Achieving optimal treatment for all groups of individuals living with HIV is essential to attaining epidemic control. About 191,395 children and adolescents under 19 are living with HIV (C/ALHIV) with only 46,461 (24%) on treatment in Nigeria. In order to close this treatment gap, the pediatric ART saturation strategy (PASS), was developed between care and treatment team and orphans and vulnerable children (OVC) team to ensure identification and treatment of C/ALHIV and return of children who were lost-to-follow-up (LTFU) in the cascade of care back to HIV treatment.
We conducted HIV risk assessments for OVC and their households during a six-month intervention period (April-September 2019) in Akwa Ibom, Cross River and Lagos state identifying children at risk for HIV. HIV testing and positive results were compared at 6 months pre-intervention and 6 months post-intervention. Pearson Chi Square test was used to determine the difference between the outcome of pre-intervention and post-intervention groups. One-way ANOVA was used to determine the differences in the means of the HIV testing indicator data between the three states at 95% CI and post-Hoc test (Tukey HSD) was used to determine the differences (P < 0.05).
A total of 116,078 children and adolescents across the three states (N = 116078; pre-PASS = 56190, post-PASS=59888) were tested and 3,809 positive C/ALHIV aged < 19, 24% (N = 894) and 77% (N = 2915) were identified pre and post-intervention respectively. Chi square shows a significant difference (χ2 = 919.610, df -1, p < 0.0005) in pre- and post-intervention results for both HIV testing and positive tests. One-way ANOVA shows a significant difference in results between the states: Testing: F = 29617.131, df = 2, p < 0.000579 - (95% CI 13532.79-13884.88) and Positives: F = 2827.303, df = 2, p < 0.0005 (95% CI 679.81-708.48). Post-Hoc test was used to determine where the differences lie. The difference in HIV testing outcome is significant and vary among the three states (P < 0.05).
PASS intervention contributed significantly to HIV outcomes among children in the three states. This integrated strategy of ensuring identification and treatment of C/ALHIV and their return to care should be adopted and scaled up to close the gap in pediatric case finding.
ART: Antiretroviral therapy; C/ALHIV: Children and Adolescents living with HIV; NAIIS: National AIDS Impact and Indicator Survey; OVC: Orphans and vulnerable children; PEPFAR: The President's Emergency Funds for AIDS Relief; PLHIV: People living with HIV
Coverage of critical HIV interventions among children remains low even though evidence reveals that early ART initiation can improve the lives of HIV positive children . Globally, 5 percent of people living with HIV (PLHIV) are children under the age of 15 . Considered under the groups vulnerable to HIV infection, children under 15 also account for about 9 percent of all new infections and 13 percent of all AIDS-related deaths . Ensuring optimal uptake of antiretroviral therapy (ART) among C/ALHIV remains a major challenge to achieving epidemic control of HIV due to inequality in access to treatment. HIV programs in different countries often demonstrate better outcomes with adult ART treatment compared to pediatric ART. For C/ALHIV, there is a concerning, well-known gap in HIV treatment. The World Health Organization (WHO) recognized that children are often not included in successful ART programs . Several factors have been associated with this, ranging from overlooking the pediatric aspect of treatment to inadequate programmatic effort and resources to achieve optimal treatment among children. Globally, out of the 1.7 million CLHIV aged 0-14, only 54 percent were receiving life-saving ART in 2018 constituting a gap of 918,000 (46%) . In Nigeria, the HIV prevalence among persons aged 15-49 is 1.5% according to the NAIIS report with about 1,900,000 PLHIV . Recent statistics estimates HIV prevalence among children and adolescents aged < 19 to be less than 1 percent, equivalent to about 191,395 children and adolescents. Only about 46,461 of them are on treatment through the President's Emergency Plan for AIDS Relief (PEPFAR) program in Nigeria
In order to achieve HIV epidemic control by 2030, HIV interventions and programs must focus on identifying positive C/ALHIV, linking them to treatment and ensuring retention and viral suppression. To achieve this, country programs must estimate the total number of PLHIVs and C/ALHIV, to identify gaps in pediatric treatment. Specific interventions to address such gaps, such as PASS, are required to improve treatment. This is further improved when programs build and implement models that create and strengthen linkages between community and facility programs . The USAID Nigeria PEPFAR program realized the need to develop a robust community-facility strategy between the OVC and facility treatment programs to improve pediatric case finding and ART uptake. Thereupon, the pediatric ART saturation strategy (PASS) was introduced in April 2019. The PASS is a community-focused intervention that uses a family centered approach bringing together community case management, index case testing, and strengthened community-clinic linkage with a health facility point of contact. The approach supports PEPFAR Nigeria's surge efforts in the focus states of Akwa Ibom, Cross River and Lagos. The PEPFAR surge project was developed as a strategic response to ensure that Nigeria meets up with the UNAIDS 90-90-90 target by 2020 for all PLHIV due to significant gaps noticed in universal access to ART and sub-optimal viral load suppression for C/ALHIV on treatment. PASS adopts an integrated service model in providing layered services to Nigeria's priority OVC sub-populations i.e. children and adolescents with the goal of improving pediatric case finding and linkage to ART services. The PASS ensures that eligible children are provided with HIV testing services and positive children followed up to access ART services through a mix of community and facility interventions focused at perceived barriers and drivers to make ART more accessible.
