Considerations to Improve Pediatric HIV Testing and Close the Treatment Gap in 16 African Countries

Abstract

Background:
In 2019, South Africa, Nigeria, Tanzania, Democratic Republic of Congo, Uganda, Mozambique, Zambia, Angola, Cameroon, Zimbabwe, Ghana, Ethiopia, Malawi, Kenya, South Sudan and Côte d’Ivoire accounted for 80% of children living with HIV (CLHIV) not receiving HIV treatment. This manuscript describes pediatric HIV testing to inform case-finding strategies.

Methods:
We analyzed US President’s Emergency Plan for AIDS Relief monitoring, evaluation, and reporting data (October 1, 2018 to September 30, 2019) for these 16 countries. Number of HIV tests and positive results were reported by age band, country, treatment coverage and testing modality. The number needed to test (NNT) to identify 1 new CLHIV 1–14 years was measured by testing modality and country. The pediatric testing gap was estimated by multiplying the estimated number of CLHIV unaware of their status by NNT per country.

Results:
Among children, 6,961,225 HIV tests were conducted, and 101,762 CLHIV were identified (NNT 68), meeting 17.6% of the pediatric testing need. Index testing accounted for 13.0% of HIV tests (29.7% of positive results, NNT 30), provider-initiated testing and counseling 65.9% of tests (43.6% of positives, NNT 103), and universal testing at sick entry points 5.3% of tests (6.5% of positives, NNT 58).

Conclusions:
As countries near HIV epidemic control for adults, the need to increase pediatric testing continues. Each testing modality – PITC, universal testing at sick entry points, and index testing – offers unique benefits. These results illustrate the comparative advantages of including a strategic mix of testing modalities in national programs to increase pediatric HIV case finding.

Full text

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The Pediatric Infectious Disease Journal • Volume XX, Number XX, XXX 2022 www.pidj.com | 1
Considerations to Improve Pediatric HIV Testing and Close the
Treatment Gap in 16 African Countries
Jessica Gross , MSN,* Amy Medley, PhD,* National HIV Testing Workgroup,
Emilia Rivadeneira, MD,* Katherine Battey, MPH,* Meena Srivastava, DO,† Michael Grillo, PhD,‡
Hilary Wolf, MD,§ Paige Simmons, BS,¶ Marisa Hast, PhD,* and Monita Patel, PhD*
Background: In 2019, South Africa, Nigeria, Tanzania, Democratic Repub-
lic of Congo, Uganda, Mozambique, Zambia, Angola, Cameroon, Zimba-
bwe, Ghana, Ethiopia, Malawi, Kenya, South Sudan and Côte d’Ivoire
accounted for 80% of children living with HIV (CLHIV) not receiving HIV
treatment. This manuscript describes pediatric HIV testing to inform case-
finding strategies.
Methods: We analyzed US President’s Emergency Plan for AIDS Relief
monitoring, evaluation, and reporting data (October 1, 2018 to September
30, 2019) for these 16 countries. Number of HIV tests and positive results
were reported by age band, country, treatment coverage and testing modal-
ity. The number needed to test (NNT) to identify 1 new CLHIV 1–14 years
was measured by testing modality and country. The pediatric testing gap
was estimated by multiplying the estimated number of CLHIV unaware of
their status by NNT per country.
Results: Among children, 6,961,225 HIV tests were conducted, and
101,762 CLHIV were identified (NNT 68), meeting 17.6% of the pediatric
testing need. Index testing accounted for 13.0% of HIV tests (29.7% of
positive results, NNT 30), provider-initiated testing and counseling 65.9%
of tests (43.6% of positives, NNT 103), and universal testing at sick entry
points 5.3% of tests (6.5% of positives, NNT 58).
Conclusions: As countries near HIV epidemic control for adults, the need
to increase pediatric testing continues. Each testing modality – PITC, uni-
versal testing at sick entry points, and index testing – oers unique benefits.
These results illustrate the comparative advantages of including a strategic
mix of testing modalities in national programs to increase pediatric HIV
case finding.
Key Words: pediatric HIV, testing, risk screening, Africa
(Pediatr Infect Dis J 2022;XX:00–00)
The United States President’s Emergency Plan for AIDS Relief
(PEPFAR), launched in 2003, has supported notable achieve-
ments towards reaching HIV epidemic control in many countries.
However, significant gaps in case identification remain, particularly
among children, adolescent girls and young women (15–29 years),
and men.1 Only 53% of the estimated 1.8 million children living
with HIV (CLHIV) <15 years globally were receiving life-saving
antiretroviral therapy (ART) in 2019.2 Sixteen sub-Saharan Afri-
can countries accounted for 80% of this treatment gap, or approxi-
mately 668,500 CLHIV not yet on ART.3
One of the main challenges hindering pediatric treat-
ment coverage is suboptimal early infant diagnosis (EID), which
increases the need for HIV testing beyond infancy. In 2019, there
were an estimated 150,000 new pediatric HIV infections.1 The
United Nations Children’s Fund estimated only 58.8% of HIV-
exposed infants had received virologic testing by 2 months1 due to
numerous health systems challenges4 with poorer coverage histori-
cally aecting diagnoses among CLHIV now 1-14 years. PEPFAR-
supported programs identified 17,080 infants living with HIV in
2019,5 accounting for approximately 11% of new pediatric infec-
tions. Recent trends indicate most new pediatric HIV infections
ISSN: 0891-3668/22/XXXX-0000
DOI: 10.1097/INF.0000000000003778
Copyright © 2022 Wolters Kluwer Health, Inc. All rights reserved.
