'There's no place like home': perceptions of home-based HIV testing in Lesotho

Beyond the facility: An evaluation of seven community-based pediatric HIV testing strategies and linkage to care outcomes in a high prevalence, resource-limited setting

Diverse challenges in expanding pediatric HIV testing and treatment coverage persist, making the investigation and adoption of innovative strategies urgent. Evidence is mounting for the effectiveness of community-based testing in bringing such lifesaving services to those in need, particularly in resource-limited settings. The Mobilizing HIV Identification and Treatment project piloted seven community-based testing strategies to assess their effectiveness in reaching HIV-positive children and linking them to care in two districts of Lesotho from October 2015 to March 2018. Children testing HIV-positive were enrolled into the project's mHealth system where they received e-vouchers for transportation assistance to the facility for treatment initiation and were followed-up for a minimum of three months. An average of 7,351 HIV tests were conducted per month across all strategies for all age groups, with 46% of these tests on children 0-14 years. An average of 141.65 individuals tested positive each month; 9% were children. Among the children tested 55% were over 5 years. The yield in children was low (0.38%), however facility-based yields were only slightly higher (0.72%). Seventy-five percent of children were first-time testers and 86% of those testing HIV-positive were first-time testers. Seventy-one percent of enrolled children linked to care, all but one initiated treatment, and 82% were retained in care at three months. As facility-based testing remains the core of HIV programs, this evaluation demonstrates the effectiveness of community-based strategies in finding previously untested children and those over 5 years who have limited interactions with the conventional health system. Utilizing active follow-up mechanisms, linkage rates were high suggesting accessing treatment in a facility after community testing is not a barrier. Overall, these community-based testing strategies contributed markedly to the HIV testing landscape in which they were implemented, demonstrating their potential to help close the gap of unidentified HIV-positive children and achieve universal testing coverage.

Promoting HIV Testing by Men: A Discrete Choice Experiment to Elicit Preferences and Predict Uptake of Community-based Testing in Uganda

BACKGROUND AND OBJECTIVES

HIV testing is essential to access HIV treatment and care and plays a critical role in preventing transmission. Despite this, testing coverage is low among men in sub-Saharan Africa. Community-based testing has demonstrated potential to expand male testing coverage, yet scant evidence reveals how community-based services can be designed to optimize testing uptake. We conducted a discrete choice experiment (DCE) to elicit preferences and predict uptake of community-based testing by men in Uganda.

METHODS

Hypothetical choices between alternative community-based testing services and the option to opt-out of testing were presented to a random, population-based sample of 203 adult male residents. The testing alternatives varied by service delivery model (community health campaign, counselor-administered home-based testing, distribution of HIV self-test kits at local pharmacies), availability of multi-disease testing, access to antiretroviral therapy (ART), and provision of a US$0.85 incentive. We estimated preferences using a random parameters logit model and explored whether preferences varied by participant characteristics through subgroup analyses. We simulated uptake when a single and when two community-based testing services are made available, using reference values of observed uptake to calibrate predictions.

RESULTS

The share of the adult male population predicted to test for HIV ranged from 0.15 to 0.91 when a single community-based testing service is made available and from 0.50 to 0.96 when two community-based services are provided concurrently. ART access was the strongest driver of choices (relative importance [RI] = 3.01, 95% confidence interval [CI]: 1.74-4.29), followed by the service delivery model (RI = 1.27, 95% CI 0.72-1.82) and availability of multi-disease testing (RI = 1.27, 95% CI 0.09-2.45). A US$0.85 incentive had the least yet still significant influence on choices (RI = 0.77, 95% CI 0.06-1.49). Men who perceived their risk of having HIV to be relatively elevated had higher predicted uptake of HIV self-test kits at local pharmacies, as did young adult men compared to men aged ≥ 30 years. Men who earned ≤ the daily median income had higher predicted uptake of all community-based testing services versus men who earned above the daily median income.

CONCLUSION

Substantial opportunity exists to optimize the delivery of HIV testing to expand uptake by men; using an innovative DCE, we deliver timely, actionable guidance for promoting community-based testing by men in Uganda. We advance the stated preference literature methodologically by describing how we constructed and evaluated a pragmatic experimental design, used interaction terms to conduct subgroup analyses, and harnessed participant-specific preference estimates to predict and calibrate testing uptake.

