Towards getting more HIV-positive infants on lifesaving treatment: assessing turnaround times for early infant diagnosis in Lesotho

Background: Multiple factors contribute to delayed antiretroviral treatment (ART) initiation for HIV-positive children, including service delivery gaps in early infant HIV diagnosis (EID). Assessing the timeline of the EID process to identify bottlenecks can allow for delivery of targeted interventions to decrease the time to ART initiation for HIV-infected children.
Methods: In 2012, EGPAF conducted a retrospective cohort study to examine possible reasons for delayed EID turnaround times (TATs) in Lesotho. In-country ethical approval was obtained from Lesotho IRB and the National Research and Ethics Committee. Study staff reviewed records of all 6-8 week-old HIV-exposed infants receiving an HIV test in 2011 at 25 study sites; of these, 11 were purposively selected as hard-to-reach sites with higher-than-average EID TATs. Sites were located in all regions and represented all facility levels. Infant testing records from the central laboratory database were linked to facility and laboratory register information of the corresponding mother-infant pairs (n=1187). TATs for EID 'pathway' stages were calculated using abstracted dates from the patient database and registers. Geometric means (with 95% CI) for TATs were calculated and compared by region using linear mixed models.
Results:

Stage #Stage 1: From specimen collection to specimen transfer to laboratory headquarters for processingStage 2: From specimen transfer to laboratory headquarters to specimen transfer to laboratory for testingStage 3: From specimen transfer to laboratory to result receipt at district hospitalStage 4: From result receipt at district hospital to result receipt at facilityStage 5: From result receipt at facility to result receipt by caregiverOverall: From specimen collection to result receipt by caregiver
Mean in days and CI13.96 (CI=12.09, 16.12)2.68 (CI=1.48, 4.85)23.27 (CI=18.69, 28.97)3.20 (CI=1.85, 5.54)10.36 (CI=7.95, 13.50)61.65 (CI=55.30, 68.73)
[TATs at stages along the EID pathway]


The average S2 and S3 time intervals were significantly shorter in the Lowlands Region (0.95 and 16.20 days), compared to Highlands Region (6.04 [P=0.030] and 34.26 days [P=0.0099]. Excluded from overall TAT calculations was time from caregiver result receipt to ART initiation; of 47 HIV-positive infants, 33 were initiated on ART at an average of 1.32 days (CI=0.31, 5.67; range:-10-56) after result receipt.
Conclusion: From specimen collection to caregiver receipt of test result, average TAT was approximately two months. The longest delay occurred between the time specimen was transferred for diagnostics (in-country or South Africa) and result receipt at district hospital. Short TATs to ART initiation reflect same-day treatment initiation or treatment prior to result receipt for many infants. Interventions to expedite result transfer back to facilities or more in-country testing could shorten intervals allowing faster initiation of infants on life-saving treatment.

M. Gill1,2, H.J. Hoffman2, A. Isavwa3, M. Mokone3, M. Foso3, J.T. Safrit4, A. Tiam3
1Elizabeth Glaser Pediatric AIDS Foundation, Washington, United States, 2George Washington University, Epidemiology and Biostatistics, Washington, United States, 3Elizabeth Glaser Pediatric AIDS Foundation Lesotho, Maseru, Lesotho, 4Elizabeth Glaser Pediatric AIDS Foundation, Los Angeles, United States