HIV R
Accepted for publication October 26, 2022
From the *Division of Global HIV and TB (DGHT), U.S. Centers for Disease Con-
trol and Prevention (CDC), Atlanta, Georgia; †Division of Prevention Care and
Treatment, Pediatric Maternal Clinical Branch (PMCB), Oce of HIV/AIDS,
United States Agency for International Development (USAID), Washington, D.C.;
‡Department of Defense (DOD) HIV/AIDS Prevention Program, Defense Health
Agency, San Diego, California; §Oce of Program Quality, Oce of the Global
AIDS Coordinator and Health Diplomacy, U.S. State Department, Washington,
D.C.; and ¶Department of Health Policy and Management, Rollins School of Pub-
lic Health, Emory University, Atlanta, Georgia.
LWW
National HIV Testing Workgroup: Georey Taasi, MPH (Uganda Ministry of Health,
Kampala, Uganda), Esther Nazziwa, MMed (DGHT, CDC, Kampala, Uganda),
Madina Apolot, MSc (DGHT, CDC, Kampala, Uganda), Esther Nkolo, PhD
(PMCB, USAID, Kampala, Uganda), Peris Urasa, MPH (National AIDS Control
Programme, Ministry of Health, Community Development, Gender, Elderly and
Children, Dodoma, Tanzania), Margreth Kagashe, MPH (National AIDS Con-
trol Programme, Ministry of Health, Community Development, Gender, Elderly
and Children, Dodoma, Tanzania), Edward Machege, MD (DGHT, CDC, Dar es
Salaam, Tanzania), Oscar Rwabiyago, MD (DGHT, CDC, Dar es Salaam, Tan-
zania), Fredrick Rwegerera, MD (PMCB, USAID, Dar es Salaam, Tanzania),
Zoraima Neto, PhD (DGHT, CDC, Luanda, Angola), E. Amaka Nwankwo-Igomu,
DrPH (U.S. Embassy, Luanda, Angola), Magdalene Mayer, MD (DGHT, CDC,
Yaoundé, Cameroon), Valery Nzima, MD (PMCB, USAID, Yaoundé, Camer-
oon), Aka Kouame Herve Prao, MD (DGHT, CDC, Abidjan, Cote d’Ivoire),
Lucie Dagri, MS (PMCB, USAID, Abidjan, Cote d’Ivoire), Henri Longuma, MPH
(DGHT, CDC, Kinshasa, Democratic Republic of Congo), Wondimu Teferi, MD
(DGHT, CDC, Addis Ababa, Ethiopia), Chanie Temesgen, MD (DGHT, CDC,
Addis Ababa, Ethiopia), Tsegaye Tilahun, MPH (PMCB, USAID, Addis Ababa,
Ethiopia), Silas Quaye, MPH (DGHT, CDC, Accra, Ghana), Ekua Houphouet,
MPH (PMCB, USAID, Accra, Ghana), Lennah Nyabiage, MMed (DGHT, CDC,
Nairobi, Kenya), Immaculate Mutisya, MMed (PMCB, USAID, Nairobi, Kenya),
Teresa Simiyu, MSc (PMCB, USAID, Nairobi, Kenya), Samson Anangwe,
MScPH (Defense Health Agency, Nairobi, Kenya), Dumbani Kayira, MBBS
(DGHT, CDC, Lilongwe, Malawi), Gerald Zomba, MPH (PMCB, USAID, Lilon-
gwe, Malawi), Owen Kumwenda, MPH (PMCB, USAID, Lilongwe, Malawi),
Maria Ines de Deus, MD (DGHT, CDC, Maputo, Mozambique), Mercia Matsinhe,
MD (PMCB, USAID, Maputo, Mozambique), Bilkisu Ibrahim Jibrin (Federal
Ministry of Health, Abuja, Nigeria), Omodele Johnson Fagbamigbe, MBCHB
(DGHT, CDC, Abuja, Nigeria), Onyeka Igboelina (PMCB, USAID, Abuja, Nige-
ria), Dolapo Ogundehin (PMCB, USAID, Abuja, Nigeria), Gurpreet Kindra, PhD
(DGHT, CDC Pretoria, South Africa), Hlamalani Mabasa (PCMB, USAID, Preto-
ria, South Africa), John Mondi, MD (DGHT, CDC), Sudhir Bunga, MD (DGHT,
CDC), Nicholas Baabe, MD (Juba, South Sudan; PCMB, USAID, Juba, South
Sudan), Kebby Musokotwane, MSc (DGHT, CDC, Lusaka, Zambia), Megumi Itoh,
MD (DGHT, CDC, Lusaka, Zambia), Godfrey Lingenda, MD (PCMB, USAID,
Lusaka, Zambia), Talent Maphosa, MD (DGHT, CDC, Harare, Zimbabwe),
Solomon Mukungunugwa, MD (PCMB, USAID, Harare, Zimbabwe).
The findings and conclusions are those of the author(s) and do not necessarily
represent the ocial position of the US Centers for Disease Control and
Prevention or the US Agency for International Development.
This study was supported by the US President’s Emergency Plan for AIDS Relief
through the U.S. Centers for Disease Control and Prevention and the U.S.
Agency for International Development.
The authors have no conflicts of interest to disclose.
J.G., M.P., E.R. and A.M. led the study design. K.B., M.H. and J.G. extracted
the data. J.G. and M.H. conducted data analysis and developed visualiza-
tions. J.G., A.M. and P.S. drafted the manuscript. All co-authors reviewed the
manuscript and approved the final version.
Address for correspondence: Jessica M. Gross, Division of Global HIV and TB,
U.S. Centers for Disease Control and Prevention, 1600 Clifton Road, Atlanta,
GA 30329. E-mail: lst3@cdc.gov.
Supplemental digital content is available for this article. Direct URL citations
appear in the printed text and are provided in the HTML and PDF versions of
this article on the journal’s website (www.pidj.com).

