Brief Report: "Give Me Some Time": Facilitators of and Barriers to Uptake of Home-Based HIV Testing During Household Contact Investigation for Tuberculosis in Kampala, Uganda

Using group norms to promote acceptance of HIV testing during household tuberculosis contact investigation: A household-randomized trial

Background

HIV status awareness and linkage to care are critical for ending the HIV epidemic and preventing tuberculosis (TB). Among household contacts of persons with TB, HIV greatly increases the risk of incident TB and death. However, almost half of household contacts in routine settings decline HIV test offers during routine contact investigation. We evaluated a brief social-behavioral norming intervention to increase acceptance of HIV testing during household TB contact investigation.

Methods

We carried out a household-randomized, controlled trial to evaluate the effect of the norming strategy among household contacts of persons with pulmonary TB in Kampala, Uganda ( ClinicalTrials.gov # NCT05124665 ). Community health workers (CHW) visited homes of persons with TB to screen contacts for TB symptoms and offer free, optional, oral HIV testing. Households were randomized (1:1) to usual care or the norming strategy. Contacts were eligible if they were ≥ 15 years old, self-reported to be HIV-negative, and living in a multi-contact household. The primary outcome, the proportion of contacts accepting HIV testing, was analyzed using an intention-to-treat approach, using a mixed-effects model to account for clustering by household. We assessed HIV testing yield as a proportion of all contacts tested.

Results

We randomized 328 contacts in 99 index households to the norming strategy, of whom 285 (87%) contacts were eligible. We randomized 224 contacts in 86 index households to the usual strategy, of whom 187 (84%) contacts were eligible. Acceptance of HIV testing was higher in the intervention arm (98% versus 92%, difference +6%, 95%CI +2% to +10%, p=0.004). Yield of HIV testing was 2.1% in the intervention arm and 0.6% in the control arm (p=0.22).

Conclusion

A norming intervention significantly improved uptake of HIV testing among household contacts of persons with TB.

Funding/Support

This work was supported by the Center for Interdisciplinary Research on AIDS (P30MH062294) and the Fogarty International Center of the National Institutes of Health (R21TW011270). The content is solely the responsibility of the authors and does not necessarily represent the official views of the NIH or other sponsors.

Modeled estimates of HIV-serodifferent couples in tuberculosis-affected households in four sub-Saharan African countries

Household-based tuberculosis (TB) contact evaluation may be an efficient strategy to reach people who could benefit from oral pre-exposure prophylaxis (PrEP) because of the epidemiological links between HIV and TB. This study estimated the number of HIV serodifferent couples in TB-affected households and potential HIV acquisitions averted through their PrEP use in 4 TB-HIV high-burden countries. We conducted a model-based analysis set in Ethiopia, Kenya, South Africa, and Uganda using parameters from population-based household surveys, systematic literature review and meta-analyses, and estimates from the Global Burden of Diseases, Injuries, and Risk Factors Study 2019. We parameterized the nonlinear relationship between the proportion of serodifferent couples among people living with HIV and population-level HIV prevalence using Markov chain Monte Carlo methods. We integrated all parameters in a mathematical model and propagated uncertainty using a Monte Carlo approach. We estimated the HIV prevalence among adults aged 15-49 living in TB-affected households to be higher than in the general population in all 4 countries. The proportion of serodifferent couples among all couples in TB-affected households was also higher than in the general population (South Africa: 20.7% vs. 15.7%, Kenya: 15.7% vs. 5.7%, Uganda: 14.5% vs. 6.0%, Ethiopia: 4.1% vs. 0.8%). We estimated that up to 1,799 (95% UI: 1,256-2,341) HIV acquisitions in South Africa could be prevented annually by PrEP use in serodifferent couples in TB-affected households, 918 (95% UI: 409-1,450) in Kenya, 686 (95% UI: 505-871) in Uganda, and 408 (95% UI: 298-522) in Ethiopia. As couples in TB-affected households are more likely to be serodifferent than couples in the general population, offering PrEP during household TB contact evaluation may prevent a substantial number of HIV acquisitions.

