Barriers to HIV testing in older children

More than three million children globally are living with HIV (90% of whom are 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 are diminished in children who develop symptoms of immune system failure before infection is discovered.

Dr Rashida A Ferrand of the London School of Hygiene & Tropical Medicine and colleagues investigated the provision and uptake of provider-initiated HIV testing and counselling (PITC) among children between 6 and 15 years old, by collecting and analysing data from staff at six clinics in Harare, Zimbabwe. PITC involves healthcare providers routinely recommending HIV testing and counselling when people attend healthcare facilities.

Among 2831 eligible children, about three-quarters were offered PITC, of whom 1534 (54.2%) consented to HIV testing. The researchers diagnosed HIV infection in about 1 in 20 (5.3%) of the children tested, highlighting the need for more effective PITC. HIV infection was also found in 1 out of 5 guardians who tested with a child.

The main reasons that healthcare 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, healthcare workers raised a number of concerns associated with testing. They included: fear that a child might experience maltreatment if he or she tested positive; uncertainty around whether testing of the guardian was mandatory and whether only a parent (if one was living) could legally provide consent; and, when parents were alive but not present, 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 did not explore the reasons for refusal of HIV testing by clients. Also, because the relationship of the child to the accompanying adult was not available, the appropriateness of the guardian could not be independently ascertained.

Lead author Dr Rashida A Ferrand 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 healthcare workers and properly implement HIV testing and counselling.”