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Gross et al
occur during breastfeeding.6 The HIV risk among infants is particu-
larly high following maternal acquisition of HIV during the breast-
feeding period.7,8 However, many CLHIV remain undiagnosed due
to poor implementation of maternal re-testing9–11 and misconcep-
tions among frontline workers that older children are not at risk
for HIV.12
The World Health Organization (WHO) and PEPFAR rec-
ommend a combination of index testing, provider-initiated testing
and counseling (PITC), and universal testing of sick children to
identify undiagnosed CLHIV.13,14 Index, or exposure-based, test-
ing oered to the biological children of parents or siblings living
with HIV facilitates the identification of well CLHIV before they
develop symptoms.13,15,16 While PEPFAR supports exposure-based
screening, testing for children is not dependent on maternal sta-
tus alone, given challenges with stigma, disclosure, and mothers
working in distant geographic locations, to avoid delays in pediat-
ric HIV diagnoses. PEPFAR support for targeted PITC using HIV
risk screening in outpatient and routine well-child health services,
orphan and vulnerable children (OVC) programs, and voluntary
medical male circumcision (VMMC) settings started in October
2019. Testing in VMMC programs confirms an individual’s status
to provide relevant program interventions. While not considered a
case-finding approach, many boys 10–14 were newly diagnosed
through VMMC programs. PEPFAR guidance supported the use
of screening tools in age groups with low HIV risk17 and recom-
mended increasing the minimum age for VMMC to ≥15 years
from ≥10 years,14 starting October 2020. Ideal screening tools
would decrease the number needed to test (NNT) to identify 1
new CLHIV in these entry points while maintaining the overall
number of CLHIV diagnosed.17,18 HIV risk screening tools assess
signs, symptoms, or medical history to prioritize children for test-
ing,14,17,19–21 yet risk missing some CLHIV depending on tool sensi-
tivity.21 Although WHO recommends HIV testing among children
in health facilities in inpatient and outpatient departments, PITC
implementation has faced several challenges, especially in outpa-
tient settings.12,22–26 Universal testing, or the testing of all children
without a documented HIV status, is recommended for all children
who are hospitalized, infected with tuberculosis (TB) or malnour-
ished in generalized epidemics13,27 due to high HIV-positivity.28–32
While universal testing at sick entry points remains important, it
typically identifies children late in disease progression when they
are already symptomatic with advanced disease.33
PEPFAR-supported country programs report monitoring,
evaluation, and reporting (MER) indicators quarterly to a central
repository. These data facilitate close monitoring of pediatric HIV
testing by age band and testing modality. This manuscript high-
lights pediatric testing gaps in programs supported by PEPFAR and
provides considerations to improve pediatric case findings.
MATERIALS AND METHODS
We analyzed routine program MER data from October 1,
2018 to September 30, 2019 (fiscal year, FY19) for children 1–14
years from 16 sub-Saharan African countries: South Africa, Nige-
ria, Tanzania, Democratic Republic of Congo (DRC), Uganda,
Mozambique, Zambia, Angola, Cameroon, Zimbabwe, Ghana,
Ethiopia, Malawi, Kenya, South Sudan, and Côte d’Ivoire. Infants
<1 year were excluded because their virologic testing results are
reported through a dierent EID MER indicator monitoring the
prevention of mother-to-child transmission. Countries were purpo-
sively selected because they account for 80% of the pediatric treat-
ment gap. MER data represent sub-national regions (eg, provinces,
districts) receiving PEPFAR support, which varies by country. The
Joint United Nations Programme on HIV/AIDS (UNAIDS) data
were used to estimate the pediatric HIV treatment coverage by
country and number of CLHIV, not on treatment (1 − % CLHIV
on treatment = estimated % treatment gap; UNAIDS country
CLHIV estimate × % on treatment = estimated number CLHIV
on treatment).3 National HIV testing guidelines and the Barr-
DiChiara updated review34 were used to classify countries into 2
categories according to the age of consent for HIV testing (<15
and ≥15 years). Countries were categorized by treatment coverage
(% CLHIV receiving ART) into 3 categories (<50%, 50–69% and
≥70%).
Descriptive statistics were used to calculate the total num-
ber of HIV antibody tests conducted, positive test results, and
newly diagnosed CLHIV initiated on ART. Proxy linkage was
calculated, using (aggregate # CLHIV new on ART/aggregate #
positive test results), due to the inability to measure ART initia-
tion rates at the individual level among children newly diagnosed.
NNT, which provides realistic expectations for frontline HIV test-
ing counselors of the number of tests needed to diagnose a new
CLHIV, was measured by testing modality, age band, and coun-
try; (# HIV tests/# positive results).35 Like testing yield, NNT is
aected by serval factors, including the proportion of undiagnosed
PHLIV in various settings, testing and ART coverage, and testing
modality. The estimated pediatric testing gap (FY19 NNT × the
estimated number of CLHIV unaware of their HIV status) and
proportion of pediatric HIV testing need met (# tests conducted/#
estimated tests needed) were calculated by country, region, and
ART coverage. The proportion of HIV tests (# HIV number of
tests conducted in a modality/total # of tests conducted) and posi-
tive test results (# positive results in a modality/ total # of positive
results across all modalities) were calculated by modality. Results
were disaggregated by age band (1–4, 5–9, 10–14 years), testing
approach (index testing in facility and community settings; PITC
in outpatient, pediatric under-5 clinics, and VMMC settings; and
universal testing in TB, inpatient and malnutrition entry points),
geographic sub-region (Eastern and Southern Africa and Western
and Central Africa), ART coverage, and age of consent for HIV
testing.
RESULTS
Ten of the 16 countries responsible for the largest pediat-
ric treatment gaps were in Eastern and Southern Africa (Table1).