Community views on active case finding for tuberculosis in low- and middle-income countries: a qualitative evidence synthesis

BACKGROUND

Active case finding (ACF) refers to the systematic identification of people with tuberculosis in communities and amongst populations who do not present to health facilities, through approaches such as door-to-door screening or contact tracing. ACF may improve access to tuberculosis diagnosis and treatment for the poor and for people remote from diagnostic and treatment facilities. As a result, ACF may also reduce onward transmission. However, there is a need to understand how these programmes are experienced by communities in order to design appropriate services.

OBJECTIVES

To synthesize community views on tuberculosis active case finding (ACF) programmes in low- and middle-income countries.

SEARCH METHODS

We searched MEDLINE, Embase, and eight other databases up to 22 June 2023, together with reference checking, citation searching, and contact with study authors to identify additional studies. We did not include grey literature.

SELECTION CRITERIA

This review synthesized qualitative research and mixed-methods studies with separate qualitative data. Eligible studies explored community experiences, perceptions, or attitudes towards ACF programmes for tuberculosis in any endemic low- or middle-income country, with no time restrictions.

DATA COLLECTION AND ANALYSIS

Due to the large volume of studies identified, we chose to sample studies that had 'thick' description and that investigated key subgroups of children and refugees. We followed standard Cochrane methods for study description and appraisal of methodological limitations. We conducted thematic synthesis and developed codes inductively using ATLAS.ti software. We examined codes for underlying ideas, connections, and interpretations and, from this, generated analytical themes. We assessed the confidence in the findings using the GRADE-CERQual approach, and produced a conceptual model to display how the different findings interact.

MAIN RESULTS

We included 45 studies in this synthesis, and sampled 20. The studies covered a broad range of World Health Organization (WHO) regions (Africa, South-East Asia, Eastern Mediterranean, and the Americas) and explored the views and experiences of community members, community health workers, and clinical staff in low- and middle-income countries endemic for tuberculosis. The following five themes emerged. • ACF improves access to diagnosis for many, but does little to help communities on the edge. Tuberculosis ACF and contact tracing improve access to health services for people with worse health and fewer resources (High confidence). ACF helps to find this population, exposed to deprived living conditions, but is not sensitive to additional dimensions of their plight (High confidence) and out-of-pocket costs necessary to continue care (High confidence). Finally, migration and difficult geography further reduce communities' access to ACF (High confidence). • People are afraid of diagnosis and its impact. Some community members find screening frightening. It exposes them to discrimination along distinct pathways (isolation from their families and wider community, lost employment and housing). HIV stigma compounds tuberculosis stigma and heightens vulnerability to discrimination along these same pathways (High confidence). Consequently, community members may refuse to participate in screening, contact tracing, and treatment (High confidence). In addition, people with tuberculosis reported their emotional turmoil upon diagnosis, as they anticipated intense treatment regimens and the prospect of living with a serious illness (High confidence). • Screening is undermined by weak health infrastructure. In many settings, a lack of resources results in weak services in competition with other disease control programmes (Moderate confidence). In this context of low investment, people face repeated tests and clinic visits, wasted time, and fraught social interaction with health providers (Moderate confidence). ACF can create expectations for follow-up health care that it cannot deliver (High confidence). Finally, community education improves awareness of tuberculosis in some settings, but lack of full information impacts community members, parents, and health workers, and sometimes leads to harm for children (High confidence). • Health workers are an undervalued but important part of ACF. ACF can feel difficult for health workers in the context of a poorly resourced health system and with people who may not wish to be identified. In addition, the evidence suggests health workers are poorly protected against tuberculosis and fear they or their families might become infected (Moderate confidence). However, they appear to be central to programme success, as the humanity they offer often acts as a driving force for retaining people with tuberculosis in care (Moderate confidence). • Local leadership is necessary but not sufficient for ensuring appropriate programmes. Local leadership creates an intrinsic motivation for communities to value health services (High confidence). However, local leadership cannot guarantee the success of ACF and contact tracing programmes. It is important to balance professional authority with local knowledge and rapport (High confidence).

