Improvements in pediatric and adolescent HIV testing and identification in western Kenya under the Accelerating Children's HIV/AIDS Treatment initiative.

Pediatric HIV remains a significant global concern, with 160,000 new infections annually. Accelerating Children's HIV/AIDS Treatment (ACT) provided a strategic response to the "treatment gap" for children. We examined whether activities under ACT increased testing and identification of youth living with HIV (YLWH). Family AIDS Care & Education Services implemented ACT across 130 health facilities in western Kenya between October 2015 and September 2016, providing: HIV-testing counselors and space; training on the Family Information Table (FIT) and chart audits; community outreach testing; and text message reminders for pregnant women. We analyzed the number of youths tested and identified with HIV over time and between intervention and control sites using interrupted time series analysis. We tested 268,312 youths (7,183 infants <18 months; 145,833 children 18 months to 9 years; and 115,296 adolescents 10-14 years). Mean monthly number tested per health facility increased from 2.8 to 7.2 (p < 0.0001) in infants, 44.8-142.0 (p < 0.0001) in children, and 30.1-123.3 (p < 0.0001) in adolescents. Mean monthly number identified with HIV per facility increased from 0.06 to 0.37 (p < 0.0001) in infants; 0.34-0.62 (p = 0.008) in children; and 0.17-0.26 (p = 0.04) in adolescents, resulting in 1,328 diagnoses. Among infants, FIT training was associated with increased HIV testing over time, incidence rate ratio (IRR) = 3.85 (95% confidence interval [CI] 2.16-6.84; p < 0.0001). Text messaging increased testing, IRR = 2.10 (95% CI 1.57-2.80; p < 0.0001) and identification of HIV in infants, IRR = 1.83 (95% CI 1.06-3.18; p = 0.0381) and older children, IRR = 2.25 (95% CI 1.62, 3.13; p < 0.0001). Chart audits increased testing over time among adolescents (IRR = 2.11; 95% CI 1.21-3.66; p = 0.0082). Outreach was associated with identification of adolescents with HIV, IRR = 1.58 (95% CI 1.22-2.06; p = 0.0005). In lower-income settings, targeted interventions effective at reaching YLWH can help optimize resource allocation to address gaps in testing and identification to further reduce HIV-related morbidity and mortality.

The contribution of HIV point-of-care tests in early HIV diagnosis: community-based HIV testing monitoring in Catalonia, 1995 to 2018.

BackgroundCommunity-based HIV testing services combined with the use of point-of-care tests (POCT) have the potential to improve early diagnosis through increasing availability, accessibility and uptake of HIV testing.AimTo describe community-based HIV testing activity in Catalonia, Spain, from 1995 to 2018, and to evaluate the impact of HIV POCT on the HIV continuum of care.MethodsA community-based network of voluntary counselling and testing services in Catalonia, Spain has been collecting systematic data on activity, process and results since 1995. A descriptive analysis was performed on pooled data, describing the data in terms of people tested and reactive screening test results.ResultsBetween 1995 and 2018, 125,876 HIV tests were performed (2.1% reactive). Since the introduction of HIV POCT in 2007, a large increase in the number of tests performed was observed, reaching 14,537 tests alone in 2018 (1.3% reactive). Men who have sex with men (MSM), as a proportion of all people tested, has increased greatly over time reaching 74.7% in 2018. The highest percentage of reactive tests was found in people who inject drugs followed by MSM. The contribution of community-based HIV testing to the overall total notified cases in the Catalonia HIV registry has gradually increased, reaching 37.9% in 2018, and 70% of all MSM cases. In 2018, the percentage of individuals with a reactive screening test who were linked to care was 89.0%.ConclusionOur study reinforces the important role that community-based HIV POCT has on the diagnosis of HIV in key populations.

