Beyond the facility: An evaluation of seven community-based pediatric HIV testing strategies and linkage to care outcomes in a high prevalence, resource-limited setting

Abstract

Diverse challenges in expanding pediatric HIV testing and treatment coverage persist, making the investigation and adoption of innovative strategies urgent. Evidence is mounting for the effectiveness of community-based testing in bringing such lifesaving services to those in need, particularly in resource-limited settings. The Mobilizing HIV Identification and Treatment project piloted seven community-based testing strategies to assess their effectiveness in reaching HIV-positive children and linking them to care in two districts of Lesotho from October 2015 to March 2018. Children testing HIV-positive were enrolled into the project's mHealth system where they received e-vouchers for transportation assistance to the facility for treatment initiation and were followed-up for a minimum of three months. An average of 7,351 HIV tests were conducted per month across all strategies for all age groups, with 46% of these tests on children 0-14 years. An average of 141.65 individuals tested positive each month; 9% were children. Among the children tested 55% were over 5 years. The yield in children was low (0.38%), however facility-based yields were only slightly higher (0.72%). Seventy-five percent of children were first-time testers and 86% of those testing HIV-positive were first-time testers. Seventy-one percent of enrolled children linked to care, all but one initiated treatment, and 82% were retained in care at three months. As facility-based testing remains the core of HIV programs, this evaluation demonstrates the effectiveness of community-based strategies in finding previously untested children and those over 5 years who have limited interactions with the conventional health system. Utilizing active follow-up mechanisms, linkage rates were high suggesting accessing treatment in a facility after community testing is not a barrier. Overall, these community-based testing strategies contributed markedly to the HIV testing landscape in which they were implemented, demonstrating their potential to help close the gap of unidentified HIV-positive children and achieve universal testing coverage.

Rates of confirmatory HIV testing, linkage to HIV services, and rapid initiation of antiretroviral treatment among newly diagnosed children living with HIV in Ethiopia: perspectives from caregivers and healthcare workers

“…Several studies noted phone-or home-based tracing by community health workers for all newly diagnosed clients [11] or for clients that were not linked to HIV services [13,[17][18]. The PoP-ART-Y study found high linkage rates in young adolescents 10-14 years (92.9% in boys, 98.2% in girls) with multiple active linkage interventions including escorts to clinics, specially-trained counselors, use of community health workers to track clients, and multi-disciplinary meetings to review those not yet linked to care or initiated on ART [19]. Another study from Kenya showed improved linkage rates in 10-14-year-old children after an adolescent-focused intervention that included capacity building, extended clinic hours, and program tools (53.8% to 83.6% for boys, 44.8% to 94.7% for girls) [20].…”

Rates of confirmatory HIV testing, linkage to HIV services, and rapid initiation of antiretroviral treatment among newly diagnosed children living with HIV in Ethiopia: perspectives from caregivers and healthcare workers

“…Reported linkage rates of enrollment into HIV services or ART initiation rates in CLHIV vary widely across studies (45–100%) [ 9 – 18 ], likely due to differing time points for follow-up assessments, different settings of HIV testing and diagnosis, and different age bands. For instance, one study from Cameroon found that linkage rates to HIV care or ART initiation were higher in index testing strategies compared to outpatient department (OPD) (85.0% vs. 52.5%) and in children ≤12 years compared to children 13–19 years [ 10 ].…”

“…Many studies, including ours, did not capture or report details around strategies for supporting linkage. Several studies noted phone- or home-based tracing by community health workers for all newly diagnosed clients [ 11 ] or for clients that were not linked to HIV services [ 13 , 17 , 18 ]. The PoP-ART-Y study found high linkage rates in young adolescents 10–14 years (92.9% in boys, 98.2% in girls) with multiple active linkage interventions including escorts to clinics, specially-trained counselors, use of community health workers to track clients, and multi-disciplinary meetings to review those not yet linked to care or initiated on ART [ 19 ].…”

“…More intensive screening and support for pediatric advanced HIV disease at diagnosis is needed, to ensure rapid ART initiation and management of co-infections and comorbidities to prevent HIV-related mortality. Reported linkage rates of enrollment into HIV services or ART initiation rates in CLHIV vary widely across studies (45-100%) [9][10][11][12][13][14][15][16][17][18], likely due to differing time points for follow-up assessments, different settings of HIV testing and diagnosis, and different age bands. For instance, one study from Cameroon found that linkage rates to HIV care or ART initiation were higher in index testing strategies compared to outpatient department (OPD) (85.0% vs. 52.5%) and in children ≤12 years compared to children 13-19 years [10].…”

“…For instance, one study from Cameroon found that linkage rates to HIV care or ART initiation were higher in index testing strategies compared to outpatient department (OPD) (85.0% vs. 52.5%) and in children ≤12 years compared to children 13-19 years [10]. Several studies were also conducted before [10][11][12][13][14][15] or during [16][17][18] the rollout of test and treat, which may have impacted enrollment and ART initiation rates. Another study in Cameroon also found that children aged 5-9 years, in primary school, and female were more likely to be enrolled on ART, but none of these were found to be statistically significant [16].…”