Reaching hard-to-reach men through home-based couple HIV testing among pregnant women and their male partners in western Kenya: a qualitative study

Background

Globally only 79% of adults living with HIV (human immunodeficiency virus) know their status and men in sub-Saharan Africa are considered a particularly hard-to-reach population for HIV testing. Home-based HIV couple testing during the antenatal period is a safe and effective method that has been used to test male partners of pregnant women. The goal of this qualitative study was to identify elements that made couple testing successful and describe important characteristics of this home-based intervention from couples’ perspectives.

Methods

Couples who received scheduled home-based couple testing during pregnancy in Kisumu, Kenya, were purposively sampled based on HIV status from January to May 2015. An interviewer administered all of the in-depth interviews and two coders were directly involved in the data analysis and reconciled codes several times in the process.

Results

Twenty-one couples were enrolled: 9 concordant HIV-negative couples, 8 HIV discordant couples, 3 HIV concordant HIV-positive couples, and 1 whose concordance status was unknown. Median age at the time of home-based couple testing was 24 and 28 years for women and men, respectively. Median relationship duration was 3 years and couples had a median of two pregnancies. The major themes that emerged were that home-based couple testing 1) removed the female burden of requesting couple testing, 2) overcame logistical barriers associated with clinic-based testing, 3) encouraged participants to overcome their fear of testing and disclosure, 4) provided privacy in the home, and 5) provided quality time with the health advisors. Importantly, some women appreciated individual testing at the clinic before couple testing and some couples preferred skilled, anonymous health advisors delivering the intervention rather than known community health workers.

Conclusions

The results of this qualitative study suggest that home-based couple testing during pregnancy overcame many of the barriers that limit men’s access to and uptake of clinic-based testing. It encouraged participants to overcome their fear of testing and disclosure through a setting that afforded privacy and quality time with skilled health advisors. These qualitative results may help design effective partner and couple HIV testing programs in the antenatal setting and alongside or within other assisted partner notification services.

Trial Registration

Clinicaltrials.gov registry: NCT01784783. Registered prospectively on June 15, 2012.

HIV Treatment Outcomes Among Patients Initiated on Antiretroviral Therapy Pre and Post-Universal Test and Treat Guidelines in South Africa

Introduction

Officially rolled out on 01 September 2016, South Africa’s Universal Test and Treat (UTT) policy calls for first-line antiretroviral treatment (ART) initiation among all known HIV-positive patients, irrespective of CD4 cell count. We evaluate treatment outcomes of patients initiated on first-line ART directly before and after the implementation of UTT.

Methods

We analysed prospectively collected clinical cohort data among ART-naïve adult patients within two HIV clinics in Johannesburg, South Africa. We compare two groups: 1) an unexposed pre-UTT group initiating treatment from 01 December 2014 to 31 May 2015; and 2) an exposed UTT group initiating treatment from 01 December 2016 to 31 May 2017. Primary treatment outcomes included lost to follow-up (LTFU) (>90 days late for the last scheduled visit with no subsequent clinical visit). Cox proportional hazards models were used to estimate the association between pre-UTT vs UTT initiation on LTFU by 12 months.

Results

We included 2410 patients. A total of 1267 (52.6%) patients initiated ART before UTT implementation and 1143 (47.4%) after the change in policy. LTFU (adjusted Hazard Ratio (aHR): 1.51; 95% Confidence Interval (CI): 1.16–1.98) between groups and specifically among those initiating with a CD4 cell count ≤500 cells/mm³ (aHR: 1.59; 95% CI: 1.21–2.10) was higher among patients initiating ART under UTT.

Conclusion

LTFU under UTT proved higher than that of previous periods. Patients initiating first-line therapy under the treat-all policy may often start treatment in better health, subsequently not perceiving a direct benefit to treatment which may deter patients from consistent engagement in HIV treatment programmes.

Impact of Home-Based HIV Testing Services on Progress Toward the UNAIDS 90-90-90 Targets in a Hyperendemic Area of South Africa

BACKGROUND

In several subgroups of South Africa, the percentage of HIV-positive individuals aware of their status falls well below the UNAIDS 90% target. This study examined the impact that home-based HIV testing services (HBHTS) had on knowledge of status in a hyperendemic area of South Africa.

METHODS

We analysed data from the second cross-sectional HIV Incidence Provincial Surveillance System survey (2015/2016), a representative sample (n = 10,236) of individuals aged 15-49 years. Participants completed a questionnaire, provided blood samples for laboratory testing (used to estimate HIV prevalence), and were offered HBHTS. The proportion of people living with HIV (n = 3870) made aware of their status through HBHTS was measured, and factors associated with HBHTS uptake were identified.