Factors associated with prenatal care and HIV and syphilis testing during pregnancy in primary health care

ABSTRACT OBJECTIVE To evaluate the factors associated with HIV and syphilis testing during pregnancy in Brazil. METHODS This was an ecological study covering all Brazilian municipalities evaluated by the second cycle of the National Program for Access and Quality Improvement in Primary Care, 2013-2014. The dependent variables were based on prenatal care access: prenatal care appointments, and HIV and syphilis tests during prenatal care. The independent variables were compared with demographic and social characteristics. Bivariate analysis was performed assessing the three outcomes with the independent variables. Variables with significant associations in this bivariate analysis were fit in a Poisson multiple regression analysis with robust variance to obtain adjusted estimates. RESULT Poisson regression analysis showed a statistically significant association with the variables "less than eight years of study" [prevalence ratio (PR) = 1.31; 95%CI 1.19-1.45; p < 0.001] and "participants of the cash transfer program" (PR = 0.80; 95%CI 0.72-0.88; p < 0.001) for the outcome of "having less than six prenatal care appointments" and individual variables. A statistically significant association was found for "participants of the cash transfer program" (PR = 1.43; 95%CI 1.19-1.72; p < 0.001) regarding the outcome from the comparison between HIV testing absence during prenatal care and demographic and social characteristics. The absence of syphilis testing during prenatal care, and demographic and social characteristics presented a statistically significant association for the education level variable "less than eight years of study" (PR =1.75; 95%CI 1.56-1.96; p < 0.001) and "participants of the cash transfer program" (PR = 1.21, 95%CI 1.07-1.36; p < 0.001). CONCLUSIONS The individual factors were associated with prenatal care appointments and HIV and syphilis tests in Brazilian pregnant women. They show missed opportunities for diagnosing HIV and syphilis infection during prenatal care and indicate weaknesses in the quality of maternal health care services to eliminate mother-to-child transmission.

[Cobatest network: users' characteristics of community-based voluntary,counselling and testing centres in Spain.] / Red COBATEST: Características de los usuarios de los centros comunitarios de diagnóstico y orientación para el VIH en España.

OBJECTIVE: The COBATEST network (European network of community-based voluntary, counselling and testing centers) allows standardized collection of information to monitor HIV testing at these centers. The objective was to describe the performance of the Spanish centers of the COBATEST network and the epidemiological profile of its users, and to analyze the factors associated with having an earlier HIV test. METHODS: Descriptive analysis of the data collected in the 19 Spanish centers that used the common information collection tools during the year 2015. A multivariate logistic regression model was used to identify factors associated with having an earlier test. RESULTS: A total of 6,077 HIV rapid tests were performed and 1.8% were reactive (3.0% MSM, 3.1% SW, 2.3% PWID, 0.6% heterosexual). 82.1% of the reactives were referred to perform a confirmatory test and 94 (97.9%) were HIV positive, of whom 54% were diverted to the health system. 38% said they had never been tested for HIV. Factors associated with having a previous HIV test were: being over 20 years old; being HSH, SW, or PWID; being foreign; having used condoms at the last penetration; having had an STI in the last year; and having been in jail. CONCLUSIONS: The results show the great potential of these services to reach people who have never been tested for HIV. The HIV cases are concentrated in vulnerable groups. It is necessary to improve the linkage of diagnosed people to health care services.

