In 2017, point of care (POC) birth testing was introduced into routine care at the 3 highest volume maternity sites in Eswatini. POC birth testing was offered to HIV-exposed infants born at, or presenting to, the maternities within 3 days of birth. Two of the POC platforms were used only for birth testing; one was shared with another hospital unit. National guidance states that infants testing negative at birth should return for a 6-week test; infants testing positive at birth should start nevirapine (NVP) immediately and return at 14 days of life to begin a lopinavir/ritonavir regimen (LPV/r).
Prospective data were collected on tests occurring 1 Aug 2017-1 Aug 2018. Variables included number of infants eligible for birth testing, percentage of infants tested, turnaround time from sample collection to receipt of results, positivity, percentage of infected infants initiated on treatment, turnaround time from sample collection to treatment initiation, and percentage of infants testing negative at birth who received a subsequent test at 6 weeks.
Of 3385 eligible infants, 1999 (59.1%) received a birth test. Of those producing a positive or negative result (n=1928; 96.4%), 98.9% (n=1906) reached the caregiver. Median turnaround time from sample collection to caregiver receipt of results was 0 days (range 0-31; IQR 0-0). Testing uptake was lower, but turnaround time to result receipt was not longer for the shared platform. 12 HIV-infected infants were identified (yield = 0.6%) and 11 were initiated on treatment (91.7%); 3 on day 14 after diagnosis, 4 after 15 days, and 4 after 60 days. The median time from sample collection to initiation on treatment for positive infants was 32 days (range 14-124; IQR 16-65). One infant died after diagnosis but prior to initiation. Analysis of subsequent tests of infants who tested negative at birth is ongoing (and will be available to be presented at CROI).
POC EID at birth is a feasible strategy in this setting. However, not all eligible infants were tested, possibly due to staff shortages or queues for platform use. In practice, infants received no treatment until they returned to begin LPV/r. Same-day pediatric treatment initiation is uncommon in Eswatini due to caregiver desire to consult with male family members. Policymakers may consider better promotion of NVP at birth, the introduction of new pediatric formulations that can be used at birth and beyond, and/or better linkage to care to ensure timely initiation on treatment.