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Rashida A. Ndhlovu, Shungu Munyati, Frances M. Cowan, Diana M. Gibb, Elizabeth L. Mother-to-child transmission of human immunodeficiency virus HIV infection was extremely common in southern Africa during the s, and a substantial minority of infected infants have survived to reach adolescence undiagnosed.

Studies have shown a high prevalence of HIV infection in hospitalized adolescents who have features associated with long-standing HIV infection, including stunting and frequent minor illnesses. We therefore investigated the epidemiology of HIV infection at the primary care level. Adolescents aged 10—18 years attending two primary care clinics underwent HIV and Herpes simplex virus-2 HSV-2 serological testing, clinical examination, and anthropometry.

All were offered routine HIV counseling and testing. Unrecognized HIV infection was a common cause of primary care attendance. Routine HIV counseling and testing implemented at the primary care level may provide a simple and effective way of identifying older long-term survivors of mother-to-child transmission before the onset of severe immunosuppression and irreversible complications.

The global incidence of human immunodeficiency virus HIV infection remains high, with nearly 3 million new infections in [ 1 ]. Adult HIV infection prevalence has been at these extremely high rates for the past 10 to 15 years, with even higher rates among pregnant women, resulting in large s of infants being exposed to HIV transmission. Adolescents who present for the first time with features suggesting long-standing HIV infection are an increasingly prominent cause of adolescent morbidity in countries such as Zimbabwe, which has been severely affected since early in the HIV epidemic [ 6—8 ].

We recently reported that hospitalized adolescents in Harare had a high burden of HIV infection, with an adult spectrum of opportunistic infections plus severe complications of untreated pediatric HIV infection, such as chronic lung disease and growth failure [ 9 ]. Inpatient mortality was extremely high, and although most cases were known to be HIV infected by the time of admission, the diagnosis had often been made only a short time earlier, following presentation with severe immunosuppression or irreversible chronic complications [ 9 ].

These findings suggested the need to investigate routine HIV testing at the primary care level as a potential intervention for achieving earlier diagnosis and entry into care. The aims of this current study were to investigate the burden of HIV infection, including ly undiagnosed infection, and to further explore the likely mode of HIV acquisition among adolescents attending primary care services in Harare, Zimbabwe. Study population. Participants were recruited from Epworth and Mabvuku clinics, both primary care polyclinics in the highdensity suburbs of Harare, Zimbabwe, with catchment populations of aboutand 60, people, respectively.

Primary care clinics are run by nurses, and services offered by primary care polyclinics include acute primary care APC as well as antenatal care ANC. ANC attendees, but not all APC attendees, are routinely offered provider-initiated testing and counseling. Single-dose nevirapine to pregnant HIV-infected mothers is offered for prevention of mother-to-child transmission. Patients aged 10 through 18 years attending the primary care clinics for any reason were enrolled consecutively on weekdays during a 6-month period in ANC attendees were included in the study as a control group to investigate the association of factors suggestive of long-term survival following vertical transmission such as stunting, pubertal delay, and maternal orphanhood among APC attendees.

Study procedures.

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All participants were asked to consent to providing blood for anonymized HIV testing for study purposes, and all were offered provider-initiated HIV testing and counseling following group pretesting counseling, either through study personnel for the APC attendees or through the program for the prevention of mother-to-child transmission.

The HIV-infected APC attendees were given a self-administered questionnaire and were asked to choose the most likely source of their HIV infection from the following options: born with it, from injections or blood transfusion, from boyfriend or girlfriend or from husband or wife, or from an unwanted sexual encounter.

Pre-set diagnostic algorithms were adapted from the World Health Organization Integrated Management of Adult and Adolescent Illness to broadly classify the presenting complaints [ 12 ]. All participants had mid-upper arm circumference, height, and weight measured and received a Tanner pubertal staging to assess growth. HIV testing was performed at the clinics in accordance with the national guidelines, by use of 2 rapid tests run in parallel SD Bioline and Abbott Determine.

HIV-positive participants were given cotrimoxazole and were referred for HIV infection care to adolescent clinics at one of the 2 central hospitals in Harare, where CD4 cell counts were determined by flow cytometry CyFlow Counter; Partec. Data analysis. Data were entered and analyzed using Stata 10 StataCorp. However, emancipated minors i.

If there was disagreement between the guardian and adolescent about participating in the study or undergoing diagnostic HIV testing, both were counseled until consensus was reached. Written informed consent and assent was obtained from participants and from guardians. Participants were encouraged to have a guardian present when HIV test were given, but the participant could refuse permission to have their test result disclosed to the guardian.

In reality, refusal to have test disclosed to a guardian did not occur.

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Baseline participant characteristics. Study recruitment and of human immunodeficiency virus HIV testing. PITC, provider-initiated testing and counseling. Burden of undiagnosed HIV infection in primary care. Presenting complaints. The most common presenting complaints in APC patients were diarrhea; ear, nose, or throat infection; and skin infection. Mode of HIV acquisition. As shown in Table 1age and sex did not differ by HIV status, but HIV-infected APC attendees were ificantly more likely to be maternal or double orphans than were their HIV-negative counterparts and ificantly more likely to be stunted.