The PASS strategy targeted improvement in pediatric case finding by scaling up identification of new HIV positive children from the community, enrolling C/ALHIV from health facilities who are referred for OVC services and tracking C/ALHIV who were lost to follow up (LTFU) with support of network of PLHIV. PASS also ensured testing at EID points for at risk adolescents' girls and young women (AGYW), especially teenage mothers, adolescents with STI, and out-of-school teenagers. The following strategic approach was utilized for implementation:
1. Case management processes: Identification of eligible OVC using needs and risk assessments at the household level, enrolment into care, case plan development, HIV counselling and testing (HTS), service provision, referrals to ART and other health services and case plan completion.
2. Assisted referral services for clients identified as at risk of HIV to clinic facilities for HTS and ART services.
3. Scaling up case finding and linkage to treatment in communities without a clinic facility and hard to reach areas (such as creeks and riverine communities).
4. Strong collaboration with government at state and local government.
5. Strengthening community - Facility Linkages through partnership with HIV care and treatment implementing partners and OVC implementing partners.
6. Incentivized enrolment and retention in care.
7. Partnership with the care and treatment services, index client tracking (ICT) team and other stakeholders in communities and use of genealogy testing.
The aim of this study is to elucidate the effect of PASS on paediatric case identification in three high burden states in Nigeria.
This community and facility intervention-based study was conducted in three states: Akwa Ibom, Cross River and Lagos, representing the southern region of Nigeria.
This is an uncontrolled interventional study involving OVC under the age of 19 years as the target population. Sample size was non-randomly selected as all children under the age of 19 years at risk of HIV were targeted, screened, tested and those who were positive were enrolled in care. Inclusion criteria included being under 19 years, living with HIV positive biologic parents, children of key population groups, children with history of violence, being enrolled on the OVC program with unknown HIV status, and being LTFU. We conducted family-based testing for biological children of PLHIV and female sex workers (FSW) and linked positive children to treatment.
We conducted HIV risk assessments for those included during the intervention period of six months identifying children at risk for HIV. A comprehensive list of children LTFU was generated at clinic facilities with each child followed up by an OVC case manager embedded at the facility and brought back to care and linked to the OVC program.
Data collection took place in health facilities where we pulled out list of PLHIVs from Retention and Audit Determination Tool (RADET) between April - October 2019. The biological children of these PLHIVs were elicited and tracked after obtaining the consent of the parents and explaining the need to test their children to them. The list of children was collected on an excel sheet. We identified OVCs at high risk of HIV at household level using the modified Banderson tool. All identified high risk children were offered HIV testing and counselling with a rapid two-test algorithm in accordance with Nigeria's national guidelines, with onsite reporting of results. Data was then transported to SPSS version 24 for analysis.
HIV Positive OVC were commenced on antiretroviral therapy and entered into Electronic Medical Record (EMR) where RADET is generated and the National OVC Management Information System (NOMIS), the OVC database after enrollment into the OVC program.
OVC classified as high risk using the modified Bandason tool were tested and those who tested positive were linked to treatment. HIV Testing and positive results 6 months pre-intervention and 6 months post-intervention were compared. Pearson Chi Square test was used to determine the difference between the outcome of pre-intervention and post-intervention groups. One-way analysis of variance (ANOVA) was used to determine the differences in the means of the testing indicator data between the three states at 95% CI. Post-Hoc test (Tukey HSD) was used to determine where the differences lie.
This study involving human participants followed the ethical standards of the Institutional Research Committee and the Helsinki declaration. Consent and permission by a parent, guardian or authorized representative were obtained for the OVC under the age of 18 years. The PEPFAR program in Nigeria also had approval from the IRB to carry out program related research.
We conducted a total of 116,078 HIV tests and identified 3,809 new HIV positive children and adolescents aged < 19 years during the pre-intervention and intervention periods. 56,290 HIV tests were conducted during the first half of the program year (Quarters 1 and 2) preceding the PASS intervention with only 894 new HIV positive children and adolescent identified during that period. During the second half of the program year (Quarters 3 and 4, intervention period) 59,888 tests were conducted, and 2,915 HIV positive children were identified using PASS. Table 1 shows the disaggregation of the indicators by state.
Table 1: Frequency table showing HIV testing uptake and new positives identified among children before and after the PASS intervention disaggregated by state. View Table 1
Table 2 shows that the difference observed in the data was statistically significant (Pearson's Chi square = 919.401, degree of freedom = 1, continuity correction = 918.401, p < 0.05.
Table 2: Chi Square result of the Pass intervention study. View Table 2
Description of the data summary for ANOVA test is shown in Table 3.
Table 3: Descriptive statistics for ANOVA. View Table 3
The difference in HTS outcome differs significantly from one state to the other as shown by Tukey HSD Post Hoc test. Akwa Ibom state outcome is significantly different from those of the other two state. We recorded better outcome in this state (Table 4).
