significantly lower odds of being offered HIV testing. Male guardians were less likely to consent to their child being tested. 82 (5.3%) children tested HIV-positive, with 95% linking to care. Of the 940 guardians who tested with the child, 186 (19.8%) were HIV-positive. Conclusions: The HIV prevalence among children tested was high, highlighting the need for PITC. For PITC to be successfully implemented, clear legislation about consent and guardianship needs to be developed, and structural issues addressed. HCWs require training on counselling children and guardians, particularly male guardians, who are less likely to engage with health care services. Increased awareness of the risk of HIV infection in asymptomatic older children is needed. Please see later in the article for the Editors' Summary. - Funding: The study was funded by the Wellcome Trust through an Intermediate Fellowship to RAF (Grant No: 095878/Z/11Z). The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript. Competing Interests: The authors have declared that no competing interests exist. Abbreviations: ART, antiretroviral therapy; HCW, health care worker; IQR, interquartile range; PITC, provider-initiated HIV testing and counselling. Thirty years after the advent of the HIV pandemic, more than 3 million children globally are living with HIV, 90% of them in sub-Saharan Africa [1]. Although numbers of infant infections have fallen by 40% in the last decade because of scale-up of interventions to prevent mother-to-child transmission, global coverage of such programmes remains suboptimal: an estimated 1,000 infant infections occurred daily in 2011 [1]. In addition, coverage of early infant diagnosis among HIVexposed infants is highly variable, ranging from 10% to 80%with nearly half of the priority countries having a coverage of under 20%and only approximately 15% of HIVinfected infants have access to antiretroviral therapy (ART) following diagnosis [2,3]. For those not diagnosed in infancy, subsequent diagnosis largely depends on HIV testing in health care facilities. We have previously described the substantial burden of undiagnosed HIV in older children and adolescents, the majority of whom are diagnosed only after presentation with advanced disease [48]. The coverage of ART among children significantly lags behind that in adults (34% in children versus 68% in adults in 2012), and strategies to enable diag (...truncated)


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Katharina Kranzer, Jamilah Meghji, Tsitsi Bandason, Ethel Dauya, Stanley Mungofa, Joanna Busza, Karin Hatzold, Khameer Kidia, Hilda Mujuru, Rashida A. Ferrand. Barriers to Provider-Initiated Testing and Counselling for Children in a High HIV Prevalence Setting: A Mixed Methods Study, PLoS Medicine, 2014, 5, DOI: 10.1371/journal.pmed.1001649