Background: Index case contact testing is an effective strategy for identifying HIV-positive children and adolescents missed by PMTCT and early child health services. HIV-diagnosed adults have traditionally been index clients. However, millions of HIV-positive adults have died, potentially without disclosing their HIV status to family members or having their children tested. Also, many adolescents independently present for HIV testing and initiate ART at a facility other than where their parents receive ART.
Methods: We adapted index testing approaches to use deceased individuals with known or suspected HIV infection as index clients at 22 sites, and adolescents as index clients at 14 sites in Kenya. Records of deceased index clients were reviewed to determine the eligibility of their children for HIV testing. Ministry of Health patient cards were used to obtain family contact information, and providers contacted them with the discrete offer of HIV home-based testing, without disclosing the HIV status of the deceased family member. Providers were trained to collect information on adolescents'' siblings, document eligibility for HIV testing, and contact caregivers for consent for siblings below 15 years of age. Known HIV-positive adolescents and their siblings were encouraged to attend clinic days for health talks and HIV testing, or provided with testing at home.
Results: Using deceased individuals as the index client among 1,021 tested resulted in positivity of 3.2% (4 positive) among children aged 18 months-4 years, 3.7% (9 positive) among children 5-9 years, and 4.1% (11 positive) among adolescents 10-14 years. Among 1,390 children tested using adolescents as index clients, positivity was 0% among those aged 18 months-4 years, 3.4% (16 positive) among 5-9 year olds, and 3.7% (16 positive) among 10-14 year olds. Comparatively, index case contact testing using a living, HIV-positive adult resulted in a positivity of 1.4% among 27,732 children tested aged 0-14 years.
Conclusions: These approaches were particularly effective at diagnosing children aged 5-14 years, the group often missed once they age out of facility-based PMTCT and early childhood health services. Expanding the use of deceased individuals and adolescents as index clients should be considered for scale, alongside the continued expansion of traditional index testing approaches.