Superior uptake and outcomes of early infant diagnosis of HIV services at an immunization clinic versus an "under-five" general pediatric clinic in Malawi

Objective: Although the Malawian government recommends HIV-exposed infants receive early infant diagnosis (EID) of HIV at "under-five" pediatric clinics (U5Cs), most never enroll. Therefore, we evaluated the integration of EID testing into an immunization clinic (IC) compared with the current standard of EID testing at an U5C. Design: Prospective observational study. Methods: Using routine provider-initiated HIV testing and counseling (PITC) registers, we prospectively studied 1757 children offered PITC at a government IC and U5C. Infants tested by HIV DNA polymerase chain reaction (PCR) were followed until PCR result disclosure or defaulting. Results: We sampled 877 and 880 consecutive PITC recipients at U5C and IC, respectively. Overall, a 7-fold greater proportion received PITC at IC (84.2% vs. 11.4%, P < 0.001). PITC recipients at IC were more than 14 months younger (2.6 vs. 17.0, P < 0.001), with greater proportions HIV exposed (17.6% vs. 5.3%, P < 0.001) and PCR eligible (7.9% vs. 3.5%, P < 0.001). A higher percentage of IC infants accepted PCR testing (100.0% vs. 90.3%, P = 0.03). Additionally, IC PCR recipients were 2.5 months younger (3.1 vs. 5.6, P < 0.001) with 4 times less testing PCR positive (7.1% vs. 32.1%, P < 0.001). Importantly, a more than 3-fold greater proportion of HIV-exposed infants at IC returned for their PCR result and enrolled into care (78.6% vs. 25.0%, P < 0.001). Conclusions: Compared with an U5C, integrating EID testing into an IC is more acceptable, more feasible, enrolls more infants into EID at younger ages, and would likely strengthen Malawi's EID services if expanded.