Abstract
BackgroundUganda’s HIV Early Infant Diagnosis (EID) program rapidly scaled up testing of HIV-exposed infants (HEI) in its early years. However, little was known about retention outcomes of HEI after testing. Provision of transport refunds to HEI caregivers was piloted at 3 hospitals to improve retention. This study was conducted to quantify retention outcomes of tested HEI, identify factors driving loss-to-follow-up, and assess the effect of transport refunds on HEI retention.MethodsThis mixed-methods study included 7 health facilities— retrospective cohort review at 3 hospitals and qualitative assessment at all facilities. The cohort comprised all HEI tested from September-2007 to February-2009. Retention data was collected manually at each hospital. Qualitative methods included health worker interviews and structured clinic observation. Qualitative data was synthesized, analyzed and triangulated to identify factors driving HEI loss-to-follow-up.ResultsThe cohort included 1268 HEI, with 244 testing HIV-positive. Only 57% (718/1268) of tested HEI received results. The transport refund pilot increased the percent of HEI caregivers receiving test results from 54% (n = 763) to 58% (n = 505) (p = .08). HEI were tested at late ages (Mean = 7.0 months, n = 1268). Many HEI weren’t tested at all: at 1 hospital, only 18% (67/367) of HIV+ pregnant women brought their HEI for testing after birth. Among HIV+ infants, only 40% (98/244) received results and enrolled at an ART Clinic. Of enrolled HIV+ infants, only 43% (57/98) were still active in chronic care. 36% (27/75) of eligible HIV+ infants started ART. Our analysis identified 6 categories of factors driving HEI loss-to-follow-up: fragmentation of EID services across several clinics, with most poorly equipped for HEI care/follow-up; poor referral mechanisms and data management systems; inconsistent clinical care; substandard counseling; poor health worker knowledge of EID; long sample-result turnaround times.DiscussionThe poor outcomes for HEI and HIV+ infants have highlighted an urgent need to improve retention and linkage to care. To address the identified gaps, Uganda’s Ministry of Health and the Clinton Health Access Initiative developed a new implementation model, shifting EID from a lab-based diagnostic service to an integrated clinic-based chronic care model. This model was piloted at 21 facilities. An evaluation is needed.
Highlights
Uganda’s HIV Early Infant Diagnosis (EID) program rapidly scaled up testing of HIV-exposed infants (HEI) in its early years
The number of HIV+ pregnant women receiving Prevention of Mother-to-Child Transmission (PMTCT) services at the hospitals served as a reasonable proxy for the minimum number of HEI needing to be tested
Analysis of qualitative observation and interview data revealed that HWs at many other entry points were not proactively screening infants for possible exposure to HIV, nor taking active steps to ensure that identified HEI successfully reached the EID testing point
Summary
Uganda’s HIV Early Infant Diagnosis (EID) program rapidly scaled up testing of HIV-exposed infants (HEI) in its early years. In Uganda, an estimated 91,000 HIV-exposed infants (HEI)— infants aged 0– 18 months born to HIV+ mothers— were born in 2010, yet only 41,340 (46%) were tested [5, 6]. Out of 78,000 total HIV+ children (aged 0–14 years) who were eligible for ART in Uganda in 2010, only 24,031 (31%) were diagnosed and started on ART [6]. Initiation of HIV+ infants on ART slows disease progression, suppresses viral load, and dramatically reduces mortality rates [9,10,11]. Diagnosis of HEI is conducted in resource-limited settings by DNA Polymerase Chain Reaction (PCR) testing of Dried Blood Spot (DBS) samples [12, 13]. In Uganda, DBS samples are drawn from HEI at health facilities and referred to a specialized reference laboratory for DNA PCR testing
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