Article Critique

Courtney Vaughan
Global Health
HSC 6625

Screening tool to identify adolescents living with HIV in a community setting in Zimbabwe:
A validation study

Bandason, T., Dauya, E., Dakshina, S., McHugh, G., Chonzi, P., Munyati, S., Weiss, H. A., Simms, V.,
Kranzer, K., & Ferrand, R. A. (2018). Screening tool to identify adolescents living with HIV in a
community setting in Zimbabwe: A validation study. PLoS ONE, 13(10), 1–10. https://doi-
org.dax.lib.unf.edu/10.1371/journal.pone.0204891

Identify and Introduce

Human Immunodeficiency virus or HIV is a virus that attacks a person’s immune system
and can develop to a more serious illness, AIDS, if left untreated (About HIV/AIDS, 2020). HIV
is a preventable illness with the proper interventions and screening tools. However, despite the
fact that HIV is preventable, HIV/AIDS are the leading cause of deaths, premature deaths, and
causing the most disability (Zimbabwe, 2017). The prevalence of adults and children living with
HIV in Zimbabwe is about 1.4 million, with 84,000 estimated children ages 0-14 (Zimbabwe,
2020). Throughout the review you will see the terms sensitivity and specificity, so these terms
will be defined. Sensitivity “measures how often a test correctly generates a positive result for
people who have the condition that’s being tested for” (Understanding medical tests: Sensitivity,
specificity, and positive predictive value, 2020). Specificity “measures a test’s ability to
correctly generate a negative result for people who don’t have the condition that’s being tested
for” (Understanding medical tests: Sensitivity, specificity, and positive predictive value, 2020).
We will review and critique “Screening tool to identify adolescents living with HIV in a
community setting in Zimbabwe: A validation study” conducted and written by Tsitsi Bandason,
Ethel Dauya, Subathira Dakshina, Grace McHugh, Prosper Chonzi, Shungu Munyati, Helen A.
Weiss, Victoria Simms, Katharina Kranzer, & Rashida Abbas Ferrand.
There is a HIV crisis worldwide that can result in death, premature death, and disability.
HIV is preventive and with proper screening tools and resources, we will see a decline in those
affected. This article used a community-based HIV prevalence survey along with their 4-item
screening tool and Oral Mucosal Transudate to conduct their survey (Bandason et al, 2018). The
purpose for this study is evident in its efforts of HIV preventive, but they focus more on the
younger population due to the high number in undiagnosed cases (Bandason et al, 2018). The
authors validated the 4-item screening tool that was used within the HIV prevalence study to
identify this younger population’s risk of HIV (Bandason et al, 2018). This article stresses for
the need of intervention within this population to decrease the lives that are lost to HIV. The
authors also focus these efforts on the young population due to the high undiagnosed rates.
The main takeaway we see in this article is this screening tool is a preventive method,
which will lower the prevalence, and is cost effective/efficient. There is a problem with how the
HIV crisis is being handled in the terms of treating it once a person already has it. The authors
are striving to use community-based settings to access hard reach populations and focuses its
efforts on the younger population that has a higher burden of undiagnosed HIV. Overall, this
article addressed a pressing issue for this population of Zimbabwe and is working towards
improving the preventive side of healthcare. The authors however could have included more data
on why this issue needs to be addressed with statistics from other studies.