AUTHORS' CONCLUSIONS

Tuberculosis active case finding (ACF) and contact tracing bring a diagnostic service to people who may otherwise not receive it, such as those who are well or without symptoms and those who are sick but who have fewer resources and live further from health facilities. However, capturing these 'missing cases' may in itself be insufficient without appropriate health system strengthening to retain people in care. People who receive a tuberculosis diagnosis must contend with a complex and unsustainable cascade of care, and this affects their perception of ACF and their decision to engage with it.

The impact of time at home on potential yield of home-based TB contact investigation

BACKGROUND: The yield of TB contact tracing is often limited by challenges in reaching individuals during the screening process. We investigated the times at which index patients and household contacts were typically at home and the potential effects of expanding the timing of home-based contact investigation.METHODS: Index patients and household contacts in Kampala, Uganda, were asked about their likely availability at different day/time combinations. We calculated the "participant identification gap" (defined as the proportion of participants who reported being home <50% of the time) during business hours only. We then estimated the incremental reduction in the participant identification gap if hours were expanded to include weekday evenings, Saturdays, and Sundays. Statistical significance was assessed using McNemar´s tests.RESULTS: Nearly half of eligible individuals (42% of index patients and 52% of contacts) were not likely to be home during contact investigation conducted only during business hours. Expanding to weekday evenings, Saturdays, and Sundays would reduce this participant identification gap to 15% among index patients and 18% among contacts - while also reducing differences by sex and employment.CONCLUSIONS: Expanding hours for conducting contact investigation or other home-based health interventions could substantially reduce the number of individuals missed and address disparities in access to care.

Assessing the quality of tuberculosis care using routine surveillance data: a process evaluation employing the Zero TB Indicator Framework in Mongolia

OBJECTIVES

To evaluate the feasibility of the Zero TB Indicator Framework as a tool for assessing the quality of tuberculosis (TB) case-finding, treatment and prevention services in Mongolia.

SETTING

Primary health centres, TB dispensaries, and surrounding communities in four districts of Mongolia.

DESIGN

Three retrospective cross-sectional cohort studies, and two longitudinal studies each individually nested in one of the cohort studies.

PARTICIPANTS

15 947 community members from high TB-risk populations; 8518 patients screened for TB in primary health centres and referred to dispensaries; 857 patients with index TB and 2352 household contacts.

PRIMARY AND SECONDARY OUTCOME MEASURES

14 indicators of the quality of TB care defined by the Zero TB Indicator Framework and organised into three care cascades, evaluating community-based active case-finding, passive case-finding in health facilities and TB screening and prevention among close contacts; individual and health-system predictors of these indicators.

RESULTS

The cumulative proportions of participants receiving guideline-adherent care varied widely, from 96% for community-based active case-finding, to 79% for TB preventive therapy among household contacts, to only 67% for passive case-finding in primary health centres and TB dispensaries (range: 29%-80% across districts). The odds of patients completing active TB treatment decreased substantially with increasing age (aOR: 0.76 per decade, 95% CI: 0.71 to 0.83, p<0.001) and among men (aOR: 0.56, 95% CI: 0.36 to 0.88, p=0.013). Contacts of older index patients also had lower odds of initiating and completing of TB preventive therapy (aOR: 0.60 per decade, 95% CI: 0.38 to 0.93, p=0.022).

CONCLUSIONS

The Zero TB Framework provided a feasible and adaptable approach for using routine surveillance data to evaluate the quality of TB care and identify associated individual and health system factors. Future research should evaluate strategies for collecting process indicators more efficiently; gather qualitative data on explanations for low-quality care; and deploy quality improvement interventions.

