Background:  In Nigeria, routine screening of children for HIV-exposure and infection in health care settings is not standard care. Because overall HIV prevalence in Nigeria is low (4%) compared to other African settings, the benefit of routine testing outside of antenatal clinics with prevention of mother-to-child transmission (PMTCT) services is unclear.

Methods:  During a 6-month demonstration project, early infant diagnostic testing using DNA PCR on dried blood spots (DBS) was instituted at 6 health facilities in Lagos. HIV-exposed infants (6 weeks to 18 months of age) were identified for early infant diagnostic services by referral from PMTCT programs. Sick infants with signs and symptoms of HIV or whose mother’s status was unknown were also screened with rapid antibody tests and, if found positive (i.e. HIV-exposed), DBS polymerase chain reaction (PCR) testing was done to confirm diagnosis. For each HIV-exposed child tested by DNA PCR, information was recorded on: where the child was seen, reason for the visit, current clinical signs and symptoms of HIV, and PMTCT interventions received.

Results:  Of the first 255 HIV-exposed infants with available DNA PCR results, 54 (21.2%) were found to be HIV-infected. Of these, 33 (61%) were sick children seeking care for illness. When results were stratified by site, 44 (83%) infected infants came from 2 facilities, both of which tested higher numbers of sick children. Of 59 sick outpatients, and 8 pediatric inpatients tested, 27 (45.8%) and 6 (75.0%) were diagnosed as HIV-infected, respectively. HIV infection was significantly associated with the child’s point of entry for services (p <0.05), facility (p <0.001), reason for the child’s visit (p <0.001), and the number of clinical signs and symptoms of HIV noted for the child (p <0.001).

Conclusions:  We found high rates of HIV infection among sick infants presenting with symptoms of HIV who may not have been identified as HIV-exposed until they were screened by rapid antibody testing. More than half the children found to be HIV-infected in our sample were from 1 health facility that offers routine HIV testing to all sick children. Even in relatively low-prevalence settings, sick children with signs and symptoms consistent with HIV should have diagnostic HIV testing. A policy of routinely offering screening to determine HIV exposure and subsequent HIV testing for all sick children can effectively identify those who would benefit from ongoing follow-up and interventions such as cotrimoxazole prophylaxis, infant feeding support, and ART.