Four countries had a pediatric ART coverage of ≥70%, includ-
ing Kenya (81%), Mozambique (72%), Zimbabwe (71%) and
Malawi (70%). The gap in pediatric HIV treatment ranged from
approximately 12,000 in Côte d’Ivoire to 175,000 in South
Africa. South Africa, Nigeria, Tanzania and DRC had the largest
numbers of CLHIV (<15 years) not on treatment. While coun-
tries in Eastern and Southern Africa met 23.8% of their esti-
mated pediatric HIV testing need, Mozambique (45.6%), Kenya
(41.4%) and Zambia (37.5%) exceeded the regional average.
Countries in West and Central Africa met 7.0% of their esti-
mated testing need, while Cote d’Ivoire (17.2%) and Nigeria
(10.7%) exceeded the regional average. Age of consent for HIV
testing ranged from 12 years in South Africa and Uganda to 18
years in Nigeria, DRC and South Sudan, and 72.2% of HIV tests
among children 1–14 years were in countries where age of con-
sent was ≥15 years.
In FY19, PEPFAR reported 6,961,225 HIV tests among
children: 33.7% for children 1–4 years, 24.9% (5–9 years) and
41.4% (10–14 years) (Table2) across supported sites. There were
101,762 positive HIV tests (63.0%) among school-aged children
(5–14 years). Twenty fewer tests were needed to identify 1 new
CLHIV 1–4 years (NNT 62) or 5–9 years (NNT 60) compared with
a new CLHIV 10–14 years (NNT 82). The mean proxy linkage to
ART rate for all newly diagnosed CLHIV 1–14 years was 80.5%,

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The Pediatric Infectious Disease Journal • Volume XX, Number XX, XXX 2022
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Considerations to Improve Pediatric HIV Test
highest (89.6%) among younger children (1–4 years) and lowest
(66.5%) among younger adolescents (10–14 years).
The Western and Central Africa sub-region accounted for
14.6% of HIV tests (Table2). Although HIV prevalence is generally
lower in Western and Central Africa, NNT was similar in countries in
Western and Central Africa (NNT 65, range NNT17–NNT157) and
Eastern and Southern Africa (NNT 69, range NNT56–NNT122).
Nine countries with <50% ART coverage—South Africa, South
Sudan, Ethiopia, Nigeria, DRC (geographical coverage for PEP-
FAR DRC includes support for 3 of 26 provinces). Angola, Ghana,
Cameroon, and Cote d’Ivoire—accounted for 32.4% of HIV tests
(2,256,924), 11.2% of their pediatric testing need met and 36,978
positive tests (36.3% of positive results). Four countries with ≥70%
ART coverage accounted for 35.1% of HIV tests (2,445,923),
34.3% of their pediatric testing need met, and 33,151 positive tests
(32.6% of positive results). While 68 tests were needed to identify 1
new CLHIV, the ratio of tests per CLHIV unaware of their status for
the 9 countries with <50% ART coverage was much lower (4.6 tests
per CLHIV unaware of their status) compared with the 4 countries
with ≥70% ART coverage (16.4 tests per CLHIV unaware of their
status). The proxy linkage rate, however, was higher for countries
in Western and Central African (88.7%) than Eastern and Southern
Africa (79.0%).
PITC accounted for 65.9% of tests and 43.6% of positive
test results (Table 3). The PITC NNT (103) was higher than the
overall NNT (68) to identify one new CLHIV. Nearly half of all
pediatric HIV testing (46.6%) occurred in outpatient departments
(OPD). Pediatric (<5 years) well-child clinics accounted for 6.4%
of tests and 4.5% of positive results. VMMC programs accounted
for 12.8% of tests and 6.1% of positive results with 99.5% of tests
and 99.9% of positive results among boys 10-14 years. South Africa
(20.6%), Mozambique (20.6%), and Uganda (20.7%) accounted
for more than half of the testing conducted in VMMC, and South
Africa (59.8%) and Mozambique (24.0%) accounted for over two-
thirds of positive results.
Index testing accounted for 13.0% of HIV tests and 29.7% of
positive test results (NNT 30). The proportion of tests from facility-
based index testing was nearly 3 times higher (667,027 tests) than
community-based index testing (239,820 tests). The NNT for index
testing was low in facility (28) and community (37) settings. Index
testing accounted for ≥20% of positive test results for all coun-
tries except South Africa (10%), Angola (18%), Uganda (19%) and
Ghana (19%) (Fig. 1). Index testing identified 32% less CLHIV
(30,199) compared with PITC (44,375) due to the larger number
of children tested through PITC. The proportion of tests conducted
using index testing was lowest in South Africa (4%), Uganda (4%)
and Nigeria (5%) (Fig.1).
Universal testing at sick entry points accounted for 5.3%
of tests and 6.5% of positive results (NNT 58). Nearly half of the
CLHIV identified through universal testing were diagnosed in inpa-
tient settings (3482 CLHIV), followed by TB (2896 CLHIV). The
NNT was lowest for HIV testing overall in TB.16 Inpatient NNT was
86 and malnutrition NNT was 75.
NNTs varied across HIV testing modalities and countries
(Fig.2). For PITC, the NNT was highest in OPD (NNT 96) and pedi-
atric under-5 clinics (NNT 101). For OPD, the NNT was lower in
countries implementing screening tools, including Ghana (NNT 17),
DRC (NNT 50), Zimbabwe (NNT 51) and Uganda (NNT 56). These
4 countries implementing risk screening accounted for 6.6% of OPD
tests and 12.4% of OPD positives (OPD NNT 52) compared with
the other 12 countries (OPD NNT 102). Index testing required 50%
less testing (NNT 30) to identify a CLHIV compared with pediatric
HIV testing overall (NNT 68). The NNT was lowest for index testing
in Ghana (NNT 9), Nigeria (NNT 10), DRC (NNT 11) and Angola
(NNT 13)—countries with the lowest pediatric ART coverage.