Summarize and Evaluate

This study cross-sectional HIV prevalence survey objective is to validate the screening
tool that our authors used in a community-based setting. This screening tool aims to eliminate the
high burden of undiagnosed HIV and used to determine one’s risk of becoming HIV-positive
(Bandason et al, 2018). The overall point this journal is trying to convey, is preventive medicine
and screening tools should be in place to decreases the leading cause of death for this population
(HIV). Globally there is a lower amount of coverage of ART in the younger population
compared to the adult population, which is the main reason we see high rates of undiagnosed
HIV infections (Bandason et al, 2018). The authors argue that utilizing a pre-testing screening
tool not only may increase yield of HIV testing/counseling but is more efficient and cost-
effective (Bandason et al, 2018).
For this study, 130 Census Enumeration Areas within Zimbabwe’s capital, Harare, were
randomly selected to conduct a cross-sectional HIV prevalence survey on the young population
(8-17 years) (Bandason et al, 2018). This survey was conducted from February 2015 to
December 2015 and was approved by the Medical Research Council of Zimbabwe and Ethical
Review Committees of the London School of Hygiene and Tropical Medicine and the
Biomedical Research and Training Institute (Bandason et al, 2018). The authors used the 4-item
screening tool that asked yes/no questions regarding one’s socio-demographic status including
questions on: previous hospitalization, orphan hood, poor health status, and recurring skin
problems (Bandason et al, 2018). Each participant had consent from their guardians and were
asked a series of questions based on socio-demographic data needed for the screening. The
researchers who were properly trained in the collection of OMT/other test kits also provided
confidential HIV testing and record the data (Bandason et al, 2018). The analysis of the data
utilized the Chi-squared test, p-vales, and t-tests. The authors also used sensitivity and specificity
data that was collect, along with Odds Ratio.
This screening tool has been used in other populations and in different settings. This
screening tool for HIV was previously developed to assess the prevalence of HIV-positive in the
younger population in healthcare setting in Zimbabwe, but now is working into community-
based settings (Bandason et al, 2018). This original screening test done in healthcare setting
provided and 80% sensitivity and a 66% specificity compared to in the community -based setting
sensitivity of 56.3% and a 75.1% specificity (Bandason et al, 2018). This means that in
community-based setting you will find less people who are suffering from HIV than in a
healthcare facility, affecting the sensitivity and specificity due to participants. This original
analysis (healthcare setting) provided data and knowledge on this population and provided
results that intrigued others to use the screening tool, along with other interventions. Like I stated
earlier, I believe they used the proper technique of using a screening tool and using the
sensitivity and specificity test to determine the tests reliability and validity. The authors wrote
this article in a nice format that was easy to follow and was able to condense the numbers into a
readable script. Reaching communities and providing prevention for these communities is the
authors goals and they explain the reason for picking this screening tool with the strengths it
holds.
Response or Reaction
After reading and reviewing this article, I believe that the authors displayed knowledge
and insight to this topic and measured using p values, sensitivity, and specificity. Knowing that
the data collected was coded and then also ran as a Chi-squared test provides us as readers with
statistically significant data. The authors also took this screening tool from previous studies,
where it also showed a higher sensitivity to those suffering from HIV, but the setting wasn’t
community-based but the healthcare facility setting.
In the authors efforts to explain the problem they emphasized the need for intervention to
address the HIV prevalence problem in Zimbabwe. However, even though it might seem like
common knowledge to some, others need to have more background information on why there is
a need for this screening tool. If the authors would have provided data on the younger
population’s HIV rates in previous years, then this study would have a more defined reason on
why there is a need for it. The authors however do explain the lack of coverage of ART in the
younger population that is resulting in higher rates of undiagnosed HIV (Bandason et al, 2018).
Instead of a hypothesis, the authors were looking for validation of this screening tool in a
community-based setting using the previous study being healthcare setting. The authors did
achieve the results they were looking for because their 4-item screening tool not only provided
us with a high sensitivity, but provided a easier way of recording data by halving the amount of
participants tested to identify one HIV- positive child (Bandason et al, 2018). The authors then
were able to conclude that this is an effective method to be used and that it should be exercised
in more HIV prevalence surveys. The study provided us with strengths that include cost-
effective, large sample sizes, high participation rates, random selection of participants, reaches
more populations with community-based interventions, and these findings can be generalized in
the surrounding African areas that share similar HIV prevalence (Bandason et al, 2018).
However, this analysis does have weaknesses and limitations, one of them being underreporting
of HIV status. Weaknesses of this analysis also include bias in many forms. Extrapolation bias
could have occurred because this screening tool was originally created to test 6-16-year-old
instead of 8-17-year-old (Bandason et al, 2018). Spectrum bias also is something to consider
because it could increase the sensitivity of the test providing untrue performance of the tool
(Bandason et al, 2018). The weariest weakness, however, pertains to the OMT test producing
false negatives if a person is taking ART, which could then result in affecting the tool’s
sensitivity (Bandason et al, 2018).

Conclusion
In the conclusion of this article, the authors recognize the weaknesses and differences that
this screening tool might cause but believe it to be the most practical and cost-effective. The
authors stress the targeted goal that the UNAIDS put in place for 2020 being, “to test 90% of all
individuals living with HIV by 2020” (Bandason et al, 2018). The authors leave us encouraging
others to invest in the preventive healthcare measures and to utilize this screening tool. They do
add that this screening tool will need to be tweaked to fit the community at hand needs and to
pair the screening with other HIV intervention strategies and care for those who suffer from HIV
(Bandason et al, 2018).
This article provides an effective method for preventive and shows us that with the proper
funds we can provide community-based interventions. This article uses the proper test including
sensitivity and specificity and analyzes the data to determine the results of its effectiveness.
Working efforts with this screening tool to reduce HIV prevalence among the younger
population ultimately puts one ahead in reducing the overall prevalence for the population and
will save money in the future. However, if a person had no knowledge on Zimbabwe or the HIV
prevalence rates, the reasoning behind the need for the screening tool might not seem like a
priority. Overall this article does a good job providing the results of this screening and shows a
cost-effective method. The authors provide a more efficient way of collecting data and cuts the
number of participants in half decreasing the workload for this study.

References:
About HIV/AIDS. (2020, July 14). Retrieved from
https://www.cdc.gov/hiv/basics/whatishiv.html#:~:text=What is HIV?-,HIV (human
immunodeficiency virus) is a virus that attacks the,they have it for life.
Bandason, T., Dauya, E., Dakshina, S., McHugh, G., Chonzi, P., Munyati, S., Weiss, H. A.,
Simms, V., Kranzer, K., & Ferrand, R. A. (2018). Screening tool to identify adolescents
living with HIV in a community setting in Zimbabwe: A validation study. PLoS
ONE, 13(10), 1–10. https://doi-org.dax.lib.unf.edu/10.1371/journal.pone.0204891
Understanding medical tests: Sensitivity, specificity, and positive predictive value. (n.d.).
Retrieved 2020, from https://www.healthnewsreview.org/toolkit/tips-for-understanding-
studies/understanding-medical-tests-sensitivity-specificity-and-positive-predictive-value/
Zimbabwe. (2020, March 04). Retrieved July 15, 2020, from
https://www.unaids.org/en/regionscountries/countries/zimbabwe
Zimbabwe. (2017, September 20). Retrieved from http://www.healthdata.org/zimbabwe