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Description : High HIV prevalence in infants attending nutrition and inpatient entry points

Tags : Pediatrics, Child Health, pediatric practice, pediatrician, health providers, HIV-infected infants, Adolescent Transition, HIV-infected adolescents, epidemiology, south Africa, nutrition

Published on : Jul 16, 2020 | Views : 1224 | Downloads : 0

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Where have all the children gone? High HIV prevalence in infants attending nutrition and inpatient entry points Charles Kiyaga, MSc, MPhil National EID, VL, and Sickle Cell Programs Coordinator Central Public Health Laboratories, Uganda 8th International Workshop on HIV Pediatrics Durban, South Africa 16 July 2016
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Significant progress has been made in increasing access to EID, but too few infants receive a timely test, and too few are retained in the PMTCT cascade. 51% Percentage of infants born to women living with HIV receiving a virological test within the first two months by country, 2015 2
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UNAIDS estimates that more than half of new pediatric infections occur during the breastfeeding period. 8.9% overall transmission Six-week and final mother-to-child transmission rates by country, 2015 3
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WHO recommends universal pediatric PITC in malnutrition and inpatient wards, but with low-quality evidence. Many countries include these policies in national guidelines, but practice is inconsistent and insufficient. Gaps remain in the existing literature around this recommendation: Few studies have examined HIV prevalence comparing entry points to each other; Many studies lack a comparator, such as PMTCT; Many studies review targeted testing yields rather than consecutive or systematic sampling for true prevalence yields. We sought to understand how to allocate resources more efficiently to identify HIV-positive infants and link them to care and treatment. 4
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Research question, methodology, and study population 4 health facilities Mulago NRH St. Mary’s Hospital Lacor Mbale RRH Mbarara RRH 150 infants, regardless of symptoms or known history, are consecutively or systematically enrolled and tested at each entry point (750 infants tested per facility + historical data for 150 infants at PMTCT per facility) Each infant receives a rapid diagnostic test to establish HIV exposure AND a DBS sample to determine HIV infection 6 entry points at each health facility Immunization Clinic Pediatric OPD/ Young Child Clinic Pediatric Inpatient Ward Nutrition Ward 150 infants between the age of 0 weeks and 24 months at each entry point PMTCT (Historical or “Natural” Data) Outreach 5 Research Question What is the HIV prevalence among infants at different entry points in health facilities in Uganda? Methodology & Study Population
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Results: Half of the 117 HIV-positive infants were found in the Nutrition entry point (9.8% prevalence), and 68% were found in Nutrition and Inpatient combined. 0 4 8 12 16 EMTCT Immunization Outreach Outpatient Inpatient Nutrition HIV positivity rate (%) p=0.000 p=0.756 p=0.041 p=0.001 p=0.002 6 Number and prevalence of HIV-positive infants by entry point EMTCT Immunization Inpatient Nutrition Outpatient Outreach Number Prevalence 23 3.8% 1 0.2% 21 3.5% 59 9.8% 11 1.8% 2 0.3% Demographics Study population: 3,600 infants identified; 2 excluded due to invalid EID results Median age at study inclusion for all infants: 7 months Median age at study inclusion for HIV-positive infants: 11 months Previous facility attendance: ~50% of infants attended a health care facility in the last 12 months
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Results: We were 3X as likely to find an HIV-positive infant in Nutrition than in PMTCT. We were over 60X as likely to find a positive infant in Nutrition than in Immunization. 0 1 2 3 Immunization Nutrition Inpatient Outpatient Outreach Odds ratio compared to EMTCT p=0.001 p=1.000 p=0.274 p=0.008 p=0.018 0 7 10 20 30 40 50 60 70 Outreach EMTCT Inpatient Outpatient Nutrition Odds ratio compared to Immunization p=0.000 p=0.018 p=0.025 p=0.160 p=0.992
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Results: 80% of HIV+ mothers enrolled in the study knew their status. But only 60% of HIV+ mothers enrolled in PMTCT, and only 18% of HIV+ infants were in PMTCT. 194 17 177 0% 10% 20% 30% 40% 50% 60% 70% 80% All HIV+ Mothers HIV+ Mothers, HIV+ Infants HIV+ Mothers, HIV- Infants PMTCT Characteristics of HIV-Positive Mother Study Participants 100% Total Population 90% Mother Correctly Self- Identified as HIV+ Mother-Infant Pair Enrolled in PMTCT 18% 60% 8
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Recommendations from findings and implementation considerations Recommendations Looking beyond the PMTCT entry point is critical to closing the EID gap. Different strategies can be tailored to specific entry points. Routine EID testing of infants admitted to nutrition and inpatient entry points may be a high-yield strategy. Maternal re-testing in settings that are low-yield but see large volumes of infants, such as immunization and community outreach, may be a strategy to reliably find HIV-exposed infants and refer them to PMTCT. Implementation Considerations Addressing persistent gaps in PMTCT? POC EID placement in high-yield testing settings? Application of routine EID testing at high-volume facilities vs. low-volume facilities? Optimal approaches and opportunities for maternal retesting? Considerations for opportunities to leverage EPI and EID? 9
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Thank you! 10

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MarieAltmann

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