DISCUSSION
Key considerations for pediatric HIV testing programs are
important across testing modalities (Figure, Supplemental Digital
TABLE 1. Sixteen Countries With the Largest Pediatric HIV Testing and Treatment Gaps by Geographic Sub-
region, 2019, and Age of Consent for HIV Testing
Adult HIV Preva-
lence* (15–49 yr)
(Uncertainty Bounds) Estimated Number of CLHIV*
(0–14 yr) (Uncertainty Bounds)
Estimated
CLHIV Una-
ware of Their
Status*
Estimated Test-
ing Gap (NNT x #
CLHIV Unaware)
Estimated
Number of
CLHIV on
ART*
Pediatric
ART Cov-
erage*
Age of
Consent for
HIV Test-
ing (yr)†,34
Eastern and Southern Africa
South Africa 19.3% (12.2–25.0%) 330,200 (205,700–547,800) 86,600 4,850,400 156,200 47.3% 12
Tanzania 4.8% (4.5–5.1%) 121,100 (101,100–139,200) 57,900 4,171,900 61,200 50.6% 16
Uganda 5.7% (5.3–6.0%) 106,300 (95,200–119,300) 40,100 3,731,900 66,200 62.3% 12
Mozambique 11.7% (9.4–14.6%) 132,800 (104,400–179,800) 37,800 2,302,800 95,100 71.6% 15
Zambia 11.3% (10.8–11.8%) 85,600 (76,700–95,100) 35,300 2,190,800 50,200 58.7% 16
Zimbabwe 12.4% (11.1–13.7%) 84,300 (71,100–98,900) 24,500 1,469,100 59,800 71.0% 16
Ethiopia 0.9% (0.7–1.1%) 47,900 (32,000–67,100) 28,800 2,624,700 19,100 39.8% 15
Malawi 8.5% (8.0–8.8%) 68,600 (57,000–78,200) 20,600 1,299,300 48,000 69.9% 13
Kenya 4.4% (3.8–5.1%) 90,000 (72,700–114,700) 16,900 2,064,600 73,100 81.2% 15
South Sudan 2.3% (1.8–2.9%) 15,800 (11,500–20,700) 13,900 833,000 1900 12.0% 18
Subtotal 7.4% (4.7–9.5%) 1,082,500 (674,400–1,796,200) 362,400 25,014,700 630,700 58.3%
Western and Central Africa
Nigeria 1.3% (1.0–1.8%) 128,500 (85,800 (194,300) 75,000 4,123,000 53,500 41.7% 18
DRC 0.8% (0.7–0.9%) 74,200 (59,400–88,200) 51,400 1,438,300 22,800 30.8% 18
Angola 1.8% (1.6–2.2%) 40,200 (32,700–50,000) 35,100 702,500 5100 12.7% 15
Cameroon 3.1% (2.8–3.3%) 36,600 (29,200–42,500) 26,200 3,356,200 10,400 28.4% 14
Ghana 1.7% (1.5–2.0%) 30,100 (23,900–36,300) 23,400 398,300 6600 22.1% 16
Cote d’Ivoire 2.2% (1.9–2.5%) 23,500 (18,400–29,400) 12,100 1,905,800 11,300 48.3% 16
Subtotal 1.4% (1.1–1.9%) 333,100 (222,300–503,700) 223,200 14,510,700 109,800 33.0%
*AIDSinfo | UNAIDS [Internet]. 2021 [cited 2021 Oct 5]. Available from: https://aidsinfo.unaids.org/ (data source for HIV prevalence, PLHIV and CLHIV estimates, and ART
coverage and gap estimates by country). All figures are rounded to the nearest 100 to reflect level of precision.
†Most countries allow emancipated minors, including adolescents that are sexually active, married or living with a partner, head of household, or pregnant, among other condi-
tions, to consent to HIV testing.

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The Pediatric Infectious Disease Journal • Volume XX, Number XX, XXX 2022
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Gross et al
Content 1, http://links.lww.com/INF/E875). While countries deter-
mine what proportion of the estimated testing need is feasible to
program annually, the ratio of HIV tests per CLHIV unaware of
their status was low across countries, indicating the need for more
pediatric testing overall. The testing ratio was lowest in countries
with <50% pediatric ART coverage with the majority located in
the West and Central Africa sub-region, highlighting the need to
increase pediatric HIV testing in these settings. Low-prevalence
TABLE 2. Pediatric HIV Testing, Linkage and Treatment Cascade by Age, Geographic Sub-region, National ART
Coverage, and Age of Consent for Testing in 16 PEPFAR-funded Countries, October 1, 2018 to September 30, 2019
Number of HIV
Tests Conducted % Pediatric HIV
Testing Need Met Number of Posi-
tive Test Results NNT* Number of PLHIV† New
on HIV Treatment Proxy Linkage
Rate‡
Age (1–14 yr) (%) 6,961,225 17.6% 101,762 68 81,926 80.5%
1–4 2,342,723
(33.7%) — 37,651
(37.0%) 62 33,750
(41.2%) 89.6%
5–9 1,735,040
(24.9%) — 28,747
(28.2%) 60 24,672
(30.1%) 85.8%
10–14 2,883,492
(41.4%) — 35,364
(34.8%) 82 23,504
(28.7%) 66.5%
Sub-region or country (%)
Eastern and Southern Africa 5,945,318
(85.4%) 23.8% 86,101
(84.6%) 69 68,027
(83.0%) 79.0%
South Africa 1,108,589
(15.9%) 22.9% 19,695
(19.4%) 56 11,374
(13.9%) 57.8%