RESULTS

Knowledge of HIV-positive status at the time of the survey was 62.9% among men and 73.4% among women. Through HBHTS, the percentage of HIV-positive men and women who knew their status rose to 74.2% and 80.5%, respectively. The largest impact was observed among youth (15-24 years). Knowledge of status increased from 36.6% to 59.3% and from 50.8% to 64.8% among young men and women, respectively. In addition, 51.4% of those who had previously never tested received their first test. Key reasons for declining HBHTS among undiagnosed HIV-positive individuals included fear and self-report of an HIV-negative status.

CONCLUSIONS

HBHTS was effective in increasing awareness of HIV-positive status, particularly among youth, men, and those who had never tested. HBHTS could have a marked impact on progress toward the UNAIDS 90-90-90 targets within these subgroups.

Offering Self-administered Oral HIV Testing as a Choice to Truck Drivers in Kenya: Predictors of Uptake and Need for Guidance While Self-testing

We assessed predictors of choosing self-administered oral HIV testing in the clinic with supervision versus the standard provider-administered blood test when offered the choice among 149 Kenyan truck drivers, described the types of guidance participants needed during self-testing and predictors of needing guidance. Overall, 56.38% of participants chose the self-test, 23.49% the provider-administered test, and 20.13% refused testing. In the adjusted regression models, each additional unit on the fatalism and self-efficacy scales was associated with 0.97 (p = 0.003) and 0.83 (p = 0.008) times lower odds of choosing the self-test, respectively. Overall, 52.38% of self-testers did so correctly without questions, 47.61% asked questions, and 13.10% required unsolicited correction from the provider. Each additional unit on the fatalism scale was associated with 1.07 times higher odds of asking for guidance when self-testing (p < 0.001). Self-administered oral HIV testing seems to be acceptable and feasible among Kenyan truck drivers, especially if given the opportunity to ask questions.

Predictors of loss to follow-up among patients on ART at a rural hospital in KwaZulu-Natal, South Africa

INTRODUCTION

Improved HIV outcomes as a result of expanded antiretroviral therapy (ART) access is threatened by increasing rates of loss to follow up (LTFU) among those on ART, largely reported in urban populations. Some reports suggest that LTFU rates are overestimated due to patient movement to other facilities and inadequate medical records.

STUDY OBJECTIVE

To define the proportion disengaging from HIV care as well as the characteristics of those LTFU in order to design and implement appropriate interventions to increase retention.

METHODS

We performed a retrospective review of patients who discontinued ART at a central hospital ART clinic in rural South Africa and compared with patients receiving care at the 15 primary health clinics (PHCs) to determine the true proportion of those who were LTFU. We also compared those who discontinued ART with those who did not at the central hospital ART clinic to determine predictors of loss to follow up.

RESULTS

Among 3242 patients on ART, 820 were originally marked as LTFU. Among all patients, 272 (8.4%) were found at a clinic on treatment, 56 (1.7%) were found at a clinic from which they had since discontinued treatment, and 10 (0.3%) returned to care between June and July 2016, leaving 475 (14.7%) unaccounted for and thus categorized as 'true' LTFU. Factors found to be associated with discontinuation include being male, age 18-35, having a CD4 count under 200 cells/μL, and being on ART for under six months.

CONCLUSIONS

Young men with low CD4 counts early after ART initiation are at highest risk of ART disengagement in this rural South African HIV clinic. Novel interventions targeting this group are needed to improve retention in care.

Linkage to HIV care after home-based HIV counselling and testing in sub-Saharan Africa: a systematic review

BACKGROUND

Home-based HIV counselling and testing (HBHCT) has the potential to increase HIV testing uptake in sub-Saharan Africa (SSA), but data on linkage to HIV care after HBHCT are scarce. We conducted a systematic review of linkage to care after HBHCT in SSA.

METHODS

Five databases were searched for studies published between 1st January 2000 and 19th August 2016 that reported on linkage to care among adults newly identified with HIV infection through HBHCT. Eligible studies were reviewed, assessed for risk of bias and findings summarised using the PRISMA guidelines.

