Sustaining Early Infant Diagnosis of HIV During Coronavirus Disease 2019 Pandemic

To the Editors:

Despite advances in prevention of mother to child transmission (PMTCT) of HIV, 160,000 new pediatric HIV infections were reported in 2020.¹ Vertical transmission of HIV in Nigeria remains high at 22%, with 37,000 new infections among children 0–14 years annually.² In Nigeria, access to early infant diagnosis (EID) has improved significantly; however, only 27% of HIV-exposed infants received an HIV test by 2 months of age in 2019.³ EID programs require mothers to bring their infants to the health facility for testing. However, the global coronavirus disease 2019 (COVID-19) pandemic movement restrictions necessitated changes to the PMTCT service delivery model for infant follow-up to ensure uninterrupted service delivery.

Nigeria reported its first COVID-19 case on February 27, 2020.⁴ By March, a mandatory lock down with subsequent movement restrictions limited access to health facilities for nonemergency presentations including PMTCT services.⁴ The Reaching Impact Saturation and Epidemic (RISE) Control program, which currently provides comprehensive HIV prevention, care and treatment services to over 82,000 recipients of care, rapidly pivoted to a community service delivery model to ensure uninterrupted access to HIV services. To circumvent the challenges faced by mothers and caregivers in accessing health facilities during the COVID-19 lockdown period, RISE deployed trained nurses to collect dried blood spot (DBS) samples for HIV viral load and EID in the communities where children, infants and their caregivers live. EID samples were collected by trained nurses in the home and transported to the health facility for onward transportation to regional labs. When sample collection was not feasible in the home, caregivers were escorted to the nearest health facility for sample collection. Case managers also provided antiretroviral drug refills for recipients of care in the community including antiretroviral prophylaxis refills for infants.

Prelock down (October 2019 to March 2020), RISE collected 690 samples of which 57% (393/690) were collected within 2 months of birth with average turnaround time of 30 days. Postlock down (April to September 2020), 634 samples were collected of which 60% (379/634) were within 2 months of birth while maintaining an average turnaround time of 34 days. Regarding actual tests done, prelock down tests were done for 75% of samples for infants <2 months (n = 295) with 1.0 % positivity rate, while postlock down, 77% (n = 291) were tested with 0.3% positivity.

Early results from the RISE program have shown that DBS specimens for HIV diagnosis in infants can be safely collected at home while maintaining specimen integrity and delivery of results back to caregivers. Several adaptations have been made to HIV programming to improve service delivery for HIV-infected pregnant, breast-feeding women, infants, children and adolescents.⁴ We propose that HIV programs consider implementing home-based DBS collection to increase access to timely EID services for HIV-exposed infants both as an adaption during the COVID-19 pandemic and as an enduring solution thereafter.