PMTCT, and National's - Health Systems Trust

Current Status of Infant Testing
Currently National DOH Guidelines for infant testing in PMTCT pilot sites indicate that an
ELISA test should be performed at age 12 months. Previously HIV antibody assays were being
performed between 9-12 months but this has shown to generate a large number of false
positives particularly when testing at around 9 months, due to persistence of maternal HIV
antibodies.
A study conducted at King Edward Hospital (KZN) site of the PETRA study showed HIV ELISA
test specificity at 9 months and 12 months of only 59% and 89% respectively 1 . The low specificity
at 9 months suggested the change in policy to delay the rapid test to 1 year (with a repeat
test at 15 months in the event of a positive result). Provincial departments have been asked
to stop testing at 9 months and to ensure that the 1 st antibody HIV test is performed on a child
1 year or older. Despite this recommendation, some provinces such as the Western Cape
continue to test infants at 9 months.
Some experts think that a rapid test at 12 months may still be too early 5 . A study conducted
at the Coronation Hospital in Gauteng showed that 40% of HIV uninfected children tested HIV
ELISA positive at 12 months of age with a lab based ELISA test 4 . Delaying testing further,
however, may be impractical and result in further loss to follow up.
Problems with the Current Testing Protocol
The delay of 1 year in being able to make a reasonably accurate diagnosis in infants has the
following repercussions:
• Unacceptable rates of loss to follow up (in some provinces >50%)
• Inability to adequately evaluate the effectiveness of the PMTCT programme
• Inability to provide appropriate clinical and social support to families
• Immeasurable emotional costs to families waiting for the HIV status of an infant
• Direct and indirect costs of providing co-trimoxazole to HIVnegative babies
• Large numbers (70-94%) of HIV negative babies treated as HIV positive for the first
year of life.
Advantages of Earlier Testing
There are numerous benefits to performing early nucleic acid testing of HIV exposed infants,
which clearly have enormous social implications and will affect management of HIV in these
children, their families, and society. Using earlier NAT would have the following benefits:
• Reduction in the loss to follow up
By offering testing of infants at 6 weeks this would provide some incentive for mothers to
adhere to this follow up visit and they may be more willing to disclose their status in order
for their infant to be tested. Women who learn that their infants are positive at this early
stage may be more motivated to return for frequent clinic visits in order to maintain the
health of their infants and to benefit from ongoing care.
• Improved monitoring of the effectiveness of the PMTCT programme
Earlier testing of infants would enable the National Department of Health to have more
accurate records of HIV transmission rates in which to evaluate programme effectiveness.
This is an important monitoring tool as unacceptably high vertical transmission rates may
be due to problems in other aspects of the programme such as poor uptake of nevirapine,
inappropriate obstetric practices or poor infant feeding counselling.
• Reducing the numbers of children requiring long term follow up by 90%
The HIV status of infants could be tested at a 6 week visit and HIV uninfected children
discharged from specific HIV follow up as early as 10-14 weeks of age with certain provisos.
Only HIV infected children (about 10% of the total HIV exposed, non breastfed children)
would require specific further follow up and prophylaxis for opportunistic infections.
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