OBJETIVO: La red COBATEST (red europea de centros comunitarios de cribado del VIH) permite la recogida estandarizada de información para monitorizar las pruebas de VIH realizadas en estos centros. El objetivo fue describir el rendimiento de los centros españoles de la red COBATEST y el perfil epidemiológico de sus usuarios, y analizar los factores asociados a tener una prueba de VIH anterior. METODOS: Análisis descriptivo de los datos recogidos en los 19 centros españoles que usaron las herramientas comunes de recogida de información durante el año 2015. Se realizó un modelo multivariado de regresión logística para identificar factores asociados a tener una prueba anterior. RESULTADOS: Se realizaron un total de 6.077 pruebas rápidas de VIH y de éstas un 1,8% fueron reactivas [3,0% HSH (hombres que tienen sexo con hombres); 3,1% TS (trabajadores/as sexuales); 2,3% UDI (usuarios/as de drogas inyectables); 0,6% heterosexuales)]. El 82,1% de los reactivos se realizaron la prueba confirmatoria y 94 (97,9%) fueron diagnosticados de VIH siendo derivados al sistema sanitario el 54%. El 38% afirmó no haberse realizado nunca la prueba del VIH. Los factores asociados a tener una prueba del VIH anterior son: ser mayor de 20 años; ser HSH, TS, o UDI; ser extranjero; haber usado preservativo en la última penetración; haber tenido una ITS en el último año; y haber estado en prisión. CONCLUSIONES: Los resultados muestran el gran potencial de estos servicios para llegar a personas que nunca se han realizado la prueba del VIH. Los casos de VIH se concentran en colectivos vulnerables. Es necesario mejorar la vinculación de las personas diagnosticadas a los servicios sanitarios.

Determining the factors associated with blood-borne virus testing of substance misusers presenting to hospital.

BACKGROUND: Diagnosing blood-borne virus (BBV) infection is an essential first step in eliminating transmission and securing access to treatment amongst substance misusers. AIMS: To determine the proportion of substance misusers presenting to hospital who undergo BBV testing and the factors influencing testing. METHODS: A retrospective cross-sectional study was performed of patients presenting to two Sydney teaching hospitals with substance misuse diagnoses between January and April 2015. Proportions tested for human immunodeficiency virus, hepatitis C and hepatitis B previously and during the index hospitalisation presentation were examined. Multivariable analysis was performed to determine factors associated with testing. RESULTS: Of 239 patients, 47 (19.7%) had a documented BBV at baseline. Of those with unknown BBV status, 29 (12.8%) had undergone some attempt at testing during presentation; 3.1% had their hepatitis B immunity assessed. Factors associated with an increased likelihood of testing during presentation included documented injecting drug use (odds ratio (OR) 15.14; 95% confidence interval (CI) 4.21-54.50; P < 0.001), admission under a physician (OR 11.79; 95% CI 2.82-49.40; P = 0.001) and admission on a Friday (OR 4.46; 95% CI 1.28-15.48; P = 0.02). Patients who had had more than one previous admission in the preceding 6 months (OR 0.24; 95% CI 0.078-0.73; P = 0.01) or a length of stay of 1 day or less (OR 0.17; 95% CI 0.032-0.87; P = 0.033) were less likely to be tested. CONCLUSION: Despite the high baseline prevalence of BBV infections in the population, there were many missed opportunities for BBV testing. We found patient-, admission- and clinician-level barriers that could be addressed to enhance BBV testing uptake.

Deficiencies in the health care system contribute to a high rate of late HIV diagnosis in Sweden.

OBJECTIVES: The aim of the study was to identify factors in HIV-infected patients and the health care system which contribute to late diagnosis. METHODS: All patients who were newly diagnosed with HIV infection at 12 clinics in Sweden over a period of 2.5 years (n = 575) were included in the study, corresponding to three-quarters of newly diagnosed HIV infections in the country. The patients were classified as non-late presenters or late presenters (LPs), defined as those with a CD4 count < 350 cells/µL or AIDS. LPs were subdivided into those without and those with advanced HIV disease, which was defined as a CD4 count < 200 cells/µL or AIDS. Demographics, missed AIDS and HIV-associated symptoms in the preceding 3 years, immigration date, and health examination at immigration were recorded. RESULTS: Fifty-eight per cent of the patients were LPs, of whom 66% had advanced disease. Age > 30 years, origin in sub-Saharan Africa or Eastern Europe/Asia/the Pacific region, and country of transmission being in sub-Saharan Africa or unknown were associated with late presentation. Half of the patients of non-Swedish origin had lived for more than 1 year in Sweden at diagnosis and 66% had a missed HIV testing opportunity at immigration. Twenty-seven per cent of all patients had presented for health care with AIDS- and/or HIV-associated conditions without having an HIV test. Sixteen per cent had a history of symptoms without seeking care. CONCLUSIONS: Deficiencies in the health care system with missed HIV testing opportunities contribute to the high proportion of late presenters in Sweden, especially among migrants. With increased testing at immigration and further incorporation of "indicator-guided" testing in general practice, most patients could be diagnosed earlier.

