Background:  Although the Malawian government recommends that HIV-exposed infants receive early infant diagnosis of HIV (EID) services at maternity clinics soon after birth, most either never enroll or present to other facilities HIV-infected and acutely ill. Therefore, our aim was to evaluate early infant diagnosis testing at 2 other potential entry points, an immunization clinic and a general pediatric clinic.

Methods:  Using routine provider-initiated HIV testing and counseling (PITC) program registers, we prospectively studied 1760 children offered PITC at a government immunization clinic and a general pediatric clinic in Lilongwe. Each clinic’s PITC service was similarly staffed. Children were HIV DNA polymerase chain reaction (PCR) eligible if they were <12 months of age, their mother was HIV⁺, and they were not already enrolled in HIV care with a previous or pending PCR test. Patients were followed until disclosure of the PCR test result, which was scheduled after 4 weeks, per EID program protocol. Associations between health clinics and individual co-variates were tested using c², Fisher’s exact test, and Student’s t-tests where appropriate; a was set to 0.05.

Results:  We sampled 877 and 880 consecutive PITC recipients at the general pediatric and immunization clinic, respectively. Overall, a 7-fold greater proportion of children received PITC at the immunization clinic versus the general clinic (84.2% vs 11.4%, p <0.001). PITC recipients at the immunization clinic were also >14 months younger (2.6 vs 17.0, p <0.001), with greater proportions classified as HIV-exposed (17.6% vs 5.3%, p <0.001) and PCR test-eligible (7.9% vs 3.5%, p <0.001). With respect to PCR testing, a higher percentage of infants at the immunization clinic accepted testing (100.0% vs 90.3%, p = 0.03). Additionally, immunization clinic PCR recipients were also 2.5 months younger (3.1 vs 5.6, p <0.001) with 4 times fewer testing PCR-positive (7.1% vs 32.1%, p <0.001). Importantly, a >3-fold greater proportion of HIV-exposed infants at the immunization clinic returned for their PCR result and enrolled into HIV care (78.6% vs 25.0%, p <0.001).

Conclusions:  EID testing at an immunization clinic is more acceptable to caregivers, more feasible for healthcare providers to routinely deliver, and enrolls more infants into the EID program at a younger age. Scaling-up EID testing at immunization clinics is likely to strengthen EID services in Malawi.