London School of Hygiene & Tropical Medicine

Health care providers in Zimbabwe feel discouraged from testing children for HIV due to the fear of the stigma faced by the child and their family if they tested positive, according to new research published in PLOS Medicine.

More than three million children globally are living with HIV (90% in sub-Saharan Africa) and in 2011 an estimated 1000 infant infections occurred every day. HIV acquired through mother-to-child transmission around the time of birth is often unsuspected in older children, and the benefits of treatment may be diminished in children who develop symptoms before infection is discovered.

Lead study author Dr Rashida Ferrand from the London School of Hygiene & Tropical Medicine said: "The fear of the stigma faced by the child and their family seems to be discouraging caregivers from testing children for HIV. However, with improved clarity of guidelines, engagement with staff, and organisational adjustments within clinics, it should be possible to harness the commitment of health-care workers and properly implement HIV testing and counseling."

Provider-initiated HIV testing and counseling (PITC) involves health care providers routinely recommending HIV testing and counseling when people attend health care facilities. To investigate the provision and uptake of PITC among children between six and 15 years old, the researchers collected and analysed data from staff at six clinics in Harare, Zimbabwe.

Among 2,831 eligible children, about three-quarters were offered PITC, of whom 54% consented to HIV testing. The researchers diagnosed HIV infection in about one in 20 (5.3%) of the children tested, highlighting the need for more effective PITC. HIV infection was also found in one out of five guardians who tested with a child.

The main reasons that health-care workers gave for not offering PITC were 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 were less likely to be offered HIV testing. Male guardians were less likely to consent to their child being tested.

In interviews, health-care workers raised concerns that a child might experience maltreatment if he or she tested positive, and showed uncertainty around whether testing of the guardian was mandatory and whether only a parent could legally provide consent.  When parents were alive but not present, seeking consent from another adult raised ethical concerns that a positive HIV test in a child would disclose the HIV status of a parent who hadn't provided consent.

The study was funded by the Wellcome Trust.

Publication

• Kranzer K, Meghji J, Bandason T, Dauya E, Mungofa S, et al. (2014) Barriers to Provider-Initiated Testing and Counselling for Children in a High HIV Prevalence Setting: A Mixed Methods Study. PLoS Med 11(5): e1001649. doi:10.1371/journal.pmed.1001649