1. Moving Towards Targeted HIV Testing In Older Children Bandason T, McHugh G, Dauya E, Mungofa S, Kranzer K, Ferrand RA BRTI ZIMA Conference - August 2014

2. 2 Background Objectives Methods Results Conclusions Recommendations Outline of this presentation

3. Background More than 70% of HIV-infected children undiagnosed 1 and ART coverage lags behind that of adults (46% in Zimbabwe in 2013) 2 Delayed diagnosis and treatment results in not only a high risk of mortality but also of chronic clinical complications and disability 3 : Prompt identification essential 3 1 Ferrand RA et al (2010) 2 Global AIDS Response Country Progress Report, Zimbabwe 2014 3 Ferrand RA et al (2007) Zimbabwe Adults HIV Prevalence -15% On ART -77%

4. 4 Stunting All patients/guardians consented to pictures 18 years Older Brother aged 17years

5. Current Testing Strategy WHO 4 recommends PITC for high-burden settings to facilitate earlier diagnosis Successful implementation of this strategy in PMTCT program-every pregnant woman offered HIV testing 5 However, PITC often excludes adolescents: perceived to be low-risk and testing usually driven only by presence of symptoms 5 4 WHO 2007 PITC Guidelines 5 Global AIDS Response Country Progress Report, Zimbabwe 2014

6. Rationale for Targeted HIV Screening Resources not adequate to test everyone Use of risk scores algorithms proved reliable in resource limited settings: High sensitivity algorithms widely used for other diseases e.g Tuberculosis 6 Test accuracy of the proposed screening algorithm in older children Contribute to the development of HIV screening guidelines taking into account the HIV prevalence, resource availability and logistical aspects 6 6 Corbett et al (2010)

7. A simple clinical algorithm proposed for screening older children at risk of HIV infection 7 Admitted to hospital before Recurring skin problems One or both parents deceased Poor health in the last 3 months Focuses mainly on children acquiring HIV through MTCT (Sensitivity of 74% and specificity of 80%) 7 Proposed Screening algorithm 7 Ferrand et al (2011)

8. Objective 8 Primary: Validate the performance of algorithm for screening older children at risk of MCT HIV infection in a primary care setting Secondary: To detect older children who would benefit from an HIV test with screening by low cadre healthcare providers To help reduce the waste of limited resources and allow early HIV detection and treatment

9. Methodology Setting 7 Purposively Selected Primary Health Care polyclinics in southwest Harare ⁻Establish HIV treatment services at clinics to ensure immediate linkage to care and treatment Budiriro Dzivarasekwa Highfield Kuwadzana Glen View Glen Norah Mufakose 9

10. Methodology Eligibility Children aged 6-15 years attending for primary care ⁻Not tested within the last 6 months ⁻Accompanied by an appropriate guardian or emancipated youth ⁻Consent to an HIV Test 10

11. Methodology cont. Respond to 4 algorithm questions -has previously been admitted to hospital - has had recurring skin problems - is a single or double orphan -has experienced poor health in the past 3 months. Simple HIV Symptom Score ⁻Presence of screening symptom scores one – Max score=4 Ethical approval obtained from all relevant ethical bodies 11

12. 12 Results: Participant Flow 7,486(57%) ELIGIBLE FOR PITC 6,162 (82%)TESTED 13,046 Children attended PHC 21 st January 2013 – 31 March 2014 5,560 NOT ELIGIBLE FOR PITC - 1,700 OI Clinic Consultation - 1,939 no guardian - 1,117 Tested -ve in the last 6 months - 804 Inappropriate guardian 1,324 NOT TESTED - 604 Refused Testing - 720 Other Reasons 6,102 (99%) SELECTED FOR THE ALGORITHM VALIDATION 60 DID NOT RESPOND TO ALL/SOME ALGORITHM QUESTIONS

13. 13 Baseline Characteristics (N=6,012) Median age 9 years (IQR 7 -11 years) Male 3,138 (51.4%) HIV Positive 290 (4.8%) Past hospital admission585 (9.6%) Had recurring skin problems 995 (16.3%) One or both parents deceased 899 (14.7%) Poor health in the last 3 months 493 (8.1%) Algorithm score 1 1,609 (26.4%) Algorithm score 2 489 (8.0%) Algorithm score 3 96 (1.6%) Algorithm score 4 16 (0.3%)

14. 14 Prevalence of HIV by Algorithm p<0.001 for all Yes No

15. 15 Prevalence of HIV by algorithm score p<0.001

16. 16 Sensitivity and Specificity by Algorithm Any orphanhood had 8 times odds of being HIV positive, but sensitivity was poor Symptom Sensitivity (95% CI) Specificity (95% CI) Odds Ratio (95% CI) Been admitted to hospital before 18.4% (14.1-23.5) 90.8% (90.0-91.5) 2.2 % (1.6-3.1) Had recurring skin problems 34.6% (29.1-40.5) 84.5% (83.6-85.4) 2.9% (2.2 – 3.7) One or both parents deceased 53.5% (47.5-59.5) 87.1% (86.2-87.9) 7.8% (6.1-9.9) Had poor health in the last 3 months 32.2% (26.7-37.9) 93.1% (92.4-93.7) 6.4% (4.8 – 8.3)

17. 17 Sensitivity and Specificity by Age-group Algorithm score of 1 or more correctly identified 80% of children with HIV infection and 66% without Sensitivity higher in those aged ≥10 years All<10 years≥10 yearsp-value Sensitivity 95% CI 80.4%69.8%85.9%0.001 (75.3 - 84.9)(59.6 - 78.7)(80.1 - 90.6) Specificity 65.6%66.5%64.3%0.081 95% CI (64.9 - 68.1)(64.3 - 66.8)(62.4 - 66.2)

18. Number Needed To Screen (NNS) Need to screen more among those <10years < 10 years – NNS: 22(95% CI:16-32) ≥10 years – NNS:7(95% CI:6-9) 18 Screen 11 1 HIV positive

19. Conclusions The algorithm maintained its integrity and demonstrated that it is a sensitive tool for screening older children at risk of HIV infection Symptom screening algorithm is an attractive screening method since it does not involve use of equipment The algorithm can be used by lower cadre healthcare workers and can help prioritise limited resources 19

20. Stock outs of testing kits and paediatric drugs “Suitable guardian” to consent to testing of child The lowest entry point to healthcare which is Primary Healthcare Clinic, is understaffed: Counsellor not available Lack of confidence in providing HIV testing to children Older children are still not a recognized group in HIV healthcare facilities: Priority given to PMTCT 20 Challenges to HIV testing

21. Recommendations Since this algorithm is a simple screening tool – it is appropriate to use it for screening to identify older children With presumptive MTC HIV, with Primary Health Care Facilities as the entry point. HIV testing of older children with a score of one or more can identify over 80% of undiagnosed HIV-positives. 21

22. Look out for any this in older children Admitted to hospital before Recurring skin problems One or both parents deceased Poor health in the last 3 months 22 OFFER AN HIV TEST! The power to improve quality of life is in your hands 80% of the time!

23. 23 Acknowledgements Wellcome Trust Biomedical Research and Training Institute Project Team Collaborators Ministry of Health and Child Care Harare City Health UZ Depts. of Medicine & Paediatrics Harare & Parirenyatwa Hospitals Population Services International (PSI) Patients, study participants & their families

24. Thank You 24