[Acceptability of HIV testing provided to infants in pediatric services in Cote d'Ivoire, meanings for pediatric diagnostic coverage]. / Acceptabilite´ du test VIH propose´ aux nourrissons dans les services pediatriques, en Cote d'Ivoire, significations pour la couverture du diagnostic pediatrique

PROBLEM: HIV testing in children had rarely been a central concern for researchers. When pediatric tracking retained the attention, it was more to inform on the diagnosis tools' performances rather than the fact the pediatric test can be accepted or refused. This article highlights the parents' reasons which explain why pediatric HIV test is accepted or refused. OBJECTIVE: To study among parents, the explanatory factors of the acceptability of pediatric HIV testing among infant less than six months. METHODS: Semi-structured interview with repeated passages in the parents of infants less than six months attending in health care facilities for the pediatric weighing/vaccination and consultations. RESULTS: We highlight that the parents' acceptance of the pediatric HIV screening is based on three elements. Firstly, the health care workers by his speech (which indicates its own knowledge and perceptions on the infection) directed towards mothers' influences their acceptance or not of the HIV test. Secondly, the mother who by her knowledge and perceptions on HIV, whose particular status, give an impression of her own wellbeing for her and her child influences any acceptance of the pediatric HIV test. Thirdly, the marital environment of the mother, particularly characterized by the ease of communication within the couple, to speak about the HIV test and its realization for the parents or the mother only are many factors which influence the effective realization of the pediatric HIV testing. The preventive principle of HIV transmission and the desire to realize the test in the newborn are not enough alone to lead to its effective realization, according to certain mothers confronted with the father's refusal. On the other hand, the other mothers refusing the realization of the pediatric test told to be opposed to it; of course, even if their partner would accept it. DISCUSSION: The mothers are the principal facing the pediatric HIV question and fear the reprimands and stigma. The father, the partner could be an obstacle, when he is opposed to the infant HIV testing, or also the facilitator with his realization if he is convinced. The father position thus remains essential face to the question of pediatric HIV testing acceptability. The mothers are aware of this and predict the difficulties of achieving their infant to be tested without the preliminary opinion of their partner at the same time father, and head of the family. CONCLUSION: The issue of pediatric HIV testing, at the end of our analysis, highlights three elements which require a comprehensive management to improve the coverage of pediatric HIV test. These three elements would not exist without being influenced; therefore they are constantly in interaction and prevent or support the realization or not pediatric test. Also, with the aim to improve the pediatric HIV test coverage, it is necessary to take into account the harmonious management of these elements. Firstly, the mother alone (with her knowledge, and perceptions), its marital environment (with the proposal of the HIV test integrating (1) the partner and/or father with his perceptions and knowledge on HIV infection and (2) facility of speaking about the test and its realization at both or one about the parents, the mother) and of the knowledge, attitudes and practices about the infection of health care workers of the sanitary institution. RECOMMENDATIONS: Our recommendations proposed taking into account a redefinition of the HIV/AIDS approach towards the families exposed to HIV and a more accentuated integration of the father facilitating their own HIV test acceptation and that of his child.

Antiretroviral treatment response of HIV-infected children after prevention of mother-to-child transmission in West Africa.

INTRODUCTION: We assessed the rate of treatment failure of HIV-infected children after 12 months on antiretroviral treatment (ART) in the Paediatric IeDEA West African Collaboration according to their perinatal exposure to antiretroviral drugs for preventing mother-to-child transmission (PMTCT). METHODS: A retrospective cohort study in children younger than five years at ART initiation between 2004 and 2009 was nested within the pWADA cohort, in Bamako-Mali and Abidjan-Côte d'Ivoire. Data on PMTCT exposure were collected through a direct review of children's medical records. The 12-month Kaplan-Meier survival without treatment failure (clinical or immunological) was estimated and their baseline factors studied using a Cox model analysis. Clinical failure was defined as the appearance or reappearance of WHO clinical stage 3 or 4 events or any death occurring within the first 12 months of ART. Immunological failure was defined according to the 2006 World Health Organization age-related immunological thresholds for severe immunodeficiency. RESULTS: Among the 1035 eligible children, PMTCT exposure was only documented for 353 children (34.1%) and remained unknown for 682 (65.9%). Among children with a documented PMTCT exposure, 73 (20.7%) were PMTCT exposed, of whom 61.0% were initiated on a protease inhibitor-based regimen, and 280 (79.3%) were PMTCT unexposed. At 12 months on ART, the survival without treatment failure was 40.6% in the PMTCT-exposed group, 25.2% in the unexposed group and 18.5% in the children with unknown exposure status (p=0.002). In univariate analysis, treatment failure was significantly higher in children unexposed (HR 1.4; 95% CI: 1.0-1.9) and with unknown PMTCT exposure (HR 1.5; 95% CI: 1.2-2.1) rather than children PMTCT-exposed (p=0.01). In the adjusted analysis, treatment failure was not significantly associated with PMTCT exposure (p=0.15) but was associated with immunodeficiency (aHR 1.6; 95% CI: 1.4-1.9; p=0.001), AIDS clinical events (aHR 1.4; 95% CI: 1.0-1.9; p=0.02) at ART initiation and receiving care in Mali compared to Côte d'Ivoire (aHR 1.2; 95% CI: 1.0-1.4; p=0.04). CONCLUSIONS: Despite a low data quality, PMTCT-exposed West African children did not have a poorer 12-month response to ART than others. Immunodeficiency and AIDS events at ART initiation remain the main predictors associated with treatment failure in this operational context.

Universal HIV screening at postnatal points of care: which public health approach for early infant diagnosis in Côte d'Ivoire?

