Group Work RecommendationsTesting

Group Members-names

Population HIV-exposed infants

HIV exposure unknown

Recommendation • Virological testing at 4-6 weeks of age

• Infant testing at first contact with health system1

Notes 1(Including delivery). Antibody testing followed by virological testing if appropriate (+Ab test, age)

Identification of symptomatic infants should be improved, especially during neonatal period to enable virological testing at 4-6 weeks

Strength STRONG STRONG

When to Test

Evidence –early infant ART

Evidence Comment

Natural history and mortality data

Modelling and sensitivity / specificity data

Country programme data

Rapid disease progression (esp in early infancy); peak in mortality at 2-4mo; CHER trial data (early diagnosis and treatment reduces mortality)

Support 4-6 week timing for single test; earlier testing with repeat at 4-6w not feasible recommendation

Data show feasibility and expansion of DBS testing; evidence for good EPI coverage strengthens 6 week visit as current point of contact

EVIDENCE: STRONG

Benefits and desired effects: 4-6 week viral testing in HIV exposed

Benefit Explanation

Early diagnosis

Early treatment

May clarify choice of feeding

Point of entry for other family members

Knowledge of child’s status for family and healthcare personnel

Dependent on early diagnosis; early treatment reduces morbidity and mortality and reduces loss to follow-up

Eg HIV-infected child to continue breastfeeding

Maternal health (CTX, ART, family planning); diagnosis of other family members

Risks or undesired effectsRisks Explanation Incorrect diagnosis

Early cessation of breastfeeding

Child is not retested

May discourage use of presumptive diagnosis

Insufficient programme capacity

Diversion of resources

Need strategy for repeat testing to rule out false-positive and false-negative test results

Mothers may choose to stop BF if child uninfected

Breastfeeding infants need to be retested but perception may be that child is definitely uninfected

In settings where PCR is not available, may be a reduced emphasis on presumptive diagnosis

Infants may be tested but unable to access ART

Other aspects of child health programme may suffer

Risks/Benefit assessment: 4-6 week viral testing in HIV exposed

Decision Explanation

Benefits > Risks

STRONG recommendation

Values and preferences: 4-6 week viral testing in HIV exposed

Decision Explanation

Denial and stigma

Neglect of child HIV status may prejudice maternal care of child

FeasibilityDecision Explanation

Capacity

Integration of pMTCT / MCH services

Interpretation of results

Timing of turnaround

Repeat testing

Early ART

Clinic and lab personnel, PCR kits, lab facilities, transportation, mentorship, QA (massive scale up to 100% coverage!)

‘Run-through’ pathway needs to be strengthened and clarified

Clear referral pathways, training, supervision

Critical to reduce delays: testing and access to ART

Strategy appropriate to setting required

Availability, regimens, formulations, willingness to treat

Costs: 4-6 week viral testing in HIV exposed

Decision Explanation

Technology costs

Programme costs

Treatment costs

Emotional costs

Laboratory equipment, PCR testing kits

Training, personnel, counsellors, transport

Identification of more HIV-infected infants eligible for ART

Families and staff

Population HIV-exposed infants

HIV exposure unknown

Recommendation • Virological testing at 4-6 weeks of age

• HIV exposure status of all infants should be determined at first contact with healthcare system1

Notes 1(Including delivery). Antibody testing followed by virological testing if appropriate (+Ab test, age)

Identification of symptomatic infants should be improved, especially during neonatal period to enable virological testing at 4-6 weeks

Strength STRONG CONDITIONAL

When to Test

HIV-exposed HIV exposure unknown

Standard testing pathway at 4-6w

Ab testing at earliest point of healthcare contact

Delivery

Identification of symptomatic infants

Beyond 6 weeks

If Ab test positive and age appropriate then confirmatory virological test if available

OR

Key outstanding questions

Issue Research or action required

Trade-off costs Within HIV programmes: pMTCT vs EID

Outwith HIV programmes: Impact on other aspects of child health programme

Long-term impact Impact on health systems

Presumptive diagnosis How this fits in with EID, can we improve identification in early life of children who miss pMTCT

Timing of CTX prophylaxis Could this be earlier?