Thinking Outside the “Circle” to Improve Early Infant Detection of HIV

The Challenge: In 2020, 37.5% of HIV-exposed infants (HEI) in Tanzania did not receive an HIV test within 6 weeks after birth. Among the 62.5% of infants who did get the test, many did not receive prompt results and treatment due to the poor quality of collected blood samples.

The Solution: An interdisciplinary team led by CDC Tanzania’s Science and Surveillance, Prevention, and Laboratory Branches, conducted rapid assessments to identify barriers and solutions to ensure that HEI have an HIV test performed by 6 weeks of age. Correct and timely results allow prompt treatment for those who need it. Since implementation of innovative solutions in January 2021, two-month Early Infant Diagnosis (EID) coverage increased from 62.5% to 90% in CDC supported facilities.

The World Health Organization (WHO) recommends that all HEI have an HIV test by 6 weeks of age. This Early Infant Diagnosis (EID) approach can help identify HIV-infected infants and initiate life-saving treatment. In 2020, more than one-third of HEI at CDC-supported facilities in Tanzania did not have a documented HIV test result by 6 weeks of age. This gap in service delivery was due to two main challenges. First, there were children brought to a clinic by caretakers for routine follow-up visits within 6 weeks, but an HIV test was not performed. Next, there were testing samples collected before 6 weeks of age, but the blood sample was inadequate.

A Simple Solution to Bring Down a Barrier

CDC Tanzania brought experts from multiple programs to identify approaches to improve EID coverage among infants to address ongoing implementation and reporting challenges.

CDC experts conducted a rapid assessment to identify barriers affecting prevention of mother-to-child transmission of HIV (PMTCT) with implementing partners and health facility staff. In a systematic approach, CDC identified areas for improvement to tackle the problems contributing to gaps in EID implementation.

Health facilities are expected to conduct HIV tests when an infant comes for the six-week routine immunization visit. However, facility staff noted that caretakers often become visibly upset when the infant cries after receiving these immunizations. This can lead to caretakers leaving with their infant before receiving an HIV blood test. To solve this challenge, CDC and partners encouraged health facilities to conduct infant HIV tests before the routine immunizations, as caretakers were more likely to stay for the entirety of the appointment.

Finding Ways to Improve HIV Test Samples

When an infant receives an HIV test, the bottom of their foot is pricked, and blood is transferred onto a sample card. Each dried blood spot (DBS) sample card has five “circles” that are to be filled before sending it to the testing laboratory. A rapid assessment showed many blood samples taken from infants were rejected because either insufficient blood was collected to cover all five circles, or there was visible overflow between the circles. In some cases, not enough blood was collected to perform the test at all.

Results from the rapid assessment revealed that at least three circles need to be filled with a drop of blood to conduct initial and confirmatory HIV tests. In response, CDC and partners implemented the Tatu Bomba initiative, instructing facility staff to focus on successfully filling three of the circles instead of the five on the diagnostic test. Leaving an empty circle in between samples also reduced the chances of contamination. Revised job aides and onsite mentorship ensured staff were equipped to collect samples correctly.

The Tatu Bomba initiative also used SMS and social media platforms to verify the quality of samples collected. In a group chat with PMTCT and laboratory staff, every sample collected is photographed and sent in the group for rapid verification while the infant is still present. If approved, the facility staff sends the sample off to the laboratory. If not approved, guidance is provided and the sample is immediately improved or retaken before the client leaves the facility.

Innovations Yield Results

Rapid Lesson Learning has allowed CDC and implementing partners to map out key areas for action:

• Sharing best implementation practices
• Focusing efforts on impactful activities
• Addressing barriers that were previously unknown

The collaboration between CDC, the Tanzania Ministry of Health, Community Development, Gender, Elderly and Children, and implementing partners at facilities helped DBS rejection rates decrease dramatically. Thinking outside of the “circle” and taking innovative approaches helped CDC-supported facilities dramatically improve EID coverage and advance progress toward HIV epidemic control.