BACKGROUND: Universal HIV pediatric screening offered at postnatal points of care (PPOC) is an entry point for early infant diagnosis (EID). We assessed the parents' acceptability of this approach in Abidjan, Côte d'Ivoire. METHODS: In this cross-sectional study, trained counselors offered systematic HIV screening to all children aged 6-26 weeks attending PPOC in three community health centers with existing access to HAART during 2008, as well as their parents/caregivers. HIV-testing acceptability was measured for parents and children; rapid HIV tests were used for parents. Both parents' consent was required according to the Ivorian Ethical Committee to perform a HIV test on HIV-exposed children. Free HIV care was offered to those who were diagnosed HIV-infected. FINDINGS: We provided 3,013 HIV tests for infants and their 2,986 mothers. While 1,731 mothers (58%) accepted the principle of EID, only 447 infants had formal parental consent 15%; 95% confidence interval (CI): [14%-16%]. Overall, 1,817 mothers (61%) accepted to test for HIV, of whom 81 were HIV-infected (4.5%; 95% CI: [3.5%-5.4%]). Among the 81 HIV-exposed children, 42 (52%) had provided parental consent and were tested: five were HIV-infected (11.9%; 95% CI: [2.1%-21.7%]). Only 46 fathers (2%) came to diagnose their child. Parental acceptance of EID was strongly correlated with prenatal self-reported HIV status: HIV-infected mothers were six times more likely to provide EID parental acceptance than mothers reporting unknown or negative prenatal HIV status (aOR: 5.9; 95% CI: [3.3-10.6], p = 0.0001). CONCLUSIONS: Although the principle of EID was moderately accepted by mothers, fathers' acceptance rate remained very low. Routine HIV screening of all infants was inefficient for EID at a community level in Abidjan in 2008. Our results suggest the need of focusing on increasing the PMTCT coverage, involving fathers and tracing children issued from PMTCT programs in low HIV prevalence countries.

Attitudes and practices of health care workers toward routine HIV testing of infants in Côte d'Ivoire: the PEDI-TEST ANRS 12165 Project.

OBJECTIVE: We assessed attitudes and practices of health care workers (HCWs) toward HIV counselling and testing (CT) routinely offered to infants in health facilities in Abidjan, Côte d'Ivoire. METHODS: We performed a cross-sectional survey inquiring on systematic HIV CT offered to children aged 6-26 weeks attending postnatal care for either immunization or pediatric care and to their parents in 4 community health centres rolling-out access to antiretroviral therapy. Data were collected using standardized anonymous self-questionnaires directed to all HCWs involved. RESULTS: One-hundred five HCWs were interviewed in 2008: 30% were social workers, 27% physicians, 24% nurses and 19% laboratory technicians. Among immunization staff (n = 45), none trained in child CT versus 26% in pediatric services (n = 60, P < 0001). Almost all staff believed that it is important to offer HIV screening services to children and the best place could be during pediatric consultations. In their daily work, 22% of immunization staff and 48% of pediatric care staff had already been dealing with early HIV CT (P = 0.01). Facing a child suspected to be HIV infected, only 54% of providers in pediatrics and 71% in immunization would offer CT to all family members (P = 0.01). CONCLUSIONS: In Abidjan, although HCWs were generally in favour of pediatric HIV screening, very few had received specific training to do so. Deleguation of CT to the primary care level could improve coverage of CT services. It is urgent to train HCWs to promote early infant HIV diagnosis to improve earlier access to antiretroviral therapy in West African HIV-infected children.

[Survival, clinical and biological outcomes of HIV-infected children treated by antiretroviral therapy in Africa: systematic review, 2004-2009]. / Survie et évolution clinique et biologique des enfants infectés par le VIH traités par les antiretroviraux en Afrique: revue de littérature, 2004-2009.

BACKGROUND: With 2.1 million HIV-infected children in 2008 in the world, especially in sub-Saharan Africa, the paediatric HIV/AIDS care remains an important public health challenge and is principally based on cotrimoxazole prophylaxis and antiretroviral treatments. This paper aims to review the effectiveness of cotrimoxole prophylaxis and antiretroviral treatment in HIV-infected children in Africa, specifically mortality and treatment outcomes. METHODS: In two times, we searched the online databases PubMed™ and Scopus™ for articles and abstracts published in English and French between January 2004 and November 2009, with the following terms : « HIV ¼ and « Africa ¼ and ["paediatric" or "children" or "child"] and ["mortality" or "survival"] and ["cotrimoxazole" or "prophylaxis"] at the first time, « HIV ¼ and « Africa ¼ and ["paediatric" or "children" or "child"] and ["mortality" or "survival"] and ["antiretroviral"] and ["treatment" or "therapy"] at the second time. Longitudinal studies on HIV-infected children under cotrimoxazole prophylaxis or antiretroviral treatment were selected when survival outcomes were reported. RESULTS: The probability of death was significantly reduced by 43% where children received cotrimoxazole prophylaxis compared to placebo. Compared to the survival without treatment, the benefit of antiretroviral therapy on HIV-infected children survival was evident in all publications but early mortality was observed within the six first months of antiretroviral treatment. Over fifty percent of deaths occurred in this period. Severe malnutrition, anaemia and lower CD4% were identified as mortality predicting factors in both children received cotrimoxazole prophylaxis or treated by antiretroviral therapy. DISCUSSION: Better knowledge of determinants of early mortality for these children are important to optimized their survival and improve their quality of care and life. Finally, the beneficial effect of cotrimoxazole prophylaxis when associated with antiretroviral treatment has not been reported and need to be exploring in detail for more information.