Differentiated community-based point-of-care early infant diagnosis to improve HIV diagnosis and ART initiation among infants and young children in Zambia: A quasi-experimental cohort study

Introduction An estimated 800,000 children (<15 years) globally
living with HIV remain undiagnosed. To reach these children with timely
HIV testing services during infancy, we implemented a community-based
differentiated care model using mobile point-of-care (POC) technology for
early infant diagnosis (EID) of HIV, and assessed its effects on EID
positivity, antiretroviral therapy (ART) initiation, and 3-month retention
in care. Methods Between 1 June 1, 2019— and 31 May 31, 2020 at six health
facilities in Lusaka, Zambia, we enrolled mother-infant pairs (MIPs) at
high risk for vertical transmission of HIV based on missing or late infant
EID testing or other maternal risk factors. We offered these MIPs
community POC EID testing (post-intervention), and compared their outcomes
to historical high-risk controls at the same sites (1 June 1, 2017—–31 May
31, 2018; pre-intervention). We used propensity score matched weighting
and mixed effects regression modeling to estimate outcome differences
pre-intervention and post-intervention, and to identify MIP
characteristics predictive of vertical transmission of HIV. Results 2,577
MIPs were included in the analysis: 1763 and 814 high-risk MIPs from the
pre-intervention and post-intervention periods, respectively. Infant HIV
positivity was significantly higher in the post-intervention (2.2%) vs
pre-intervention (1.1%) period (pp=0.038), but this difference was
attenuated (0.83%, 95% confidence interval [CI]: −0.50%, 2.15%) after
adjusting for differences in maternal age, maternal antenatal care visits,
infant birth month, and facility. During the post-intervention period,
MIPs, where the mother disengaged from care, were 12.97 (95% CI: 2.41,
69.98) times as likely to have an infant diagnosed with HIV vs those in
which the infant received late EID testing without maternal care
disengagement. Among 18 infants diagnosed with HIV by the intervention, 16
(88.9%) initiated same-day ART and all continued ART at 3-month follow-up.
Conclusion Community-based differentiated care employing POC EID
technology increased testing positivity in unadjusted analyses, and
resulted in high ART initiation and early care retention, suggesting it
may be a promising approach for reaching infants and young children living
with HIV being missed by current facility-based approaches.