Improving Early Infant Diagnosis Observations

Estimates of Timely HIV Testing and Mortality Among HIV-Exposed Infants

Karen Webb, MSc; Vivian Chitiyo, MPhil; Nyikadzino Mahachi, MD, MPH; Solomon Huruva Mukungunugwa, MD, MBChB, MPH; Angela Mushavi, MBChB, MMed; Simukai Zizhou, MBChB, MPH; Barbara Engelsmann, MD, MPH; Rashida Abbas Ferrand, MD, MSc, PhD; Melissa Neuman, ScD, MS; Wendy Hartogensis, PhD, MPH; Elvin Geng, MD, MPH


J Acquir Immune Defic Syndr. 2020;83(3):235-239. 

In This Article

Abstract and Introduction


Background: Improving efforts toward elimination of mother-to-child transmission of HIV requires timely early infant diagnosis (EID) among all HIV-exposed infants, but the occurrence of timely EID and infant survival may be underascertained in routine, facility-bound program data.

Methods: From March 2015 to May 2015, we traced a random sample of HIV-positive mother and HIV-exposed infant pairs lost to follow-up for EID in facility registers in Zimbabwe. We incorporated updated information into weighted survival analyses to estimate incidence of EID and death. Reasons for no EID were surveyed from caregivers.

Results: Among 2651 HIV-positive women attending antenatal care, 1823 (68.8%) infants had no documented EID by 3 months of age. Among a random sample of 643 (35.3%) HIV-exposed infants lost to follow-up for EID, vital status was ascertained among 371 (57.7%) and updated care status obtained from 256 (39.8%) mothers traced. Among all HIV-infected mother–HIV-exposed infant pairs, weighted estimates found cumulative incidence of infant death by 90 days of 3.9% (95% confidence interval: 3.4% to 4.4%). Cumulative incidence of timely EID with death as a competing risk was 60%. The most frequently cited reasons for failure to uptake EID were "my child died" and "I didn't know I should have my child tested."

Conclusions: Our findings indicate uptake of timely EID among HIV-exposed infants is underestimated in routine health information systems. High, early mortality among HIV-exposed infants underscores the need to more effectively identify HIV-positive mother–HIV exposed infant pairs at high risk of adverse outcomes and loss to follow-up for enhanced interventions.


The timeliness of early infant diagnosis (EID)—HIV testing of exposed infants 6–8 weeks after birth—and proportion of infants testing positive are cardinal indicators of prevention of mother-to-child transmission (PMTCT) program success.[1] However, in routine program settings, completion of EID is assessed at individual facilities, from information across several paper-based registers, which may be incomplete and/or inaccurate.[2,3]

New approaches are needed to improve confidence in estimates of EID completion and survival of HIV-exposed infants to guide on-going quality improvement and inform national modeling estimates. These become increasingly important as countries such as Zimbabwe, with an HIV prevalence of 16.0% among women,[4] seek to validate elimination of mother-to-child transmission.[5]

In this study, we randomly sampled lost-to-follow-up (LTFU) HIV-positive mother, HIV-exposed baby pairs (MB), pairs from routine health facility-based data. We actively traced MB pairs in the community to assess infant and maternal survival and EID uptake. Finally, we incorporated these findings to correct estimates of HIV-exposed infant mortality and timely EID in the entire clinic population of MB pairs using a probability weight. Although this sampling-based approach has been used in clinic-based cohorts of adult patients in HIV treatment programs and found to alter estimates of retention and mortality,[6,7] our study represents the first time the approach has been used in PMTCT programs. We reflect on key lessons from our research on program progress and persisting gaps for strengthening EID coverage on the path to elimination of MTCT in Zimbabwe.