Estimation of HIV incidence in two Brazilian municipalities, 2013 / Estimação da incidência de HIV em dois municípios brasileiros, 2013

ABSTRACT OBJECTIVE To estimate HIV incidence in two Brazilian municipalities, Recife and Curitiba, in the year of 2013. METHODS The method for estimating incidence was based on primary information, resulting from the Lag-Avidity laboratory test for detection of recent HIV infections, applied in a sample of the cases diagnosed in the two cities in 2013. For the estimation of the HIV incidence for the total population of the cities, the recent infections detected in the research were annualized and weighted by the inverse of the probability of HIV testing in 2013 among the infected and not diagnosed cases. After estimating HIV incidence for the total population, the incidence rates were estimated by sex, age group, and exposure category. RESULTS In Recife, 902 individuals aged 13 years and older were diagnosed with HIV infection. From these, 528 were included in the study, and the estimated proportion of recent infections was 13.1%. In Curitiba, 1,013 people aged 13 years and older were diagnosed, 497 participated in the study, and the proportion of recent infections was 10.5%. In Recife, the estimated incidence rate was 53.1/100,000 inhabitants of 13 years and older, while in Curitiba, it was 41.1/100,000, with male-to-female ratio of 3.5 and 2.4, respectively. We observed high rates of HIV incidence among men who have sex with men, of 1.47% in Recife and 0.92% in Curitiba. CONCLUSIONS The results obtained in the two cities showed that the group of men who have sex with men are disproportionately subject to a greater risk of new infections, and indicate that strategies to control the spread of the epidemic in this population subgroup are essential and urgent.

RESUMO OBJETIVO Estimar a incidência de HIV em dois municípios brasileiros, Recife e Curitiba, no ano de 2013. MÉTODOS O método de estimação da incidência foi baseado em informações primárias, resultantes do ensaio laboratorial Lag-Avidity para detecção de infecções recentes do HIV, aplicado em uma amostra dos casos diagnosticados nas duas cidades em 2013. Para a estimação da incidência de HIV para a população total das cidades, as infecções recentes detectadas na pesquisa foram anualizadas e ponderadas pelo inverso da probabilidade de teste de HIV no ano de 2013 entre os casos infectados e não diagnosticados. Após a estimação da incidência de HIV para a população total, foram estimadas as taxas de incidência por sexo, faixa de idade e categoria de exposição. RESULTADOS Em Recife, foram diagnosticados 902 indivíduos de 13 anos e mais com infecção de HIV. Desses, 528 foram incluídos no estudo, e a proporção estimada de infecções recentes foi de 13,1%. Em Curitiba, foram diagnosticadas 1.013 pessoas de 13 anos e mais, 497 participaram do estudo, e a proporção de infecções recentes foi de 10,5%. Em Recife, a taxa de incidência estimada foi de 53,1 por 100 mil habitantes de 13 anos e mais, enquanto em Curitiba, de 41,1 por 100 mil, com razão do sexo masculino para o feminino de 3,5 e 2,4, respectivamente. Foram evidenciadas elevadas taxas de incidência de HIV entre homens que fazem sexo com homens, de 1,47% em Recife e 0,92% em Curitiba. CONCLUSÕES Os resultados obtidos nas duas cidades mostraram que o grupo dos homens que fazem sexo com homens está desproporcionalmente sujeito ao maior risco de novas infecções, e indicam que estratégias para controle da disseminação da epidemia nesse subgrupo populacional são essenciais e urgentes.

