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Challenges in pediatric HIV referral: evidence for PMTCT, infant diagnosis, and pediatric HIV clinic integration in Lilongwe, Malawi
M. Braun1, M. Kabue2, M. Chirwa1, L. Aetker1, P. Chitowe3, M. Eliya3, I. Mofolo1, I. Hoffman1, P. Kazembe2, M. Hosseinipour1
1UNC Project, Lilongwe, Malawi, 2Baylor College of Medicine-Abbott Fund Children's Clinical Centre of Excellence, Lilongwe, Malawi, 3Early Infant Diagnosis Program, Lilongwe, Malawi
Background: PMTCT programs can identify HIV exposed infants, but prompt delivery of HIV positive infants to care requires effective collaboration between PMTCT programs, infant testing programs, and pediatric HIV clinics. We outline the successes and challenges of linking these programs in Lilongwe Malawi.
Methods: Using several electronic and paper-based sources of infant HIV test results, we compiled a list of HIV positive infants and linked PMTCT maternal data, infant testing data, and HIV outcomes for each infant to determine factors associated with successful referral and treatment. All infected infants were referred directly to HIV care.
Results: PMTCT programs in 4 Lilongwe antenatal clinics have tested 46,960 women since June 2006, with 7033 (15%) positive results. During this same time, 5168 infants were tested, with 710 (13.7%) positive results. We traced 146 (20.6%) positive infants to care with a median age at diagnosis of 89 (IQR= 32 - 245) days vs. 159 (IQR = 57-519) days for those not traced to care. Median age at ART clinic presentation was 158 days, with 26.7% presenting with WHO stage 3 or 4 disease, and an early mortality of 11.6%. Testing location was a significant predictor of younger age at both diagnosis and clinic enrollment (p< 0.0001). Challenges identified included incompatible patient identification schema, cumbersome documentation methods, and lack of systematic collaboration among programs resulting in difficulty identifying and tracing patients.
Conclusions: Despite increases in PMTCT, infant diagnosis, and pediatric HIV services, HIV infected infants remain unidentified, do not receive ART services, or present with advanced stage disease. Variability in testing and referral procedures highlights the need for staff training and targeted clinic improvements. Our findings suggest the need for a common electronic patient identification schema and improved patient referral and follow-up systems. Only through integrated systems can we fully understand the barriers to effective pediatric HIV care.
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