Assessing a norming intervention to promote acceptance of HIV testing and reduce stigma during household tuberculosis contact investigation: protocol for a cluster-randomised trial

INTRODUCTION

HIV status awareness is important for household contacts of patients with tuberculosis (TB). Home HIV testing during TB contact investigation increases HIV status awareness. Social interactions during home visits may influence perceived stigma and uptake of HIV testing. We designed an intervention to normalise and facilitate uptake of home HIV testing with five components: guided selection of first tester; prosocial invitation scripts; opt-out framing; optional sharing of decisions to test; and masking of decisions not to test.

METHODS AND ANALYSIS

We will evaluate the intervention effect in a household-randomised controlled trial. The primary aim is to assess whether contacts offered HIV testing using the norming strategy will accept HIV testing more often than those offered testing using standard strategies. Approximately 198 households will be enrolled through three public health facilities in Kampala, Uganda. Households will be randomised to receive the norming or standard strategy and visited by a community health worker (CHW) assigned to that strategy. Eligible contacts ≥15 years will be offered optional, free, home HIV testing. The primary outcome, proportion of contacts accepting HIV testing, will be assessed by CHWs and analysed using an intention-to-treat approach. Secondary outcomes will be changes in perceived HIV stigma, changes in perceived TB stigma, effects of perceived HIV stigma on HIV test uptake, effects of perceived TB stigma on HIV test uptake and proportions of first-invited contacts who accept HIV testing. Results will inform new, scalable strategies for delivering HIV testing.

ETHICS AND DISSEMINATION

This study was approved by the Yale Human Investigation Committee (2000024852), Makerere University School of Public Health Institutional Review Board (661) and Uganda National Council on Science and Technology (HS2567). All participants, including patients and their household contacts, will provide verbal informed consent. Results will be submitted to a peer-reviewed journal and disseminated to national stakeholders, including policy-makers and representatives of affected communities.

TRIAL REGISTRATION NUMBER

ClinicalTrials.gov Identifier: NCT05124665.

Enthusiasm for Introducing and Integrating HIV Self-Testing but Doubts About Users: A Baseline Qualitative Analysis of Key Stakeholders' Attitudes and Perceptions in Côte d'Ivoire, Mali and Senegal

Since 2019, the ATLAS project, coordinated by Solthis in collaboration with national AIDS programs, has introduced, promoted and delivered HIV self-testing (HIVST) in Côte d'Ivoire, Mali and Senegal. Several delivery channels have been defined, including key populations: men who have sex with men, female sex workers and people who use injectable drugs. At project initiation, a qualitative study analyzing the perceptions and attitudes of key stakeholders regarding the introduction of HIVST in their countries and its integration with other testing strategies for key populations was conducted. The study was conducted from September to November 2019 within 3 months of the initiation of HIVST distribution. Individual interviews were conducted with 60 key informants involved in the project or in providing support and care to key populations: members of health ministries, national AIDS councils, international organizations, national and international non-governmental organizations, and peer educators. Semi structured interviews were recorded, translated when necessary, and transcribed. Data were coded using Dedoose© software for thematic analyses. We found that stakeholders' perceptions and attitudes are favorable to the introduction and integration of HIVST for several reasons. Some of these reasons are held in common, and some are specific to each key population and country. Overall, HIVST is considered able to reduce stigma; preserve anonymity and confidentiality; reach key populations that do not access testing via the usual strategies; remove spatial barriers; save time for users and providers; and empower users with autonomy and responsibility. It is non-invasive and easy to use. However, participants also fear, question and doubt users' autonomy regarding their ability to use HIVST kits correctly; to ensure quality secondary distribution; to accept a reactive test result; and to use confirmation testing and care services. For stakeholders, HIVST is considered an attractive strategy to improve access to HIV testing for key populations. Their doubts about users' capacities could be a matter for reflective communication with stakeholders and local adaptation before the implementation of HIVST in new countries. Those perceptions may reflect the West African HIV situation through the emphasis they place on the roles of HIV stigma and disclosure in HIVST efficiency.

