Provider initiated testing in Kenya Ruth Nduati Associate Prof Paediatrics University of Nairobi

HIV/AIDS in Kenya > 2.5 million Kenyans have been infected since 1984 and 1.5 million have since died Life expectancy has dropped by almost 20 years Annually ~ 90,000 children are born to HIV infected women of whom ~50,000 acquire infection. >1 million children under the age of 15 years have been orphaned. 120,000 children are currently living with HIV ( UNAIDS, 2004 )

Available interventions Anti-retroviral therapy (ART) Cotrimoxazole prophylaxis Supportive care –nutrition counseling, –diagnosis and treatment of OI, –Immunizations for children, –Psychological support

Current policy position Prevention of HIV Access to HIV testing Increasing access to ARV treatment and long term care Dec 2005 targets are to reach 95,000 HIV infected people with ART

Number of sites providing HIV care services in Sept 2005  1000 PMTCT sites  > 400 VCT sites  280 Adult ARV treatment sites 76 Paediatric ART sites

Policy on testing Assumes ability to give consent. –Sane, –age of majority (> 18 years or emancipated minors) –understand what you are consenting for Policy for testing in children requires –Consent from an adult primary care giver and –Assent required for children > 10 years

Justification for provider initiated testing Early access to ARV therapy and OI prophylaxis and treatment can mitigate against mortality and especially in children with > 50% mortality seen in the first 2 years of life among perinataly infected children Early diagnosis is essential to accessing effective treatment. Routinely offering HIV testing will increase the number of children tested and entering into appropriate care early,

HIV testing – Key entry point into care Client initiated testing VCT – free standing/ client driven demand Provider initiated testing Routine CT – as in PMTCT services with informed right of refusal DT – offered to sick individuals Required testing – organ transplant, military recruitment etc. Mandatory testing – perpetrators of sexual assault Special testing – surveillance and research

Target sites for Testing and counselling PMTCT Antenatal clinics Maternity During early labour Immediate postnatal period New strategies Family planning clinics

HIV testing opportunities for exposed and infected children Diagnostic technologyIntervention HIV antibody testing in the newborn of unknown exposure status ARV’s for Post- exposure prophylaxis HIV antibody testing at any point in the first 18 months of life Entry point for Septrin prophylaxis Antibody testing > 18 months of age Diagnostic for HIV infection status

Interventions for HIV exposed and infected children Diagnostic technology Intervention Clinical staging of HIV exposed children and infected children Identifies child in need of urgent ARV initiation CD4 count (immunologic staging) Entry point for ARV therapy PCR testingDiagnostic for HIV infection status

Procedure for routine testing Group health education and discussion on pros and cons of testing by –health worker and peer counsellors in antenatal testing –Counsellor in curative service setting Individualized confidential decision regarding testing Rapid testing Post-test counselling

Acceptability of routinely offered HIV testing 99% of pregnant women at Kenyatta National Hospital are willing to be tested during labour and therefore grasping the opportunity for intrapartum and PEP for their infant (Ongech).

Uptake of testing in labour in rural District hospitals Approximately 50% of pregnant women with unknown status test in labour Data from 12 Districts in Kenya NARESA 2006

Acceptability of routinely offered HIV testing Inwani reported an 87% acceptance rate for infant cord blood testing at Kenyatta National Hospital(Inwani). 99% acceptance of HIV testing by mothers of children aged < 18 months in Uganda (Bakaki 2001).

Oyieko in 2006 study found that –95.1% acceptance of routinely offered HIV testing of children admitted into paediatric wards (2006). –60% of the guardians were aware of their own HIV status

Routine offer of HIV testing to babies in MCH Data from 12 Districts in Kenya NARESA 2006

Adverse outcomes of testing Kiarie et al AIDS in press 2006) Previous history of domestic violence associated with non-significant –increased likelihood of being sero-positive –reduced odds of couple counseling –less likely to disclose test results. Disclosure of positive test results associated with a 5-fold increased risk of domestic violence

Conclusion Routine offer of testing increases access to services. Innovative approaches to minimize harm need to be out in place –Health education, –peer counselling, –couple counselling Some women remain at risk of increased domestic violence