Effectiveness of symptom-based diagnostic HIV testing versus targeted and blanket provider-initiated testing and counseling among children and adolescents in Cameroon

Objectives
The concurrent implementation of targeted (tPITC) and blanket provider-initiated testing and counselling (bPITC) is recommended by the World Health Organization (WHO) for HIV case-finding in generalized HIV epidemics. This study assessed the effectiveness of this intervention compared to symptom-based diagnostic HIV testing (DHT) in terms of HIV testing uptake, case detection and antiretroviral therapy (ART) enrollment among children and adolescents in Cameroon, where estimated HIV prevalence is relatively low at 3.7%.
Methods
In three hospitals where DHT was the standard practice before, tPITC and bPITC were implemented by inviting HIV-positive parents in care at the ART clinics to have their biological children (6 weeks-19 years) tested for HIV (tPITC). Concurrently, at the outpatient departments, similarly-age children/adolescents were systematically offered HIV testing via accompanying parents/guardians. The mean monthly number of children tested for HIV, identified HIV-positive and ART-enrolled were used to compare the outcomes of different HIV testing strategies before and after the intervention.
Results
In comparing DHT to bPITC, there was a significant increase in the mean monthly number of children/adolescents tested for HIV (223.0 vs 348.3, p = 0.0073), but with no significant increase in the mean monthly number of children/adolescents: testing HIV-positive (10.5 vs 9.7, p = 0.7574) and ART- enrolled (7.3 vs 6.3, p = 0.5819). In comparing DHT to tPITC, there was no significant difference in the mean monthly number of children/adolescents: tested for HIV (223 vs 193.8, p = 0.4648); tested HIV-positive (10.5 vs 10.6, p = 0.9544), and ART-enrolled (7.3 vs 5.8, p = 0.4672). When comparing DHT versus bPITC+tPITC, there was a significant increase in the mean monthly number of children/adolescents: tested for HIV (223.0 to 542.2, p<0.0001), testing HIV-positive (10.5 vs 20.3, p = 0.0256), and ART-enrolled (7.3 vs 12.2, p = 0.0388).
Conclusions
These findings suggest that concurrent implementation of bPITC+tPITC was more effective compared to DHT in terms of HIV testing uptake, case detection and ART enrolment. However, considering that DHT and bPITC had comparable outcomes with regards to case detection and ART enrolment, bPITC+tPITC may not be efficient. Thus, this finding does not support concurrent bPITC+tPITC implementation as recommended by WHO. Rather, continued DHT+tPITC could effectively and efficiently accelerate HIV case detection and ART coverage among children and adolescents in Cameroon and similar low-prevalence context.

研究目标：世界卫生组织（World Health Organization, WHO）推荐在艾滋病广泛流行地区同时实施针对性提供者发起的检测与咨询（targeted provider-initiated testing and counselling, tPITC）与全面性提供者发起的检测与咨询（blanket provider-initiated testing and counselling, bPITC），用于艾滋病病例发现。本研究以艾滋病估计流行率仅为3.7%的低流行地区喀麦隆的儿童青少年群体为研究对象，评估该联合干预方案相较于基于症状的艾滋病诊断检测（symptom-based diagnostic HIV testing, DHT），在HIV检测接受度、病例发现率以及抗逆转录病毒治疗（antiretroviral therapy, ART）入组情况方面的实施效果。

研究方法：本研究在3家此前以DHT为标准检测方案的医院开展干预。针对抗逆转录病毒治疗门诊中接受治疗的HIV阳性患者的亲生子女（年龄范围为6周至19岁），通过邀请其家长的方式为儿童提供HIV检测服务，此为tPITC方案。与此同时，在医院门诊部门为同年龄段的儿童/青少年通过陪同的家长/监护人系统性提供HIV检测服务，此为bPITC方案。本研究以每月平均接受HIV检测、检出HIV阳性以及纳入ART治疗的儿童人数作为核心指标，对比干预前后不同HIV检测策略的实施效果。

研究结果：将DHT与bPITC方案对比可见，每月平均接受HIV检测的儿童/青少年人数显著提升（223.0 vs 348.3，p=0.0073），但每月平均检出HIV阳性的儿童/青少年人数（10.5 vs 9.7，p=0.7574）以及纳入ART治疗的人数（7.3 vs 6.3，p=0.5819）均无显著提升。将DHT与tPITC方案对比可见，每月平均接受HIV检测的人数（223 vs 193.8，p=0.4648）、检出HIV阳性人数（10.5 vs 10.6，p=0.9544）以及纳入ART治疗的人数（7.3 vs 5.8，p=0.4672）均无显著统计学差异。将DHT与bPITC+tPITC联合方案对比可见，每月平均接受HIV检测的人数（223.0升至542.2，p<0.0001）、检出HIV阳性人数（10.5 vs 20.3，p=0.0256）以及纳入ART治疗的人数（7.3 vs 12.2，p=0.0388）均显著提升。

研究结论：本研究结果显示，相较于DHT方案，同时实施bPITC与tPITC联合方案在提升HIV检测接受度、病例发现率以及ART入组率方面更具效果。但考虑到DHT与bPITC在病例发现率及ART入组率方面的效果相当，bPITC+tPITC联合方案的效费比未必最优。因此本研究结果并不支持WHO推荐的bPITC+tPITC联合方案的常规实施。相反，持续推行DHT+tPITC方案，可在喀麦隆及其他类似低流行率地区，高效且经济地加速儿童青少年群体的艾滋病病例发现，并提升抗逆转录病毒治疗的覆盖范围。