Guardianship an issue in HIV testing among older children

Questions as to whether a guardian was suitable to offer consent were among the reasons health care workers did not offer HIV testing and counseling to older children living in sub-Saharan Africa, new study results suggest.

More than 3 million children are living with HIV worldwide, and 90% of these children are in sub-Saharan Africa, according to background information in the study. Most older children are diagnosed after the presentation of advanced disease.

Researchers investigated the provision and uptake of provider-initiated HIV testing and counseling (PITC) among older children at six primary care clinics in Harare, Zimbabwe. Their analysis included 3,994 visits by children aged 6 to 15 years between Jan. 22 and May 31, 2013. In semi-structured interviews, health care workers gave reasons why HIV testing did not occur in eligible children. The researchers also examined factors associated with PITC and refusals by children and their guardians.

Among 2,831 children who were eligible for testing, 76% were offered PITC and 54.2% underwent HIV testing. HIV was diagnosed in 5.3% (95% CI, 4.3-6.6) of those who consented to testing, suggesting the need for improved PITC in primary care clinics. HIV also was diagnosed in approximately one-fifth (19.8%; 95% CI, 17.3-22.5) of guardians who agreed to be tested along with their children (n=940).

According to the researchers, 95% of children diagnosed with HIV were linked to care. However, 92.1% had missed an opportunity for an earlier diagnosis.

Reasons for not offering PITC included health care workers’ concerns about the appropriateness of the guardian to provide consent for testing in an older child (59%) — although the appropriateness of the guardian could not be independently ascertained by the researchers. Other reasons for not testing included shortages of counselors (17.1%) and testing kits (11.2%).

In multivariable analysis, asymptomatic children, children aged at least 11 years and children attending with a guardian younger than 25 years or a male guardian all had lower odds of being offered testing. Male guardians were less likely to consent to their child being tested.

“The fear of the stigma faced by the child and their family seems to be discouraging caregivers from testing children for HIV,” study researcher Rashida A. Ferrand,MSc, PhD, a clinical epidemiologist at the London School of Hygiene and Tropical Medicine, said in a press release. “However, with improved clarity of guidelines, engagement with staff, and organizational adjustments within clinics, it should be possible to harness the commitment of health care workers and properly implement HIV testing and counseling.”

In a related editorial, Mary-Ann Davies, MD, and Emma Kalk, PhD, of the School of Public Health and Family Medicine at the University of Cape Town, South Africa, said the results are likely generalizable and an accurate reflection of testing practices in the primary care setting.

“The fact that >90% of infected children had a previous missed opportunity for testing indicates suboptimal pediatric PITC coverage in most routine settings,” they wrote.

For more information:

Davies MA. PLoS Med. 2014;doi:10.1371/journal.pmed.1001650.

Kranzer K. PLoS Med. 2014;doi:10.1371/journal.pmed.1001649.

Disclosure: The researchers report no relevant financial disclosures.