Table 4: Result of Tukey HSD Post-Hoc test for multiple comparison of the outcomes between and within the states. View Table 4
Diagnosis of HIV infection among children has been inadequate because of multiple challenges faced in terms of access to testing and parental consent . This is due in part to lack of necessary investment and resources for adequate testing and development of child and adolescent-friendly care and treatment programs . This study evaluated an intervention to improve the HIV case finding among the age group 2-19. With an estimated 15.2 million children orphaned by HIV/AIDS in Sub-Saharan Africa, the need to scale up and bring HIV testing closer to children who need it the most is critical to the epidemic control of HIV infection . The PASS intervention utilized targeted community-initiated testing and counseling strategies through risk assessment of OVC households to increase HIV testing uptake and case finding among children and adolescents. Pre-intervention period (Quarters 1 and 2) consisted of largely clinical approach for case findings with interventions that does not directly target biological children of PLHIV. Program implementation during this period was also routine and conventional. However, during the six months (Quarters 3 and 4) intervention period, targeted case finding approaches including the introduction of the clinical and OVC integrated collaborative approach (PASS), was introduced which saw about 59, 888 tests being conducted, and the identification of 2,915 HIV positive children.
This study shows up to three-fold increase in the number of children found to be HIV infected, despite a marginal increase in HIV testing with HIV positivity rate of 1.6% at pre-intervention and 4.9% at post intervention. Chi square shows a significant difference in the pre- and post-intervention results for testing and positives. Additionally, we carried out a one-way ANOVA which shows a significant difference in results between the states as seen in Table 3. We showed where the difference lies between the states using a Post-Hoc test which revealed a significant difference in HTS outcome across board (P < 0.05). This finding is consistent with two studies carried out in Cameroon that observed that targeted provider-initiated testing and counselling (PITC) is superior to blanket PITC in HIV case finding in children [8,9]. Findings are also similar to two other studies in Malawi by Simon KR, et al.  and Saeed A, Rachael AK, et al.  that shows that in order to improve pediatric case finding of HIV, a one-size fits all approach for HIV programming would be less effective and therefore targeted and case specific approaches need to be utilized. The finding is also consistent with the Tingathe Surge HIV program in Malawi, where a multi-strategy approach was used to accelerate HIV case finding among pediatrics in Malawi . The success of the intervention can be attributed in part to the fact that testing and treatment services were made available closer to where the children who need them most live with a well-planned social support system involving the OVC community structure in active collaboration and linkage with healthcare facilities. Such collaboration between community and clinic facility systems are often fragile and difficult to implement. We overcame this barrier by scaling up the training of health care workers and community volunteers on HIV testing services and how to ensure effective collaboration in partnership with existing structures at the state level. Active participation of the state government was critical to the success of the intervention which according to this study has been found to be effective. Involvement of OVC households and parents was found to be instrumental in ensuring faster parental consent, higher HIV testing uptake among high risk children and adolescents and overall, better yield. HIV case finding interventions that meet specific needs of the families and are driven by experiences from children-centered heath projects have been found to be successful . This was found to be true also in our study.
Our finding is also consistent with the finding in a similar setting in sub-Saharan Africa where only 31% of children were tested due to factors related to access and acceptability .
This study highlights the significance of a collaborative approach between health care and community infrastructures in order to improve HIV case finding among the pediatric age groups. Case finding among this population has often been a difficult task towards global epidemic control of HIV. According to our findings, utilizing existing program platforms such as the OVC platform has proven to be an effective and possibly cost-efficient way to improve pediatric and adolescent case finding. It also provides critical information for policy makers and program implementers on delivering effective and efficient HIV case finding project among children in Nigeria. Although PMTCT has made significant inroad into the vertical transmission of HIV infection, scale up of case finding of HIV in children and adolescents outside the PMTCT catchment age range is important to reach the goal of identifying at least 90% of children living with HIV and achieve epidemic control in Nigeria.
This study has demonstrated that a collaborative, targeted approach between clinic and community structures is an effective program model in improving HIV case finding among children and adolescent in Nigeria. Scale up of such innovative approach such as the PASS is recommended to fill gaps in pediatric case finding towards global HIV epidemic control.
The authors certify that they have no potential conflict of interest in the subject matter or materials discussed in this manuscript.
The authors thank the facility staff members for their dedication towards ensuring that HIV testing and treatment is provided for all those who need it and also the patients for remaining in care and sharing their opinions on how to implement improved HIV care. This paper would not have been possible without them.
This study has been supported by the U.S. President's Emergency Plan for AIDS Relief (PEPFAR) through the United States Agency for International Development (USAID). The findings, opinions and conclusions in this report are those of the authors in their private capacity and do not necessarily reflect the views of the funding agencies.
Moses Katbi the lead author, led the design and writing of the manuscript and has the most significant contribution. Other authors contributed significantly to project implementation and were also involved in the design of PASS, analysis of results and writing of the manuscript.