Reinforcing Early Infant Diagnosis of HIV (3DE)
Client: Zambia Ministry of Health, Zambia Ministry of Community Development, Mother and Child Health
Partners: DFID, Clinton Health Access Initiative, Zambia Center for Applied Health Research and Development (ZCAHRD)
Dates of service: 2013-2014
IDinsight service: Decision-focused evaluation
IDinsight contacts: Paul Wang, Alison Connor
Additional resources: Policy Brief
Approximately 50% of untreated HIV-infected infants die before the age of 2 years. Recognizing this, Zambia has implemented early infant HIV diagnosis (EID) services in over 800 health facilities nationwide. However, only ~25% of the ~180,000 EID tests per year stipulated by national guidelines are conducted. Thus, improving EID testing rates represents a critical step in improving Zambia’s fight against the HIV epidemic.
Senior officials from Zambia’s MoH and Ministry of Community Development, Mother and Child Health (MoCDMCH) commissioned an impact evaluation to assess two interventions designed to improve EID testing rates:
1. The “Simple Intervention” targeted two potential causes of low EID rates: supply stock outs and poor understanding of testing requirements and guidelines. Health facilities receiving the Simple Intervention benefit ed from 1) a guaranteed supply of antibody and dried blood spot (DBS) DNA PCR testing materials and 2) a short workshop from district MoCDMCH staff to review and emphasize existing MoH EID guidelines.
2. The “Comprehensive Intervention” included the supply and information components of the Simple Intervention, and also introduced 1) an intentional operational optimization and integration of EID testing into routine six-week immunization visits, and 2) an additional component of opt-out rapid HIV testing for all mothers with previously negative or unknown HIV status in order to identify previously unrecognized HIV-exposed infants.
IDinsight designed and implemented a clustered randomized controlled trial to identify the impact of the Simple and Comprehensive Interventions on the number of HIV exposed infants identified, number of HIV exposed infants tested for HIV, and percentage of infants immunized.
The Simple and the Comprehensive Intervention were both successful in significantly boosting the number of mothers tested for HIV. The magnitude of the impact was similar between both interventions. Furthermore, both interventions suggested improvements in the number of infant HIV tests provided, but the magnitude was not large enough to be certain of impact. In the case of the Comprehensive Intervention, the intensification of HIV testing at the six-week immunization visit did not negatively impact immunization rates. Importantly, the evaluation uncovered critical gaps in the supply chain for important HIV testing commodities associated with both infant and mother HIV tests.
In response to the evaluation findings, Zambia’s MoH issued a memo to remind health facilities to provide HIV testing at under-five clinics. Districts have also been instructed to include under-five HIV testing as part of the district performance assessments. Finally, efforts are being focused on improving the availability of HIV testing kits to avoid stock outs.