Uptake of Testing for HIV and Syphilis Among Men Who Have Sex with Men in Baltimore, Maryland: 2004-2011.

Men who have sex with men (MSM) in Baltimore are at disproportionately high risk for HIV and syphilis infection. Testing and diagnosis are important first steps in receiving treatment and reducing transmission. We analyzed cross-sectional data collected in 2004-2005, 2008, and 2011 among MSM not reporting a previous positive HIV test (n = 1268) in Baltimore, Maryland as part of the National HIV Behavioral Surveillance System to determine the proportion of men tested for HIV and/or syphilis within the previous 12 months and examine the extent to which opportunities for testing were being missed in health care settings. Within the previous 12 months, 54 % of men had received an HIV test; 31 % had received a syphilis test; and only 23 % of men had received testing for both. Among 979 men who did not receive both tests, 72 % had seen a health care provider in the past year, suggesting missed testing opportunities.

HIV testing among clients in high HIV prevalence venues: disparities between older and younger adults.

The Centers for Disease Control and Prevention recommends routine human immunodeficiency virus (HIV) testing of every client presenting for services in venues where HIV prevalence is high. Because older adults (aged ≥50 years) have particularly poor prognosis if they receive their diagnosis late in the course of HIV disease, any screening provided to younger adults in these venues should also be provided to older adults. We examined aging-related disparities in recent (past 12 months) and ever HIV testing in a probability sample of at-risk adults (N = 1238) seeking services in needle exchange sites, sexually transmitted disease clinics, and Latino community clinics that provide HIV testing. Using multiple logistic regression with generalized estimating equations, we estimated associations between age category (<50 years vs. ≥50 years) and each HIV testing outcome. Even after controlling for covariates such as recent injection drug use, older adults had 40% lower odds than younger adults did of having tested in the past 12 months (odds ratio [OR] = 0.6; 95% confidence interval [CI] = 0.40-0.90) or ever (OR = 0.6; 95% CI = 0.40-0.90). Aging-related disparities in HIV testing exist among clients of these high HIV prevalence venues and may contribute to known aging-related disparities in late diagnosis of HIV infection and poor long-term prognosis.

Rewards and challenges of providing HIV testing and counselling services: health worker perspectives from Burkina Faso, Kenya and Uganda.

The rapid scale-up of human immunodeficiency virus (HIV) testing, counselling and treatment throughout sub-Saharan Africa has raised questions about how to protect patients' rights to consent, confidentiality, counselling and care in resource-constrained settings. The Multi-country African Testing and Counselling for HIV (MATCH) study investigated client and provider experiences with different modes of testing in sub-Saharan Africa. One component of that study was a survey of 275 HIV service providers in Burkina Faso, Kenya and Uganda that gathered quantifiable indicators and qualitative descriptions using a standardized instrument. This article presents provider perspectives on the challenges of obtaining consent, protecting confidentiality, providing counselling and helping clients manage disclosure. It also explores health workers' fear of infection within the workplace and their reports on discrimination against HIV clients within health facilities. HIV care providers in Burkina Faso, Kenya and Uganda experienced substantial rewards from their work, including satisfaction from saving lives and gaining professional skills. They also faced serious resource constraints, including staff shortages, high workloads, lack of supplies and inadequate infrastructure, and they expressed concerns about accidental exposure. Health workers described heavy emotional demands from observing clients suffer emotional, social and health consequences of being diagnosed with HIV, and also from difficult ethical dilemmas related to clients who do not disclose their HIV status to those around them, including partners. These findings suggest that providers of HIV testing and counselling need more resources and support, including better protections against HIV exposure in the workplace. The findings also suggest that health facilities could improve care by increasing attention to consent, privacy and confidentiality and that health policy makers and ethicists need to address some unresolved ethical dilemmas related to confidentiality and non-disclosure, and translate those discussions into better guidance for health workers.