Female warfighters' perceptions of urogenital health in operational settings

BACKGROUND

An increased incidence in hygiene-related urogenital infections (bacterial vaginitis, vulvovaginal candidiasis, and urinary tract) has been reported in female warfighters serving in austere environments with decreased availability of water and sanitation resources, and when personal safety outweighs concerns for hygiene. Knowledge and access to an innovative kit designed for the female warfighter to self-test, self-identify, and self-treat common urogenital symptoms is critical to force health.

PURPOSE

The purpose of this descriptive, cross-sectional, exploratory qualitative study was to explore female warfighters': 1) confidence in seeking sex-specific health care in field and deployment environments and 2) acceptance and willingness to self-test, self-identify, and self-treat urogenital symptoms and infections.

METHODOLOGICAL ORIENTATION

Qualitative data for this thematic analysis were collected during administration of the Military Women's Readiness Urogenital Health Questionnaire. Participants provided open-ended comments associated with three survey questions. Braun and Clarke's inductive thematic analysis method guided the narrative analysis.

SAMPLE

Our sample included a diverse group of US Army women (USAW; n = 152) from a large, military installation.

RESULTS

Narratives and themes demonstrate USAW's desire and need for the availability of a self-test and self-treatment kit. Access, time, mission, and prevention of self-harm by quicker resolve of symptoms are cited as key reasons in support of such a kit.

CONCLUSIONS AND PRACTICE IMPLICATIONS

Nurse practitioners (NPs) are ideally positioned to provide sex-specific educational interventions and anticipatory guidance that supports physical health, to include urogenital conditions. As urogenital self-testing becomes available for female warfighters, NPs are the model healthcare provider for educating women on their use.

Home-Based Intervention to Test and Start (HITS): a community-randomized controlled trial to increase HIV testing uptake among men in rural South Africa

Introduction

The uptake of HIV testing and linkage to care remains low among men, contributing to high HIV incidence in women in South Africa. We conducted the “Home‐Based Intervention to Test and Start” (HITS) in a 2x2 factorial cluster randomized controlled trial in one of the World’s largest ongoing HIV cohorts in rural South Africa aimed at enhancing both intrinsic and extrinsic motivations for HIV testing.

Methods

Between February and December 2018, in the uMkhanyakude district of KwaZulu‐Natal, we randomly assigned 45 communities (clusters) (n = 13,838 residents) to one of the four arms: (i) financial incentives for home‐based HIV testing and linkage to care (R50 [$3] food voucher each); (ii) male‐targeted HIV‐specific decision support application, called EPIC‐HIV; (iii) both financial incentives and male‐targeted HIV‐specific decision support application and (iv) standard of care (SoC). EPIC‐HIV was developed to encourage and serve as an intrinsic motivator for HIV testing and linkage to care, and individually offered to men via a tablet device. Financial incentives were offered to both men and women. Here we report the effect of the interventions on uptake of home‐based HIV testing among men. Intention‐to‐treat (ITT) analysis was performed using modified Poisson regression with adjustment for clustering of standard errors at the cluster levels.

Results

Among all 13,838 men ≥ 15 years living in the 45 communities, the overall population coverage during a single round of home‐based HIV testing was 20.7%. The uptake of HIV testing was 27.5% (683/2481) in the financial incentives arm, 17.1% (433/2534) in the EPIC‐HIV arm, 26.8% (568/2120) in the arm receiving both interventions and 17.8% in the SoC arm. The probability of HIV testing increased substantially by 55% in the financial incentives arm (risk ratio (RR)=1.55, 95% CI: 1.31 to 1.82, p < 0.001) and 51% in the arm receiving both interventions (RR = 1.51, 95% CI: 1.21 to 1.87 p < 0.001), compared to men in the SoC arm. The probability of HIV testing did not significantly differ in the EPIC‐HIV arm (RR = 0.96, 95% CI: 0.76 to 1.20, p = 0.70).

