Providing parents with HIV testing kits to screen children ‘feasible and accurate’
Research with around 400 parents and caregivers in Zimbabwe found the majority performed HIV tests accurately, even without a demonstration.
A study in Zimbabwe that gave parents and caregivers HIV testing kits to use on their children found most used the kits correctly. Having the test demonstrated beforehand slightly improved performance, but most caregivers used the kits accurately without support.
Around half the 1.8 million children (0-14 years) living with HIV globally in 2019 were either undiagnosed or diagnosed but not on treatment. To help address this, the World Health Organization already recommends healthcare workers use HIV self-testing kits to screen children in community settings. An extension of this would be for caregivers to use testing kits to screen children for HIV at home.
To test how workable this is, researchers offered testing kits to adults living with HIV to screen children and adolescents (aged 2-18) in their households. The adults all attended HIV clinics in Bulawayo city or Matebeleland South, a rural area.
All caregivers had written instructions in English, Shona and Ndebele (75% used local languages). In Phase One (January to December 2018), caregivers had a demonstration of how to use the kit. In Phase Two (January to May 2019), caregivers did not get a demonstration.
Four hundred caregivers (median age 38, 83% female) conducted tests on 786 children (median age 8, 55% female).
Most caregivers used the kits and interpreted results correctly, although having a demonstration slightly improved performance.
Overall, 80% of tests were conducted correctly at each key stage (collecting saliva, inserting the sample into the screening tool, using the kit’s timer, interpreting the result). Around 92% of caregivers who received a demonstration did all four stages correctly, compared to 78% of those who did not have a demonstration.
The proportion that correctly took a saliva swab was 97% with demonstration, 87% without. The proportion that correctly used the kit’s timer was 97% with demonstration, 90% without.
In almost all instances, caregivers correctly interpreted the results (97.5% with a demonstration, 97% without a demonstration).
Among those who did not have a demonstration, all the results interpreted as non-reactive by caregivers were accurate.
Of the 13 results interpreted by caregivers as reactive, which indicates a positive screen for HIV, four were correct (31% accuracy). It is hoped that such errors would be picked up when a caregiver brought their child to a clinic for confirmatory testing, but this may not always happen. The emotional impact of mistakenly believing a test result is reactive should also be considered. It is important to note that no caregivers incorrectly read a reactive result as non-reactive.
Caregivers educated above primary level were more likely to get all testing stages correct than those educated to primary or below.
Fewer than 2% of caregivers who did not receive a demonstration scored the test difficult to perform. Around 40% scored the test very easy to perform and 34% as easy.
Caregivers were more likely to ask for help with the kit when they were told they could. But, when discouraged from asking for help, the majority of caregivers were able to perform the test without asking for help.
No social harms were reported in connection to a reactive result and related HIV diagnosis. But the sample size for this measure is small as very few children were found to be living with HIV.
These findings are like results from similar studies in South Africa and Zimbabwe. This mounting evidence suggests at-home testing is a feasible and accurate way to screen children for HIV and may increase earlier diagnosis.
Operational research is now needed to support at-scale implementation of this strategy. This should also take into consideration the need for rapid and effective linkage to confirmatory testing and HIV care for children with a reactive result.