Oral rapid test: an alternative to traditional HIV screening in Chile / Prueba oral rápida: una alternativa al tamizaje tradicional del VIH en Chile

OBJECTIVE: To compare the sensitivity and specificity of an Oral Rapid Test (ORT) to that of the Enzyme-Linked Immunosorbent Assay (ELISA) for HIV testing in Santiago, Chile; to track the number of study participants returning for ELISA testing results; and to analyze the participants' perceptions of the ORT compared to the ELISA. METHODS: A total of 497 people were recruited in Santiago, Chile: 153 had previously tested positive for HIV, and 344 were of unknown status. Participants were tested for HIV using both the ELISA and the ORT to examine and compare specificity and sensitivity. Qualitative data were collected from 22 participants to compare perceptions of the testing experience with ORT versus ELISA. RESULTS: The ELISA reported 184 (37%) of the 497 participants as being "positive" for HIV antibodies; the ORT showed 181 (36.4%) as being "reactive" for HIV. The ORT showed a sensitivity of 98.4% (95.7%-99.9%, 95% Confidence Interval) and specificity of 100%. The Kappa test produced K = 0.983 (P < 0.0001). Of the 344 participants whose HIV status was unknown at the start of the study, 55 failed to return for their ELISA results. Participants positively perceived ORT as having reduced both waiting time and anxiety over obtaining their test results. ORT oral swabbing appeared more practical and less invasive than drawing blood for the ELISA. CONCLUSIONS: The ORT and ELISA were statistically equal in specificity and sensitivity. ORT provides quicker results, potentially ensuring that more people receive them, and does not require handling of or exposure to potentially hazardous blood products. Trial number: ClinicalTrials.gov identifier: NCT01733927.

OBJETIVO: Comparar la sensibilidad y la especificidad de una prueba oral rápida con las del análisis de inmunoadsorción enzimática (ELISA) para la detección del VIH en Santiago de Chile, Chile; hacer un seguimiento del número de participantes en el estudio que regresan para saber los resultados del ELISA; y analizar las percepciones de los participantes con relación a la prueba oral rápida en comparación con el ELISA. MÉTODOS: Se incluyeron 497 personas en Santiago de Chile: 153 tenían resultados positivos para el VIH, y la situación de las restantes 344 era desconocida. Se sometió a los participantes a pruebas de detección del VIH tanto mediante el ELISA como mediante la prueba oral rápida, con objeto de analizar y comparar la especificidad y la sensibilidad. Se recopilaron datos cualitativos de 22 participantes para comparar sus impresiones con relación a la experiencia de someterse a la prueba oral rápida en comparación con el ELISA. RESULTADOS: Mediante el ELISA se notificó que 184 de los 497 participantes (37%) obtuvieron un resultado "positivo" en las pruebas de detección de anticuerpos contra el VIH; mediante la prueba oral rápida 181 participantes (36,4%) fueron "reactivos" para el VIH. Esta prueba demostró una sensibilidad de 98,4% (intervalo de confianza de 95%: 95,7-99,9%) y una especificidad de 100%. El coeficiente kappa (K) fue de 0,983 (P < 0,0001). De los 344 participantes cuyo estado con respecto a la infección por el VIH era desconocido al comienzo del estudio, 55 no regresaron para conocer los resultados del ELISA. Los participantes percibieron positivamente la prueba oral rápida debido al período de espera más breve y la reducción de la ansiedad por conocer los resultados de la prueba. La obtención de una muestra oral mediante hisopo resultó más práctica y menos invasora que la extracción de sangre necesaria para llevar a cabo un ELISA. CONCLUSIONES: La prueba oral rápida y el ELISA se mostraron estadísticamente equivalentes en cuanto a especificidad y sensibilidad. La primera proporciona resultados más rápidos, garantiza que más personas puedan conocerlos, y no requiere el manejo o la exposición a hemoderivados potencialmente peligrosos. Número de ensayo: Identificador de ClinicalTrials.gov, NCT01733927.