Conclusions

The provision of a small financial incentive acted as a powerful extrinsic motivator substantially increasing the uptake of home‐based HIV testing among men in rural South Africa. In contrast, the counselling and testing application which was designed to encourage and serve as an intrinsic motivator to test for HIV did not increase the uptake of home‐based testing.

Home-based tuberculosis contact investigation in Uganda: a household randomised trial

Introduction

The World Health Organization (WHO) recommends household tuberculosis (TB) contact investigation in low-income countries, but most contacts do not complete a full clinical and laboratory evaluation.

Methods

We performed a randomised trial of home-based, SMS-facilitated, household TB contact investigation in Kampala, Uganda. Community health workers (CHWs) visited homes of index patients with pulmonary TB to screen household contacts for TB. Entire households were randomly allocated to clinic (standard-of-care) or home (intervention) evaluation. In the intervention arm, CHWs offered HIV testing to adults; collected sputum from symptomatic contacts and persons living with HIV (PLWHs) if ≥5 years; and transported sputum for microbiologic testing. CHWs referred PLWHs, children <5 years, and anyone unable to complete sputum testing to clinic. Sputum testing results and/or follow-up instructions were returned by automated SMS texts. The primary outcome was completion of a full TB evaluation within 14 days; secondary outcomes were TB and HIV diagnoses and treatments among screened contacts.

Results

There were 471 contacts of 190 index patients allocated to the intervention and 448 contacts of 182 index patients allocated to the standard-of-care. CHWs identified 190/471 (40%) intervention and 213/448 (48%) standard-of-care contacts requiring TB evaluation. In the intervention arm, CHWs obtained sputum from 35/91 (39%) of sputum-eligible contacts and SMSs were sent to 95/190 (50%). Completion of TB evaluation in the intervention and standard-of-care arms at 14 days (14% versus 15%; difference −1%, 95% CI −9% to 7%, p=0.81) and yields of confirmed TB (1.5% versus 1.1%, p=0.62) and new HIV (2.0% versus 1.8%, p=0.90) diagnoses were similar.

Conclusions

Home-based, SMS-facilitated evaluation did not improve completion or yield of household TB contact investigation, likely due to challenges delivering the intervention components.

In a household randomised trial in Kampala, Uganda, home-based, SMS-facilitated evaluation did not improve completion or yield of household TB contact investigation. Future studies will evaluate user-centred design to improve intervention delivery.http://bit.ly/2xwLpDu

Integrating home HIV counselling and testing into household TB contact investigation: a mixed-methods study

Setting: Community health workers (CHWs) increasingly deliver community-based human immunodeficiency virus (HIV) counselling and testing (HCT) services. Less is known about how this strategy performs when integrated with household tuberculosis (TB) contact investigations. Objective: We conducted a prospective mixed-methods study to evaluate the feasibility and quality of CHW-facilitated, home-based HCT among household TB contacts. Design: CHWs visited households of consenting TB patients to screen household contacts for TB and HIV. They performed HIV testing using a serial enzyme-linked immunosorbent assay rapid-antibody testing algorithm. Laboratory technicians at health facilities re-tested the samples and coordinated quarterly HIV panel testing for CHWs. We conducted focus group discussions (FGDs) with CHWs on their experiences in carrying out home-based HCT. Results: Of 114 household contacts who consented to and underwent HIV testing by CHWs, 5 (4%) tested positive, 108 (95%) tested negative, and 1 (1%) had indeterminate results; 110 (96%) samples had adequate volume for re-testing. Overall agreement between CHWs and laboratory technicians was 99.1% (κ = 0.90, 95%CI 0.71-1.00, P < 0.0001). In FGDs, CHWs described context-specific social challenges to performing HCT in a household setting, but said that their confidence grew with experience. Conclusion: Home-based HCT by CHWs was feasible among household TB contacts and produced high-quality results. Strategies to address social challenges are required to optimize yield.