title: Implementation and Operational Research: Active Referral of Children of HIV-Positive Adults Reveals High Prevalence of Undiagnosed HIV.
abstract: OBJECTIVE
  Few routine systems exist to test older, asymptomatic children for HIV. Testing all children in the population has high uptake but is inefficient, whereas testing only symptomatic children increases efficiency but misses opportunities to optimize outcomes. Testing children of HIV-infected adults in care may efficiently identify previously undiagnosed HIV-infected children before symptomatic disease.
  
  
  METHODS
  HIV-infected parents in HIV care in Nairobi, Kenya were systematically asked about their children's HIV status and testing history. Adults with untested children ≤12 years old were actively referred and offered the choice of pediatric HIV testing at home or clinic. Testing uptake and HIV prevalence were determined, as were bottlenecks in pediatric HIV testing cascade.
  
  
  RESULTS
  Of 10,426 HIV-infected adults interviewed, 8,287 reported having children, of whom 3,477 (42%) had children of unknown HIV status, and 611 (7%) had children ≤12 years of unknown HIV status. After implementation of active referral, the rate of pediatric HIV testing increased 3.8-fold from 3.5 to 13.6 children tested per month (Relative risk: 3.8, 95% confidence interval: 2.3 to 6.1). Of 611 eligible adults, 279 (48%) accepted referral and were screened, and 74 (14%) adults completed testing of 1 or more children. HIV prevalence among 108 tested children was 7.4% (95% confidence interval: 3.3 to 14.1%) and median age was 8 years (interquartile range: 2-11); 1 child was symptomatic at testing.
  
  
  CONCLUSIONS
  Referring HIV-infected parents in care to have their children tested revealed many untested children and significantly increased the rate of pediatric testing; prevalence of HIV was high. However, despite increases in pediatric testing, most adults did not complete testing of their children.
authors.affiliation: *Department of Global Health, University of Washington, Seattle, WA; †Department of Pediatrics and Child Health, University of Nairobi, Nairobi, Kenya; ‡Research Department, Kenyatta National Hospital, Nairobi, Kenya; §Departments of Global Health, Industrial Engineering, Epidemiology, University of Washington, Seattle, WA; ‖Department of Paediatrics, Kenyatta National Hospital, Nairobi, Kenya; and Departments of ¶Biostatistics; #Global Health, Medicine, Epidemiology and Pediatrics, University of Washington, Seattle, WA.
authors.forename: Anjuli D
authors.initials: AD
authors.lastname: Wagner
authors.forename: Cyrus
authors.initials: C
authors.lastname: Mugo
authors.forename: Irene N
authors.initials: IN
authors.lastname: Njuguna
authors.forename: Elizabeth
authors.initials: E
authors.lastname: Maleche-Obimbo
authors.forename: Kenneth
authors.initials: K
authors.lastname: Sherr
authors.forename: Irene W
authors.initials: IW
authors.lastname: Inwani
authors.forename: James P
authors.initials: JP
authors.lastname: Hughes
authors.forename: Dalton C
authors.initials: DC
authors.lastname: Wamalwa
authors.forename: Grace C
authors.initials: GC
authors.lastname: John-Stewart
authors.forename: Jennifer A
authors.initials: JA
authors.lastname: Slyker
mesh_terms: D000328:Adult; D002648:Child; D002675:Child, Preschool; D003955:Diagnostic Tests, Routine / Q000706:statistics & numerical data; D005260:Female; D015658:HIV Infections / Q000175:diagnosis* / Q000453:epidemiology*; D006302:Health Services Research; D006801:Humans; D007223:Infant; D007630:Kenya / Q000453:epidemiology; D008297:Male; D008403:Mass Screening / Q000706:statistics & numerical data; D010342:Patient Acceptance of Health Care; D010865:Pilot Projects; D015995:Prevalence; D011446:Prospective Studies; D012017:Referral and Consultation