Resultado do teste rápido anti-HIV após o parto: uma ameaça à amamentação ao nascimento / Delivering rapid HIV tests results after delivery: a threat to breastfeeding at birth

OBJETIVO: Analisar fatores associados à não-amamentação na primeira hora de vida, sobretudo a influência do momento do resultado do teste rápido anti-HIV. MÉTODOS: Estudo de coorte, sendo o ponto inicial a submissão ao teste rápido e o final a primeira mamada do bebê. A população estudada incluiu 944 parturientes submetidas ao teste rápido anti-HIV, com resultado negativo, em 2006, nos cinco hospitais amigos da criança do Sistema de Gestação de Alto Risco no município do Rio de Janeiro, RJ. Entrevistadoras treinadas obtiveram dados do laboratório e do prontuário e no pós-parto aplicaram questionário para entrevista às mães. O modelo multinível foi adotado para analisar a influência de características sociodemográficas, de assistência pré-natal e ao parto sobre a não-amamentação na primeira hora de vida. RESULTADOS: Dentre as participantes, apenas 15,6 por cento receberam seu resultado antes do parto, 30,8 por cento depois do parto e 53,6 por cento ainda desconheciam o resultado ao ser entrevistada. A prevalência de não-amamentação na primeira hora de vida foi de 52,5 por cento (IC 95 por cento: 49,3;55,8). Após ajuste, o recebimento do resultado do teste rápido após o parto dobrou o risco da não-amamentação na primeira hora de vida (RR=2,06; IC 95 por cento: 1,55;2,75). Outros fatores de risco foram: cor não branca, renda materna de um salário mínimo ou menos, parto cesáreo, mãe não querer amamentar o bebê ao nascimento e mãe referir que a equipe hospitalar não a escutava. O desconhecimento da realização do teste rápido anti-HIV pela mãe se mostrou como fator de proteção. CONCLUSÕES: O principal fator de risco para a não-amamentação na primeira hora de vida foi o recebimento do resultado do teste rápido após o parto. O teste anti-HIV deve ser amplamente disponibilizado no pré-natal e o teste rápido deve ser realizado sob indicação, na admissão, com busca ativa e pronta comunicação do resultado à mulher.

OBJECTIVE: To analyze factors associated with failure to breastfeed during the first hour of life, especially the influence of time of delivery of rapid HIV test results. METHODS: Cohort study, beginning with the administration of the rapid test and ending the first time the baby is breastfed. The study population included 944 delivering mothers that received rapid HIV testing with a negative result in five Baby-Friendly hospitals of the High-Risk Pregnancy System in the city of Rio de Janeiro, Southeastern Brazil, in 2006. Trained interviewers obtained data from laboratory and patient charts and interviewed mothers shortly after delivery. The influence of sociodemographic variables and antenatal and delivery care characteristics on failure to breastfeed during the first hour of life was determined through a multilevel model. RESULTS: Among participants, 15.6 percent received the result of rapid HIV testing before delivery, 30.8 percent after delivery, and 53.6 percent had not yet been informed of their results at the time of the interview. Prevalence of failure to breastfeed in the first hour of life was 52.5 percent (95 percent CI: 49.3;55.8). After adjustment, having received the result of rapid testing only after delivery doubled the risk of failing to breastfeed in the first hour (RR=2.06; 95 percent CI: 1.55;2.75). Other risk factors included nonwhite skin color, maternal income of up to one minimum wage, delivery by C-section, mother's lack of desire to breastfeed at birth, and mother's report that the hospital staff did not listen to her. Lack of knowledge of HIV testing from the mother's part was found to be a protective factor. CONCLUSIONS: The major risk factor for not breastfeeding in the first hour of life was failure to receive the results of rapid HIV testing prior to delivery. HIV testing should be made widely available during antenatal care; rapid testing should be performed upon admission, only when indicated, and with...