services on access to HIV diagnosis

Effect of provider-initiated testing and counselling and integration of ART services on access to HIV diagnosis and treatment for children in Lilongwe, Malawi: a pre- post comparison.

The HIV prevalence in Malawi is 12 % and Kamuzu Central Hospital, in the capital Lilongwe, is the main provider of adult and paediatric HIV services in the central region. The Lighthouse at Kamuzu Central Hospital offers voluntary HIV testing and counselling for adults and children. In June 2004, Lighthouse was the first clinic to provide free antiretroviral treatment in the public sector, but few children accessed the services. In response, provider-initiated HIV testing and counselling and an antiretroviral treatment clinic were introduced at the paediatric department at Kamuzu Central Hospital in Quarter 4 (Q4) 2004. The authors analysed prospectively collected, aggregated data of quarterly reports from Q1 2003 to Q4 2006 from opt-in HIV testing and counselling centre registers, antiretroviral treatment registers and clinic registrations at the antiretroviral treatment clinics of both Lighthouse and the paediatric department. By comparing data of both facilities before (Q1 2003 to Q3 2004), and after the introduction of the services at the paediatric department (Q4 2004 to Q4 2006), they assessed the effect of this intervention on the uptake of HIV services for children at Kamuzu Central Hospital. Overall, 3971 children were tested for HIV, 2428 HIV-infected children were registered for care and 1218 started antiretroviral treatment. Between the two periods, the median (IQR) number of children being tested, registered and starting antiretroviral treatment per quarter rose from 101 (53-109) to 358 (318-440), 56 (50-82) to 226 (192-234) and 18 (8-23) to 139 (115-150), respectively. The median proportion of tested clients per quarter that were children rose from 3.8% (2.7-4.3) to 9.6% (8.8 to 10.0) (p=0.0009) and the proportion of antiretroviral treatment starters that were children rose from 6.9% (4.9-9.3) to 21.1% (19.2-24.2) (p=0.0036). The proportion of registered children and adults starting antiretroviral treatment each quarter increased similarly, from 26% to 53%, and 20% to 52%, respectively. Implementation of provider-initiated HIV testing and counselling and integration of antiretroviral treatment services within the paediatric ward are likely to be the main reasons for improved access to HIV testing and counselling and antiretroviral treatment for children at Kamuzu Central Hospital, and can be recommended to other hospitals with paediatric inpatients in resource limited settings with high HIV prevalence.

Even though providers initiated an offer of HIV testing and counselling with the caregivers of only 10% of admitted children at the Kamazu Central Hospital, there was a marked increase in the absolute numbers and proportions of children tested for HIV and started on antiretroviral treatment at this facility, compared to the era of parent/caregiver-initiated voluntary testing and counselling. It is unclear whether this modest increase in provider-initiated testing and counselling made the difference or whether it was the advent of free antiretroviral treatment that changed both client and health worker attitudes towards HIV counselling and testing. In any case, 41% of all children tested at the hospital were tested through the paediatric ward and the yield there was high, providing an additional entry point to antiretroviral treatment for children in Lilongwe.