标题：Perception of Risk of Vertically Acquired HIV Infection and Acceptability of Provider-Initiated Testing and Counseling Among Adolescents in Zimbabwe
摘要：Objectives. We investigated attitudes toward provider-initiated HIV testing and counseling (PITC) in the suburbs of Harare, Zimbabwe, where late presentation after mother-to-child HIV transmission (MTCT) is a major cause of adolescent mortality. Methods. Adolescents (10–18 years) attending 2 primary clinics were offered PITC. Participants completed a questionnaire investigating acceptability of PITC, and in-depth interviews with 41 adolescents and 30 guardians explored understanding of long-term survival after MTCT. Results. Of 506 participants, 16 were known to be HIV-positive; of the remaining 490, only 5 (1%) declined HIV testing. Infected adolescents and their guardians often anticipated a positive result and reported being advised by relatives (but not health workers) to be tested because of chronic illness, especially if parents or siblings had died or were HIV-infected. However, HIV-negative participants were not aware that long-term survival following MTCT could occur. All adolescents felt that HIV diagnosed at their age would be assumed to have been sexually acquired regardless of the true mode of transmission. Conclusions. Including late diagnosis of MTCT in pretest counseling and health educational messages may facilitate PITC for older children and adolescents, especially for those who have not had their sexual debut. Almost 3 decades after the emergence of the HIV epidemic, underdiagnosis of HIV infection remains a significant issue globally, with more than 60% of adult HIV infections remaining undiagnosed in sub-Saharan Africa. 1 Much attention has been given to facilitating HIV diagnosis in adults through provision of testing services in a variety of settings. 1 The most notable change in recent years has been a shift from client-initiated to provider-initiated HIV testing and counseling (PITC) in adults, which has much lower costs per HIV-positive person tested than alternative strategies. 2,3 International guidelines recommend routine PITC for all people seen in health facilities during generalized HIV epidemics as part of universal access to HIV testing and care. 4 Routine implementation of PITC effectively increases uptake of HIV testing in a variety of health care settings. 5–10 In recent years, late presentation of vertically acquired HIV infection has become an increasingly important cause of adolescent mortality and serious morbidity in southern Africa. This trend reflects high regional HIV prevalence rates during the 1990s, lack of interventions to prevent mother-to-child transmission (MTCT) at that time, and the passage of enough time for HIV-infected infants who are long-term survivors to reach adolescence. 11,12 It is now recognized that the probability of long-term survival following MTCT was greatly underestimated in the early days of the HIV epidemic. Although only about half of infected infants survive their first 2 years without antiretroviral treatment, about a quarter will live 10 years or more. 13–15 Infants born in southern Africa during the late 1990s were exposed to exceptionally high risks of acquiring HIV infection, with no effective prevention interventions in place and national antenatal surveys of pregnant women showing an HIV prevalence of 30% or higher in several countries, including Zimbabwe. 16 Although infant diagnosis is well established, the need to consider HIV in acutely or chronically unwell older children has not been emphasized, leaving guardians and health providers alike potentially unaware of the high risk of HIV as the underlying cause of ill health in older children and adolescents in this region. 12,17 Without this awareness, older children may not be offered HIV testing and guardians may feel unable to raise their suspicion of HIV with health providers, resulting in failure to diagnose underlying HIV despite frequent consultations. HIV testing of minors also requires consent from a legal guardian, a potential barrier that may be compounded by changing or informal guardianship due to parental death. 18,19 Orphans may be further disadvantaged by poverty and suboptimal parenting. 20–22 Zimbabwe has experienced a severe HIV epidemic, with antenatal HIV prevalence rates peaking at 30% in 1997 and currently at 15% among adults and 6.8% among 15- to 19-year-old adolescents. 23–26 HIV prevalence among 10-year-old children is estimated to be around 3%, with more than 70% of adolescents with HIV infection acquired through MTCT still undiagnosed. 15,27,28 Zimbabwe has moved toward provision of PITC for adults in all health facilities, but children are not routinely offered PITC. Oral consent from a legal guardian is required, but not written consent or documentation of legal guardianship. We investigated the perception of risk of HIV infection and acceptability of PITC among adolescents attending primary health care facilities, the predominant source of health care in Zimbabwe.