Mozambique 1,049,816
(15.1%) 45.6% 17,282
(17.0%) 61 12,751
(15.6%) 73.8%
Kenya 854,915
(12.3%) 41.4% 7034
(6.9%) 122 6158
(7.5%) 87.5%
Uganda 441,806
(6.3%) 11.8% 4726
(4.6%) 93 6043
(7.4%) 127.9%
Tanzania 994,436
(14.3%) 23.8% 13,751
(13.5%) 72 11,348
(13.9%) 82.5%
Zimbabwe 281,296
(4.0%) 19.1% 4697
(4.6%) 60 3680
(4.5%) 78.3%
Ethiopia§ 103,840
(1.5%) 4.0% 1144
(1.1%) 91 1670
(2.0%) 146.0%
Malawi 259,896
(3.7%) 20.0% 4138
(4.1%) 63 4419
(5.4%) 106.8%
Zambia 822,166
(11.8%) 37.5% 13,156
(12.9%) 62 10,155
(12.4%) 77.2%
South Sudan 28,558
(0.4%) 3.4% 478
(0.5%) 60 429
(0.5%) 89.7%
Western and Central Africa 1,015,937
(14.6%) 7.0% 15,661
(15.4%) 65 13,899
(17.0%) 88.7%
Nigeria 442,908
(6.4%) 10.7% 8079
(7.9%) 55 7291
(8.9%) 90.2%
DRC§ 90,733
(1.3%) 6.3% 3265
(3.2%) 28 2981
(3.6%) 91.3%
Angola 18,244
(0.3%) 2.6% 918
(0.9%) 20 569
(0.7%) 62.0%
Cameroon 131,454
(1.9%) 3.9% 1024
(1.0%) 128 906
(1.1%) 88.5%
Ghana 4833
(0.1%) 1.2% 287
(0.3%) 17 248
(0.3%) 86.4%
Cote d’Ivoire 327,765
(4.7%) 17.2% 2088
(2.1%) 157 1904
(2.3%) 91.2%
ART coverage¶
<50% 2,256,924
(32.4%) 11.2% 36,978
(36.3%) 61 27,372
(33.4%) 74.0%
50%–69% 2,258,408
(32.4%) 22.4% 31,633
(31.1%) 71 27,546
(33.4%) 86.0%
≥70% 2,445,923
(35.1%) 34.3% 33,151
(32.6%) 74 27,008
(33.0%) 81.0%
Age of consent (yr)‖
<15 1,941,745
(27.9%) 14.7% 29,583
(29.1%) 66 22,742
(27.8%) 76.9%
≥15 5,019,510
(72.1%) 19.1% 72,179
(70.9%) 70 59,184
(72.2%) 82.0%
*NNT to identify 1 new CLHIV (eg, the number of tests divided by the number of positive test results).
† PLHIV = people living with HIV.
‡ Proxy linkage rate = percent of newly diagnosed children linked to HIV treatment divided by the total number of newly diagnosed children.
§ PEPFAR supports 3 of 26 provinces in DRC; PEPFAR Ethiopia noted the majority of tests and results were not reported for the outpatient modality in FY19, which contributed
to the high proxy linkage.
¶ ART coverage: <50%: South Sudan, Angola, Ghana, Cameroon, DRC, Ethiopia, Nigeria, South Africa, Cote d’Ivoire; 50%-69%: Tanzania, Uganda, Zambia; ≥70%: Malawi, Zim-
babwe, Mozambique, Kenya.
‖ Age of consent: <15: South Africa, Uganda, Cameroon, Malawi; ≥15: Ethiopia, Kenya, Angola, CDI, Nigeria, Mozambique, Zambia, Zimbabwe, DRC, Tanzania, Ghana, South
Sudan.

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The Pediatric Infectious Disease Journal • Volume XX, Number XX, XXX 2022
© 2022 Wolters Kluwer Health, Inc. All rights reserved. www.pidj.com | 5
Considerations to Improve Pediatric HIV Test
countries, like Ethiopia, DRC, Nigeria, Ghana and Angola, can
continue to strengthen the routine identification of pregnant women
living with HIV to decrease maternal-to-child transmission of HIV,
which ranges from 17% to 25% in these countries.1 Ethiopia’s
extremely low HIV prevalence (0.9%) means pediatric programs
test more children across modalities to identify 1 new CLHIV
(Fig.2).
Although several countries in Eastern and Southern Africa
are close to achieving 90% of PLHIV overall knowing their status,
awareness for CLHIV lags substantially. In Eastern and Southern
Africa, 78% of adults were on treatment versus 57% of CLHIV
with 95% of pregnant women living with HIV on ART. Disparities
were even larger in Western and Central Africa where only 35% of
CLHIV were on treatment versus 77% of adults with only 56% of
pregnant women living with HIV on ART.3,36 Countries with low
pediatric ART coverage (eg, South Africa, Nigeria, Ghana, South
Sudan and Angola) or low ART coverage among pregnant women
living with HIV and high rates of MTCT (eg, DRC, Nigeria, Angola,
Ghana and Ethiopia, where MTCT ranges from 17% to 25%1) can
scale up pediatric HIV testing, specifically index testing coverage
for biological children of PLHIV and siblings of CLHIV to prevent
delays in HIV diagnosis, which can lead to excess morbidity and
mortality.37–40 It is important to ensure PEPFAR programs support
host country governments and partners to prioritize a mix of facil-
ity and community testing approaches to address barriers to testing
and allocate pediatric targets and budgets that adequately address
the HIV testing and treatment gaps among children.
