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


Phase I: Facility Register Data

Among 18,065 women registered for ANC between April 2012 and May 2013, 2651 (14.7%) were HIV positive and 31.2% [95% confidence interval (CI): 29.5% to 33.0%] had documented uptake of EID for their infant within 3 months of delivery in clinic registers. After adjustment for register information and site characteristics, factors associated with documented EID completion included earlier gestational age at presentation (RR: 0.97 per 2 weeks; 95% CI: 0.95 to 0.99; P = 0.013), later calendar time of ANC presentation (RR: 1.04 per 30 days; 95% CI: 1.02 to 1.06, P = 0.011), and smaller site volume (RR: 1.85 1–200 ANC patient volume, 1001–1500 volume referent; 95% CI: 1.44 to 2.38, P < 0.001).

Phase II: Community Tracing LTFU

Among 1652 mother–baby pairs identified as LTFU with any documented locator information, a random sample of 643 (38.9%) was selected for community tracing between March 2015 and May 2015. In 371/643 (57.7%), updated vital or EID status information was obtained (22.5%; 371/1652 of the total LTFU sample). The primary reason for failure to locate clients was insufficient location information. Among 371 successfully traced patients, 256 (69.0% of located) mothers were interviewed directly on infant vital status and EID uptake, and for the remaining 115 (31.0%), informants were interviewed regarding MB pair survival outcomes (not HIV-related) (Figure 1). Among the 371 mother–baby pairs for whom vital status outcomes were determined, 66 infants (17.8%; 95% CI: 14.0% to 22.1%) and 18 mothers (4.9%; 95% CI: 2.9% to 7.6%) were found to be deceased.

Figure 1.

Flowchart of outcomes in the study population (N = 18,065).

Most mothers interviewed (190/256; 74.2%; 95% CI: 68.4% to 79.5%) reported their infant had received HIV testing; although fewer than half received EID testing before 3 months of age (92/190; 48.4%; 95% CI: 41.1% to 55.8%). Our corrected estimate following tracing resulted in a cumulative incidence of EID with death as a competing risk of 60.0% (95% CI: 58.7% to 61.3%). We estimated a cumulative incidence of mortality among HIV-exposed infants at 3 months of 3.9% (95% CI: 3.4% to 4.4%) and at 1 year of 7.7% (95% CI: 4.7% to 13.5%). Among the 66 infants with no EID at any time, the most frequently cited reason for failure to have EID was "my child died" (36.6%; 95% CI: 25.8% to 49.0%), Figure 2A. Among infants with timing of death ascertained, most did not survive to the age of recommended EID testing (6 weeks) (26/42; 61.9%). Among mothers of living infants, "I didn't know I should have my child tested" was the most frequently cited reason for no EID (16/45; 35.6%). Relocation to a different area (21.8%; 95% CI: 13.2% to 32.6%) and transport being easier/cheaper at new clinic (20.5%; 95% CI: 12.2% to 31.1%) were the most commonly reported reasons for silent transfer (Figure 2B).

Figure 2.

Prevalence of patient-reported reasons for no Early Infant Diagnosis (EID) (N = 71) (A) and switching site of EID from ANC care (N = 78) (B). Structural barriers stem from material conditions of life in resource-limited settings (eg, transportation cost and availability, family conflict, or not enough money). Psychosocial barriers are related to knowledge, beliefs, or attitudes of the patients in the given social setting (eg, "didn't know" child should be tested, fear of disclosure, or preference for spiritual healing). Clinic-based barriers are related to delivery processes at a clinic site (eg, long waiting times, healthcare worker friendliness, and quality of care). Medical barriers related to health status (such as infant death or mother too sick to the bring child to the clinic).