In the last decade, there has been remarkable progress in the coverage of programs to prevent mother-to-child transmission of HIV (PMTCT), particularly with the implementation of lifelong combined antiretroviral therapy (ART) in pregnant women living with HIV. As a result, the number of new paediatric HIV infections among infants has dropped by 52% from 550,000 in 2001 to 260,000 in 2012 (CDC/USAID, 2015). Even with this progress, an estimated 3.4 million children under the age of 15 years are living with HIV globally (CDC/USAID).
Strategies to identify and test children at increased risk for HIV are critical. In Kenya, less than half of all children between 18 months and 19 years of age with a HIV-positive parent have ever been tested for HIV (NACC, 2016). Family testing as a strategy seeks to increase identification of children and adolescents through a family-centred approach to reach children and adolescents (0-19 years) with HIV testing services (HTS).
In 2015, Kiambu County contributed 1.1% and 6.0% of the total new HIV infections in Kenya among children and adults respectively. Adolescents between the ages of 10 and 19 years and young people between the ages of 15 and 24 years contributed to 8% and 28% of all new HIV infections in the County respectively (NASCOP, 2016).
Description of Best Practice
To achieve targets for HIV testing services for children and adolescents, HTS providers used a comprehensive approach to family testing encompassing enhanced couples counselling, positive reinforcement of partner and family testing at every clinic visit, partner invitation for testing services, onsite testing and targeted home-based counselling and testing. In addition, enhanced testing at the outpatient and inpatient departments, TB clinics, malnutrition clinics, and comprehensive care centre (CCC) clinics, under-five clinics and adolescent/youth friendly centres, was adopted to improve the chances of identifying children and adolescents living with HIV.
To scale up the identification of children and adolescents through integration of HIV testing services across all service delivery points.
- To test all children of adults receiving any HIV service through facility and home-based index case testing
- To test all children and adolescents seeking outpatient services as well as those admitted to the paediatric ward
- To test mothers or infants attending immunization or under-five clinics to identify HIV-exposed and HIV infected infants
A multifaceted model was applied that included: hiring and the strategic deployment of lay counsellors for optimisation of outpatient and inpatient testing, line-listing of all eligible children of index clients, invitations to partner and family for testing, home-based counselling and testing, testing at all infant, children and adolescent clinics, as well as family counselling to facilitate disclosure and adherence.
- Use of line-listing register to list all contacts of index clients
- Use of diaries to give appointments dates at three high volume sites (Thika Level V Hospital, Gatundu Level IV Hospital and Ruiru Sub County Hospital)
- Allocation of specific HTS counsellors to carry out family and partner testing
- Home-based counselling and testing (HBCT) for index clients
- Strategic deployment of HTS counsellors with a focus on children testing is highly effective in identifying children living with HIV
- Involvement of index clients in partner/family invitation for testing services and HBCT is effective in testing children who may be living with HIV
- Family counselling and testing facilitates disclosure and communication within the family and promotes adherence and retention in HIV clinical care
- Need to make use of the HBCT register for contacts for home based testing and counselling
- There is need for improvement in follow up and appointment schedules to identify any missing contacts
- There is need to strengthen early infant diagnosis (EID) services for HIV-exposed infants
Potential for Scale-Up
This best practice can be easily adopted by other counties, low, medium and high volume facilities as well as the private sector through:
- Integration of HTS at all service delivery points aimed at scaling up identification of children and adolescents
- Use of line-listing register for follow up of index clients
- Training of health care workers on paediatric and adolescent testing to scale-up efforts in paediatric case finding
- Improved case finding of HIV-infected children, and adolescents through implementation of routine, systematic HIV testing and counselling (HTC) approaches in these settings
- Test all children and adolescents receiving services for orphaned and vulnerable children (OVC)
Between April 2016 and October 2016, a rapid response initiative was started to increase the identification of children and adolescents (0-19 years) living with HIV. A strategy to improve testing at the outpatient and inpatient departments, TB clinics, malnutrition clinics and under-five clinics was adopted to improve the chances of identification for children and adolescent with an undiagnosed HIV infection. Data from Thika Level V Hospital, Gatundu Level IV Hospital and Ruiru Sub County Hospitals shows tremendous improvement on identification as demonstrated on the graph below.
CHS acknowledges the participation and input of: Thika Level V Hospital, Gatundu Level IV Hospital and Ruiru Sub County Hospitals.