This analysis shows many children (63%) are diagnosed
later in childhood (school-aged, 5–14 years), reinforcing the need
for programs, providers and parents to test older children.41–43
Countries can simultaneously work to strengthen EID and maternal
retesting, while expanding testing options for school-age children
5–14 years. A pooled analysis from 12 studies showed children
infected through breastfeeding have a longer net survival (25%
alive at 16.9 years), even in the absence of HIV treatment, than
those infected perinatally (25% alive at 10.6 years).44 Similarly, a
study in Kenya found routine screening for children 10–14 years
increased testing by 2.7 times and case identification by 2.4 times,
indicating under-testing among eligible older children.20 Program-
matically, countries may consider retraining frontline healthcare
workers to consider HIV as an underlying diagnosis for older chil-
dren 5–14 years. High-prevalence countries may consider policies
to ensure all children entering school have a documented HIV sta-
tus, or have received risk screening for underlying HIV infection,
and oered HIV testing. This approach is currently being piloted
in Zambia (Chalilwe Chungu, MD, email communication, June
TABLE 3. Key Outcomes by HIV Case Finding Modality, October 1, 2018 to September 30, 2019
Number of HIV
Tests Conducted Proportion of HIV
Tests Conducted* Number of Posi-
tive HIV Tests Proportion of Positive
HIV Tests† NNT‡
PITC 4,589,157 65.9% 44,375 43.6% 103
Outpatient (OPD) 3,247,106 46.6% 33,745 33.2% 96
Pediatric (<5 yr) Clinics 447,931 6.4% 4453 4.5% 101
VMMC 894,120 12.8% 6177 6.1% 145
Index 906,847 13.0% 30,199 29.7% 30
Index facility 667,027 9.6% 23,654 23.9% 28
Index community 239,820 3.4% 6545 6.5% 37
Universal 366,778 5.3% 6653 6.5% 58
TB 45,109 0.6% 2896 2.9% 16
Inpatient 301,180 4.3% 3482 3.6% 86
Malnutrition 20,489 0.3% 275 0.3% 75
*Proportion of HIV tests = number of tests conducted in that modality divided by the total number of tests conducted.
†Proportion of positive tests = the number of positive results in that modality divided by the total number of positive results.
‡NNT to identify 1 child living with HIV (eg, the number of tests divided by the number of positive test results).
FIGURE 1. Number of HIV tests and positive results from index testing and all other modalities and the proportion of HIV
tests and positive results from index testing among children1–14 by country¥, October 1, 2018 to September 30, 2019.
¥Results for proportion of HIV tests and positive results through index testing for Ethiopia need to be cautiously interpreted
because most HIV tests and results in outpatient entry points were not reported in FY19; Geographic coverage for PEPFAR
DRC includes support for 3 of 26 provinces.

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The Pediatric Infectious Disease Journal • Volume XX, Number XX, XXX 2022
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Gross et al
2021). Countries can review their pediatric HIV estimates to bet-
ter understand which age bands have the largest numbers of undi-
agnosed CLHIV (eg, Eswatini, Lesotho, Malawi among children
10–14 years, Zambia and Zimbabwe among children 5–9 years, and
Tanzania among children 1–4 years).45 Programs may need to test
more older children to identify those living with HIV, as reflected
in a slightly higher NNT (82) for children 10–14 years, and iden-
tify strategies to improve linkage (66.5% among children 10–14
years). Potential interventions to improve linkage include enhanced
case management,46 peer-navigated services,47 implementation of
adolescent-friendly treatment services,48 disclosure counseling,49
and linkage and enrollment in OVC programs.50
CLHIV presenting to OPDs, well-child clinics, OVC pro-
grams, and VMMC services may appear healthy yet have an
underlying HIV infection. Nearly half of the CLHIV identified
(43.6%) were diagnosed through PITC in outpatient settings,
which was the most common testing strategy, identified the larg-
est number of CLHIV, and required more tests to identify 1 new
CLHIV than index testing and universal testing of sick children.
Programs may consider implementing a combination of screening
for maternal HIV status, or exposure screening,51 screening using
validated risk assessment tools,21,52 and eligibility screening among
adolescents20 in OPD settings. Screening can address undertest-
ing, especially when combined with a comprehensive interven-
tion package (eg, clinical mentorship, monitoring and evaluation,
extended clinic hours), as shown by 1 study in Kenya among chil-
dren 10–18 years old across 139 healthcare facilities.20 Screening
tools may oer more benefit in high-burden countries not currently
implementing universal HIV testing for children and adolescents
with an unknown HIV status, or with resource constraints limiting
the implementation of universal PITC, given the 50% reduction
in NNT. Screening tools, comprised of a mix of clinical, histori-
cal, exposure, and behavioral questions, oer the opportunity to
accelerate HIV case identification20 by identifying children eligible
for testing and linking them to testing services.21 Screening tools
should be context-specific, validated to reduce missed diagnoses
for CLHIV, and monitored closely to assess the impact on the abso-
lute number of CLHIV identified.21,53 HIV risk screening tools vali-
dated in 3 countries had the following sensitivity and specificity,
respectively: Uganda (87.8%, 62.6%), Tanzania (89.2%, 37.5%)
and Zimbabwe (80.4%, 66.3%).19,52,53 As countries near HIV epi-
demic control for adults, it will be important to maintain access to
HIV testing services for children in outpatient settings, as 37.7% of
CLHIV in this analysis were identified in OPD and pediatric under
5 clinic settings.
While South Africa and Nigeria have the largest pediatric
treatment gaps, accounting for 174,000 and 75,000 CLHIV not on
treatment, respectively, they have the lowest proportion of pedi-
atric HIV tests coming from index testing, ranging from 4% to
5%. Even small increases in index testing volumes for biological
children of PLHIV and siblings of CLHIV, especially in countries
with large gaps in pediatric treatment coverage and a low propor-
tion of tests conducted in index testing, like Uganda, Ghana and
Angola, could translate into more children identified (Fig. 1).