These associations were not observed for ANC participants, although s were small in this group. The main finding of this study was the substantial burden of ly undiagnosed HIV infection across a wide range of presenting complaints among adolescents attending APC services in Zimbabwe. In common with hospitalized adolescents, HIV-infected primary care attendees had a high prevalence of features suggesting long-standing infection, such as pubertal delay and stunting [ 1617 ], and little to suggest sexual transmission as the predominant cause.

There was an equal sex distribution of HIV infection; a strong association of HIV infection with maternal and double, but not paternal, orphanhood; and a low prevalence of HSV-2 infection. Although HSV-2 seropositivity does not establish an individual's source of infection, HSV-2 infection is a highly prevalent sexually acquired infection in southern Africans that ificantly increases the risk of HIV acquisition [ 111819 ]. As such, it serves here as an independent marker of sexually acquired HIV that can be used to corroborate the self-reported data concerning likely mode of transmission that we collected from our HIV-infected participants.

Zimbabwe is one of the few African countries to have had strong policies to prevent parenteral transmission very early on in the course of the HIV epidemic, with good evidence of effective implementation [ 2021 ]. If maternal transmission is indeed the predominant source of HIV among the acutely unwell adolescents in this study, then the main implications are that there is still a very high burden of undiagnosed long-term survivors in Zimbabwe, and that routine testing of this age group at primary care level is strongly indicated, as discussed below.

Few studies have focused on the spectrum of morbidity related to undiagnosed HIV infection presenting at the primary care level and, to our knowledge, none have focused specifically on adolescents. As in other studies, HIV-infected individuals were ificantly more likely to present with possible tuberculosis [ 22 ] or sexually transmitted infection [ 23 ] and were also more likely to have multiple complaints. However, HIV prevalence was high across the entire spectrum of common presenting complaints, suggesting that provider-initiated testing and counseling should be adopted universally, rather than targeted to specific clinical presentations [ 24 ].

Adolescents face barriers to accessing HIV testing, including the lack of availability of client-initiated HIV testing services and the need for guardian support and consent. At present, the majority of HIV-infected adolescent long-term survivors remain undiagnosed until they develop advanced disease [ 25 ], risking life-threatening illness and chronic complications that may not respond to antiretroviral therapy [ 26—28 ].

Studies have shown that HIV-infected adults commonly consult primary care with HIV-related symptoms before their eventual diagnosis, and children consult primary care services with greater frequency than do adults [ 29 ]. Thus, implementing provider-initiated testing and counseling at the primary care level is likely to have a much greater effect on reducing diagnostic delay and, if linked to prompt entry into HIV care, on improving long-term prognosis than would a similar intervention at hospital level.

The study had several limitations. Our assessment of the likely mode of HIV infection was through a brief questionnaire asking participants to report their likely mode of HIV acquisition. Other studies have shown that adolescents, particularly girls, underreport sexual debut [ 31 ]. Participants may have been unwilling to disclose risk of infection through sexual transmission, and participants' perception of personal risk of being HIV infected may have been influenced by the information obtained during pre-test counseling, particularly regarding vertical HIV infection.

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However, the very low prevalence of HSV-2 in participants selecting nonsexual transmission concurs with data obtained through self-report. We may have overestimated the proportion of HIV-infected adolescents who were newly diagnosed, because those with known HIV infection may preferentially present to their HIV care clinic with complaints.

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Evidence from Zimbabwe suggests that there are increasing s of long-term survivors of mother-to-child transmission who are reaching adolescence, the majority of whom are not yet in HIV care [ 25 ]. This is likely to be generalizable to the region [ 632 ]. The current study adds to the existing literature by demonstrating a high burden of undiagnosed HIV infection, with features suggesting mother-to-child transmission as the predominant source of infection in adolescents presenting to APC services.

Our data strongly support routine implementation of diagnostic HIV testing for younger children as well as older children and adolescents attending primary care services in countries with long-standing generalized HIV epidemics, regardless of the presenting complaint, and possibly universal testing of infants at immunization clinics [ 34 ]. Missing these opportunities will delay identification of vertically infected children, exposing them to avoidable complications of HIV infection.

Legal barriers to testing, such as the age of consent, need to be lowered to support routine testing of adolescents, especially when guardians are not available. There is also a need for frontline service providers to be made aware of the changing epidemiology of HIV infection in older children and adolescents and to be provided with appropriate information to give to affected adolescents and their guardians and siblings.

Potential conflicts of interest. All other authors: no conflicts. Google Scholar. Oxford University Press is a department of the University of Oxford. It furthers the University's objective of excellence in research, scholarship, and education by publishing worldwide. In. Advanced Search. Search Menu. Article. Close mobile search Article. Volume Article Contents Abstract.

FerrandRashida A. Reprints or correspondence: Dr Rashida A.

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