RESULTS

A total of 14 studies from six countries met the eligibility criteria; nine used specific strategies (point-of-care CD4 count testing, follow-up counselling, provision of transport funds to clinic and counsellor facilitation of HIV clinic visit) in addition to routine referral to facilitate linkage to care. Time intervals for ascertaining linkage ranged from 1 week to 12 months post-HBHCT. Linkage ranged from 8.2% [95% confidence interval (CI), 6.8-9.8%] to 99.1% (95% CI, 96.9-99.9%). Linkage was generally lower (<33%) if HBHCT was followed by referral only, and higher (>80%) if additional strategies were used. Only one study assessed linkage by means of a randomised trial. Five studies had data on cotrimoxazole (CTX) prophylaxis and 12 on ART eligibility and initiation. CTX uptake among those eligible ranged from 0% to 100%. The proportion of persons eligible for ART ranged from 16.5% (95% CI, 12.1-21.8) to 77.8% (95% CI, 40.0-97.2). ART initiation among those eligible ranged from 14.3% (95% CI, 0.36-57.9%) to 94.9% (95% CI, 91.3-97.4%). Additional linkage strategies, whilst seeming to increase linkage, were not associated with higher uptake of CTX and/or ART. Most of the studies were susceptible to risk of outcome ascertainment bias. A pooled analysis was not performed because of heterogeneity across studies with regard to design, setting and the key variable definitions.

CONCLUSION

Only few studies from SSA investigated linkage to care among adults newly diagnosed with HIV through HBHCT. Linkage was often low after routine referral but higher if additional interventions were used to facilitate it. The effectiveness of linkage strategies should be confirmed through randomised controlled trials.

An open-label cluster randomised trial to evaluate the effectiveness of a counselling intervention on linkage to care among HIV-infected patients in Uganda: Study design

Introduction

Home-based HIV counselling & testing (HBHCT) is highly acceptable and has the potential to increase HIV testing uptake in sub-Saharan Africa. However, data are lacking on strategies that can effectively link HIV-positive individuals identified through HBHCT to care. This trial was designed to assess the effectiveness of two brief home-based counselling sessions on linkage to care, provided subsequent to referral for care among HIV-positive patients identified through HBHCT in a rural community in Masaka district, Uganda.

Methods

28 communities (clusters) were randomly allocated to control (referral only) and intervention (referral and follow-up counselling) arms (n = 14 clusters/arm). Randomisation was stratified on distance from the district capital (≤10 km vs > 10 km) and cluster size (larger single village vs combined small villages), and restricted to ensure balance on selected cluster characteristics. A list of possible allocations was generated and one randomly selected at a public ceremony. HBHCT is being offered to all adults (≥18 years), and HIV-positive individuals not yet in care are eligible for enrolment. The intervention is provided at one and two months post-enrolment. Primary outcomes, assessed 6 months after enrolment, are: the proportion of individuals linking to HIV care within 6 months of HIV diagnosis and time to linkage. The primary analysis will be based on individual-level data.

Discussion

This study will provide evidence on the impact of a counselling intervention on linkage to care among adults identified with HIV infection through HBHCT. Interpretation of the trial outcomes will be aided by results from an on-going qualitative sub-study.

Choice in HIV testing: the acceptability and anticipated use of a self-administered at-home oral HIV test among South Africans

Combination HIV prevention is being widely promoted by funders. This strategy aims to offer HIV prevention choices that can be selected and combined to decrease HIV risk in ways that fit with each individual's situation. Treatment as prevention and pre-exposure prophylaxis are two new evidence-based strategies to decrease HIV incidence, both of which require high HIV testing rates to be effective, and the Joint United Nations Programme on HIV/AIDS (UNAIDS) has set a goal of 90% of HIV-positive individuals knowing their status by 2030. However, HIV testing rates in many countries remain suboptimal. Just as no single HIV prevention method is ideal for all people in all situations, no single HIV testing modality is likely to be acceptable to everyone. By offering HIV testing choices, we may be able to increase testing rates. However, many low-resourced countries have been slow to take up new HIV testing options such as the self-administered at-home oral HIV test that is currently available in the United States. In this paper, we present findings from 20 in-depth interviews, conducted in 2010, documenting opinions about self-administered at-home oral HIV testing, a testing modality still largely unavailable in Africa. Participants were clients of three primary healthcare clinics in South Africa. Self-testing was seen as enabling confidentiality/privacy, saving time, and facilitating testing together with partners. However, concerns were raised about psychological distress when testing at home without a counsellor. Some suggested this concern could be minimised by having experienced clinic-based HIV testing and counselling before getting self-testing kits for home use. Thus, self-administered HIV testing could be an option added to the current testing modalities to address some important barriers to testing.