Reducing undiagnosed HIV infection among adolescents in sub-Saharan Africa: Provider-initiated and opt-out testing are not enough

Résumé

While identifying individuals with HIV infection and linking them to subsequent antiretroviral (ARV) treatment can be effective in reducing HIV transmission at the population level, these efforts are hampered by the lack of HIV testing uptake among older children and adolescents.The prevalence of undiagnosed HIV infection is significantly higher among older children and adolescents than adults [1], particularly in sub-Saharan Africa, where only 13% of girls and 9% of boys have been tested for HIV and know their results [2].This leads to significant morbidity and mortality among children and adolescents, who are often not diagnosed until the onset of AIDS.Furthermore, these undiagnosed infections continue to drive the epidemic, particularly as adolescents become sexually active.As such, the World Health Organization has prioritized older children and adolescents as a key population for HIV testing [3].The paper by Simms and colleagues [4] appearing in this week's PLOS Medicine examines the impact of an important strategy, provider-initiated testing and counseling (PITC) among older children and adolescents in Zimbabwe. The limitations of PITCA recent systematic review concluded that PITC is the most commonly used strategy for HIV testing to identify undiagnosed children and adolescents, likely because of its seeming ease to implement and its documented high uptake and yield in previous studies [5].The review highlighted that this strategy is more likely to identify those adolescents already showing symptoms of HIV and who may therefore have more advanced disease, which prompts their provider to offer an HIV test [5].However, Simms and colleagues hypothesized that by offering PITC over a 2-year period in primary care settings through an opt-out testing approach, most older children and adolescents living with undiagnosed HIV would likely present for primary care at some point, and thus, this approach would identify a higher proportion of undiagnosed nonsymptomatic HIV infection than is typical of PITC.The authors found that uptake of testing when offered by providers at primary care clinics was relatively high (79.3%),and based on the household survey in areas served by those clinics, they found that 37.7% of HIV-infected patients were previously undiagnosed.Extrapolating from their sample to the target population, they estimate that PITC identified between 18% and 42% of previously undiagnosed children and adolescents in the community.Over one-quarter of older children or adolescents with unknown HIV status who presented to care did not have a parent or suitable guardian with them and hence were not eligible for

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