Provider-Initiated HIV Testing and Counselling for Children

Prevention of mother-to-child transmission (PMTCT) interventions have significantly reduced vertical HIV transmission but coverage is uneven and substantial gaps remain [1]. The success of PMTCT programs means that most ongoing vertical transmission is likely to be postnatal from mothers not diagnosed antenatally [2]. There is also high post-partum attrition from PMTCT programs especially for infant HIV testing after breastfeeding cessation [3,4]. Evidence that 50% of HIV-infected infants die before their second birthday and that early antiretroviral treatment (ART) significantly reduces morbidity and mortality [5], has led to an appropriate focus on early infant diagnosis (EID), with less emphasis on later testing. However, one-third of vertically infected children may be ‘‘slow progressors,’’ particularly if infected postnatally [6,7]. These children may present late, often with profound immune suppression and end-organ damage [8,9]. In this week’s PLOS Medicine, Rashida Ferrand and colleagues [10] highlight the substantial burden of HIV infection among older children and the barriers to HIV testing in this age group. Previous studies among older children in Zimbabwe and South Africa found HIV prevalence ranging from 3% to 15% depending on the age group and study population [11,12]. Most older children identified as infected have prior missed opportunities for earlier diagnosis, e.g., a known HIVinfected parent or sibling, previous tuberculosis treatment, hospital admission, or repeated presentation with minor infections [13–15]. In 2007, WHO therefore recommended routine testing of inpatients and outpatients in endemic areas [16]. Such routine testing is feasible and acceptable, although implementation and uptake are not universal [11,12]. Barriers to Testing Beyond Infancy