Although index testing accounted for only 13% of all pediatric
HIV tests, it identified 30% of all newly diagnosed CLHIV across
these 16 countries. To increase access, countries can ensure all
PLHIV accessing HIV health services in the facility and commu-
nity are oered index testing at every encounter and implement
systems to track the coverage of line-listed biological children,
FIGURE 2. Number of children that programs needed to test (NNT) to identify 1 positive child by modality and country,
October 1, 2018 to September 30, 2019∂. ∂Lines represent overall NNT by modality for pooled data from all countries.
Results for outpatient department testing in Ethiopia need to be cautiously interpreted because most HIV tests and results
in outpatient entry points were not reported in FY19; geographic coverage for PEPFAR DRC includes support for 3 of 26
provinces.

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The Pediatric Infectious Disease Journal • Volume XX, Number XX, XXX 2022
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Considerations to Improve Pediatric HIV Test
HIV testing of pediatric contacts, wraparound services to facilitate
testing for children living apart from parents, and linkage to care
for newly identified CLHIV.54 Countries may consider conduct-
ing file audits for adults newly diagnosed and already on treat-
ment, especially clients with treatment interruptions or who are
virally unsuppressed to ensure all biological children or siblings
have a documented HIV status or are oered HIV testing. Index
testing is proactive and can identify CLHIV earlier before they
develop advanced HIV disease.15 Furthermore, it is important to
integrate index testing into dierentiated service delivery models
as encounters with the health system may become less frequent for
clients stable on treatment.
Finally, countries can improve monitoring to ensure 100%
of children receiving inpatient, TB or malnutrition services are
oered HIV testing (ie, universal testing), especially for countries
with less eective prevention of mother-to-child transmission pro-
grams where children are more likely to be missed by EID or pre-
sent later with advanced disease. WHO recommends HIV testing
for all children in inpatient settings in high-prevalence countries,13
yet studies show testing coverage often remains below 100%.55,56
Pediatric HIV testing for hospitalized children has a lower NNT
in Mozambique and South Africa, as well as many Western and
Central African countries like Ghana, Angola and DRC (Fig.2).
PEPFAR guidance recommends household contact tracing for
all PLHIV co-infected with TB as a highly eective case-finding
strategy to identify other household members, including children,
who may be infected with TB and/or HIV. Recommendations
include screening all children in OPD settings for TB symptoms
and linking children with presumptive TB to TB and HIV testing
services.18 Furthermore, WHO recommends oering HIV testing
to all children receiving TB or malnutrition services.13 Programs
can conduct file audits in well-child clinics to identify children
falling o the growth curve and refer them for HIV and TB testing,
as studies show CLHIV are commonly stunted and underweight
at diagnosis.42,57 Countries may consider strategies to routinely
link CLHIV identified through inpatient, TB and malnutrition set-
tings (which accounted for 6.5% of newly diagnosed CLHIV in
this analysis), as well as for all CLHIV (<5) at diagnosis58 (rep-
resenting 37.0% of newly diagnosed CLHIV in this analysis) to
an appropriate evaluation for advanced disease and linkage to the
required package of care.
This study was subject to 5 limitations. First, although
countries follow PEPFAR monitoring and reporting guidance, data
quality and reporting by testing strategy vary across countries. For
example, Ethiopia noted underreporting in the outpatient modal-
ity, and there is the possibility that some children 12–17 months
received antibody testing and were included in the testing calcu-
lations, even though guidelines recommend PCR testing. Second,
treatment coverage and gaps are based on UNAIDS modeling data
for entire countries and MER data (HIV testing, positive results,
proxy linkage) reflect only provinces or districts receiving PEPFAR
support, which varies by country. For example, PEPFAR only sup-
ports 3 of 26 provinces in DRC. Third, PEPFAR testing indicators
track the number of tests conducted and not the number of indi-
vidual children tested. The number of reported tests and positive
results over-represents to an unknown extent the number of indi-
vidual children who were tested, and individual CLHIV identified,
overall and by country. Fourth, UNAIDS estimates for CLHIV
unaware of their status is for children <15 years and MER data
for HIV tests conducted are for children 1–14 years, causing the
estimated tests needed to be higher and percent testing need met
to be lower than expected, due to the inclusion of children <1 year
in the aggregated Spectrum data. Fifth, ART initiation rates were
not measured prospectively at the individual level among children
who received a new HIV diagnosis. Thus, the extent to which proxy
linkage rates represent the proportion of individual CLHIV newly
initiated on ART is unknown overall and by country yet serves as
a programmatic pulse check along the clinical cascade. Additional
research is needed to calculate the cost to identify 1 new CLHIV
using dierent testing modalities and inform the optimal mix of
testing strategies to rapidly diagnose the largest number of CLHIV.
CONCLUSIONS
As countries design pediatric HIV testing programs, no 1
approach will close the pediatric testing and treatment gap. Each
testing modality oers unique benefits, when it comes to early iden-
tification (ie, index testing), cost (ie, OPD testing), identifying a
high absolute number of children (ie, OPD testing), high yield (ie,
TB and index), increasing the rate of HIV case identification (ie,
exposure screening, risk screening, and eligibility screening), and
identifying children most at risk for advanced disease (eg, TB, mal-
nutrition, inpatient, and pediatric <5 years clinics) and linking them
to the appropriate package of care. Programs can evaluate their cur-
rent composition of testing modalities and re-design, where needed,
to promote a more optimal and eective mix of testing modalities.
ACKNOWLEDGMENTS
The authors recognize frontline health workers, Ministries
of Health, PEPFAR implementing partners, CDC, USAID and
DOD country oce colleagues advancing pediatric and adolescent
HIV case-finding approaches and reporting HIV testing data to
facilitate program improvements and targeted pediatric HIV testing
strategies to identify C/ALHIV earlier and link them to life-saving
treatment.
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