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Barriers to provider-initiated testing and counselling for children in a high HIV prevalence setting: a mixed methods
Katharina Kranzer1, Jamilah Meghji2, Tsitsi Bandason2
1Department of Infectious Disease Epidemiology, London School of Hygiene & Tropical Medicine, London, United Kingdom.
Insights
Provider-initiated HIV testing and counselling (PITC) for children in Zimbabwe found high HIV prevalence. Addressing consent, guardianship, and structural barriers is crucial for successful PITC implementation in primary care.
Area of Science:
- Public Health
- Pediatric Infectious Diseases
- Health Services Research
Background:
- Sub-Saharan Africa faces a significant burden of HIV in older children, often diagnosed late.
- Current healthcare practices may not adequately identify HIV in pediatric populations.
- Investigating provider-initiated HIV testing and counselling (PITC) in primary care is essential.
Purpose of the Study:
- To assess the provision and uptake of PITC among children aged 6-15 in Zimbabwean primary care.
- To identify factors influencing the offering and acceptance of PITC by healthcare workers (HCWs) and guardians.
- To explore HCW perspectives on providing HIV testing to children.
Main Methods:
- A cross-sectional study involving 2,831 eligible children across six primary care clinics in Harare, Zimbabwe.
- Data collection included reasons for not offering PITC, factors associated with offering/refusal via multivariable logistic regression, and semi-structured interviews with HCWs.
- Guardian consent and child assent were obtained for HIV testing.
Main Results:
- 76% of eligible children were offered PITC, with 54.2% consenting to testing.
- Key barriers included guardian suitability for consent and resource availability (staff, kits).
- HIV prevalence was 5.3% in children and 19.8% in tested guardians; 95% of HIV-positive children were linked to care.
Conclusions:
- High HIV prevalence underscores the need for PITC in this pediatric population.
- Clear legislation on consent/guardianship and addressing structural issues are vital for PITC success.
- Targeted HCW training and increased awareness of HIV risk in asymptomatic children are recommended.
Background:
There is a substantial burden of HIV infection among older children in sub-Saharan Africa, the majority of whom are diagnosed after presentation with advanced disease. We investigated the provision and uptake of provider-initiated HIV testing and counselling (PITC) among children in primary health care facilities, and explored health care worker (HCW) perspectives on providing HIV testing to children.
Methods And Findings:
Children aged 6 to 15 y attending six primary care clinics in Harare, Zimbabwe, were offered PITC, with guardian consent and child assent. The reasons why testing did not occur in eligible children were recorded, and factors associated with HCWs offering and children/guardians refusing HIV testing were investigated using multivariable logistic regression. Semi-structured interviews were conducted with clinic nurses and counsellors to explore these factors. Among 2,831 eligible children, 2,151 (76%) were offered PITC, of whom 1,534 (54.2%) consented to HIV testing. The main reasons HCWs gave for not offering PITC were the perceived unsuitability of the accompanying guardian to provide consent for HIV testing on behalf of the child and lack of availability of staff or HIV testing kits. Children who were asymptomatic, older, or attending with a male or a younger guardian had significantly lower odds of being offered HIV testing. Male guardians were less likely to consent to their child being tested. 82 (5.3%) children tested HIV-positive, with 95% linking to care. Of the 940 guardians who tested with the child, 186 (19.8%) were HIV-positive.
Conclusions:
The HIV prevalence among children tested was high, highlighting the need for PITC. For PITC to be successfully implemented, clear legislation about consent and guardianship needs to be developed, and structural issues addressed. HCWs require training on counselling children and guardians, particularly male guardians, who are less likely to engage with health care services. Increased awareness of the risk of HIV infection in asymptomatic older children is needed.
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