Identifying Gaps in the Pediatric Index Testing Cascade in Homa Bay, Kenya

Overview

Introduction

Despite significant advances in pediatric HIV treatment, too many children remain undiagnosed and thus without access to lifesaving antiretroviral therapy (ART). It is critical to identify these children and initiate ART as early as possible. The Pediatric-focused Accelerated Case-finding Effort (PACE) initiative was introduced in March 2020 in 30 facilities in 8 sub-counties of Homa Bay, Kenya with the aim to improve HIV case identification in children.

Methods

We report results of an evaluation conducted in 2020-21 to describe pediatric testing coverage through index testing against the backdrop of strategies introduced under the PACE initiative and the COVID-19 pandemic. This evaluation was carried out to describe the pediatric index testing cascade from line listing current ART clients to linkage to treatment for contacts < 15 years of age who tested HIV positive through index testing. Summary statistics have been used to describe the clinical and demographic characteristics of the index cases and their pediatric contacts. Proportions were used to describe the ART clients who had a line-listing completed, and for other steps along the index testing cascade by entry point and in total. Using logistic regression, selected cascade outcomes were evaluated by fitting clinical and demographic characteristics of the study population into multivariate models to determine associations with outcomes of interest.

Results

A total of 799 index client records were reviewed; of whom 592 had contacts documented and 590 had a line-listing and were eligible for the evaluation. The median age of index clients was 32.9 years (IQR: 27.7-38.2). Majority of index clients (87%) were 25 years or older and were female (62%) attending the CCC. Nearly all women in PMTCT/MCH were breastfeeding (90%) and 10% were pregnant. The median time on ART was 5.0 (IQR: 3.0, 7.2) years with majority suppressed in their most recent VL. Among the 590 index clients with a line-listing, 1369 children contacts were identified with a median of 2 (IQR: 1, 3) contacts per index client and a maximum of 6 and 8 contacts at CCC and MCH respectively per index client. Majority of contacts (89.6%) were reached for testing and 95.2% were eligible for testing and nearly all (98%) were tested for HIV. There were 6 contacts who tested HIV positive (5 tested at the PMTCT clinic) with 83.3% linked to HIV care; 1 HIV positive contact identified at the CCC was not linked to treatment. Of the remaining children tested HIV-positive, 3 children were < 1 year of age, 1 was 1 year old, and 1 child was 5 years old.

Conclusion

The findings show that line listing of contacts is very critical for good performance of Index testing cascade. Factors associated with contacts documented and reached were younger age at PMTCT entry.