Performance of clinical algorithms for HIV-1 diagnosis and antiretroviral initiation among HIV-1-exposed children aged less than 18 months in Kenya.
BACKGROUND
Ninety percent of HIV-1-infected children live in sub-Saharan Africa. In the absence of diagnosis and antiretroviral therapy, approximately 50% die before 2 years.


METHODS
We evaluated sensitivity and specificity of clinical algorithms for diagnosis of HIV-1 infection and antiretroviral therapy initiation among HIV-1-exposed children aged less than 18 months. Children were identified with routine HIV-1 testing and assessed using 3 sets of criteria: (1) Integrated Management of Childhood Illnesses (IMCI), (2) World Health Organization Presumptive Diagnosis (WHO-PD) for HIV-1 infection, and (3) CD4 T-lymphocyte cell subsets. HIV-1 infection status was determined using DNA polymerase chain reaction testing.


RESULTS
A total of 1418 children (median age 5.4 months) were screened for HIV-1 antibodies, of whom 144 (10.2%) were seropositive. Of these, 134 (93%) underwent HIV-1 DNA testing and 80 (60%) were found to be HIV-1 infected. Compared with HIV-1 DNA testing, sensitivity and specificity of the IMCI criteria were 19% and 96% and for WHO-PD criteria 43% and 88%, respectively. Inclusion of severe immune deficiency determined by CD4% improved sensitivity of IMCI and WHO-PD criteria to 74% and 84%, respectively; however, specificity declined to 43% and 41%, respectively.


CONCLUSIONS
Diagnosis of HIV-1 infection among exposed children less than 18 months in a high-prevalence resource-limited setting remains a challenge, and current recommended algorithms have low sensitivity. This underscores the need for rapid scale-up of viral assays for early infant diagnosis.
Inwani
Irene
I
Department of Paediatrics, Kenyatta National Hospital, Hospital Road, Box 29720, Nairobi 00202, Kenya. malweyi@wananchi.com.
Mbori-Ngacha
Dorothy
D
Nduati
Ruth
R
Obimbo
Elizabeth
E
Wamalwa
Dalton
D
John-Stewart
Grace
G
Farquhar
Carey
C
D000328:Adult; D000465:Algorithms; D019380:Anti-HIV Agents / Q000008:administration & dosage / Q000627:therapeutic use*; D003430:Cross-Sectional Studies; D005260:Female; D015483:HIV Antibodies / Q000097:blood; D015658:HIV Infections / Q000175:diagnosis* / Q000188:drug therapy* / Q000635:transmission; D015497:HIV-1; D006801:Humans; D007223:Infant; D018445:Infectious Disease Transmission, Vertical; D007630:Kenya; D008297:Male; D011237:Predictive Value of Tests; D011247:Pregnancy; D015203:Reproducibility of Results; D012680:Sensitivity and Specificity
D019380:Anti-HIV Agents; D015483:HIV Antibodies