Reach, Acceptability, Feasibility and Impact of a Brief Community Health Worker-Administered Index Case Testing Screening Tool "cICT" on Paediatric HIV Case Identification: Results From Malawi.

introductionDespite global initiatives to improve access to life-saving antiretroviral treatment (ART), only 54% of over 900,000 children living with HIV (CLHIV) received treatment in 2021, compared to 85% of women (WLHIV). Without timely ART, half of these children could die before age 2. We describe the design, implementation and outcomes of a child index case testing tool (cICT) that identifies WLHIV with untested children and embeds paediatric follow-up into their HIV care to identify and test their untested children.

methodsThe cICT was a card used to gather information about WLHIV and their children, including ages and HIV status (living with HIV, uninfected, exposed or unknown). Community health workers (CHWs) screened WLHIV 15 years and older at 95 ART clinics in Malawi from September 2020 to August 2023 and referred untested children to HIV testing services. De-identified data were entered in SurveyCTO (Dobility, Inc., MA) to determine WLHIV screened, children's baseline HIV status, new HIV testing completed and newly identified CLHIV. Outcomes included reach (percentage of cohort offered screening), acceptability (percentage accepting cICT) and feasibility (percentage screened who completed child testing). Impact measured the proportion of women with untested children at baseline versus study conclusion, proportion of untested children tested; new CLHIV diagnosed and HIV testing yield.

resultsOf an estimated cohort of 116,000 WLHIV active in care, 101,273 were offered and screened (87% reach, 100% acceptability), 75,262 had at least one child 0-19 years old, with 24% (18,175/75,262) of women having at least one child with unknown HIV status. At study conclusion, only 5% (4606/101,273) of WLHIV had children with unknown status. A total of 193,402 children were listed among 75,262 WLHIV who identified as having children; 39,124 (20%) of the 193,402 children listed were untested. By study conclusion, 28,808/39,124 (74%) of them were tested. Of these, 27,934 children were confirmed HIV uninfected, while 486 were newly diagnosed CLHIV, a 1.7% testing yield.

conclusionsThe cICT was acceptable and feasible to implement, revealing nearly a quarter of WLHIV had children with unknown HIV status. The tool's simplicity and scalability make it a high-impact approach for HIV programmes to quantify, track and confirm the status of HIV-exposed untested children and facilitate timely identification of CLHIV by embedding ICT screening within routine ART care for WLHIV.