HIV infection among HIV-exposed infants in Tanzania.

HIV infection among HIV-exposed infants in Tanzania.

Introducing a multi-site program for early diagnosis of

In Tanzania, less than a third of HIV infected children estimated to be in need of antiretroviral therapy are receiving it. In this setting where other infections and malnutrition mimic signs and symptoms of AIDS, early diagnosis of HIV among HIV-exposed infants without specialized virologic testing can be a complex process. The study aimed to introduce an Early Infant Diagnosis pilot program using HIV DNA Polymerase Chain Reaction (PCR) testing with the intent of making Early Infant Diagnosis nationally available based on lessons learned in the first 6 months of implementation. In September 2006, a molecular biology laboratory at Bugando Medical Center was established in order to perform HIV DNA PCR testing using Dried Blood Spots. Ninety- six health workers from 4 health facilities were trained in the identification and care of HIV-exposed infants, HIV testing algorithms and collection of dried blood spot samples. Paper-based tracking systems for monitoring the program that fed into a simple electronic database were introduced at the sites and in the laboratory. Time from birth to first HIV DNA PCR testing and to receipt of test results were assessed using Kaplan-Meier curves. From October 2006 to March 2007, 510 HIV-exposed infants were identified from the 4 health facilities. Of these, 441(87%) infants had an HIV DNA PCR test at a median age of 4 months (IQR 1 to 8 months) and 75(17%) were PCR positive. Parents/guardians for a total of 242(55%) HIV-exposed infants returned to receive PCR test results, including 51/75 (68%) of those PCR positive, 187/361 (52%) of the PCR negative, and 4/5 (80%) of those with indeterminate PCR results. The median time between blood draw for PCR testing and receipt of test results by the parent or guardian was 5 weeks (range <1week>and 10 weeks (range <1>a high response as hundreds of HIV-exposed infants were registered and tested in a 6 month period. Challenges included the large proportion of parents not returning for PCR test results. Experience from the pilot phase has informed the national roll-out of the Early Infant Diagnosis program currently underway in Tanzania.

This service delivery programme in the Lake region of Tanzania for early infant HIV diagnosis is the first for the country – similar programmes are being rolled out in Kenya and Botswana. With only a third of Tanzanian children estimated to be eligible for antiretroviral treatment actually receiving it, timely diagnosis of infant HIV infection is a priority. The critical processes set in motion to make this pilot programme a reality were: community preparation, health facility selection and preparation, capacity building, laboratory establishment, definition of the HIV testing algorithm, and registration and follow-up of HIV-exposed infants with data collection. Delays of 5 weeks for receipt of positive results and 10 weeks for negative results by parents should be shortened by all possible means, including electronic and telephone transmission of results back to facilities if this is not currently being done. Nonetheless, these times are much shorter than the wait for the disappearance of maternal antibodies at 18 months of age. To increase the proportion of parents who actually receive results beyond the 55% seen here, the first step is to explore the factors inhibiting them from returning for results and the acceptability of possible solutions. Infants with HIV infection need life-saving cotrimoxasole and initiation of antiretroviral therapy as per the new WHO paediatric treatment guidelines as soon as they are diagnosed. Better linkages between prevention of mother-to-child transmission programmes and the follow-up of HIV-exposed infants will reduce the number of infants presenting with advanced HIV disease or dying before anything can be done.