High accuracy of home-based community rapid HIV testing in rural Malawi

Estimating pneumococcal carriage dynamics in adults living with HIV in a mature infant pneumococcal conjugate vaccine programme in Malawi, a modelling study

BACKGROUND

Adults living with human immunodeficiency virus (ALWHIV) receiving antiretroviral therapy (ART) exhibit higher pneumococcal carriage prevalence than adults without HIV (HIV-). To assess factors influencing high pneumococcal carriage in ALWHIV, we estimated pneumococcal carriage acquisition and clearance rates in a high transmission and disease-burdened setting at least 10 years after introducing infant PCV13 in routine immunisation.

METHODS

We collected longitudinal nasopharyngeal swabs from individuals aged 18-45 in Blantyre, Malawi. The study group included both HIV- individuals and those living with HIV, categorised based on ART duration as either exceeding 1 year (ART > 1y) or less than 3 months (ART < 3 m). Samples were collected at baseline and then weekly for 16 visits. To detect pneumococcal carriage, we used classical culture microbiology, and to determine pneumococcal serotypes, we used latex agglutination. We modelled trajectories of serotype colonisation using multi-state Markov models to capture pneumococcal carriage dynamics, adjusting for age, sex, number of under 5 year old (< 5y) children, social economic status (SES), and seasonality.

RESULTS

We enrolled 195 adults, 65 adults in each of the study groups. 51.8% were females, 25.6% lived with more than one child under 5 years old, and 41.6% lived in low socioeconomic areas. The median age was 33 years (IQR 25-37 years). The baseline pneumococcal carriage prevalence of all serotypes was 31.3%, with non-PCV13 serotypes (NVT) at 26.2% and PCV13 serotypes (VT) at 5.1%. In a multivariate longitudinal analysis, pneumococcal carriage acquisition was higher in females than males (hazard ratio [HR], NVT [1.53]; VT [1.96]). It was also higher in low than high SES (NVT [1.38]; VT [2.06]), in adults living with 2 + than 1 child < 5y (VT [1.78]), and in ALWHIV on ART > 1y than HIV- adults (NVT [1.43]). Moreover, ALWHIV on ART > 1y cleared pneumococci slower than HIV- adults ([0.65]). Residual VT 19F and 3 were highly acquired, although NVT remained dominant.

CONCLUSIONS

The disproportionately high point prevalence of pneumococcal carriage in ALWHIV on ART > 1y is likely due to impaired nasopharyngeal clearance, which results in prolonged carriage. Our findings provide baseline estimates for comparing pneumococcal carriage dynamics after implementing new PCV strategies in ALWHIV.

Evaluating the sensitivity and specificity of Determine™ HIV-1/2 rapid test using a 0.01M phosphate-buffered saline produced at the Medical Research Council Unit The Gambia for the diagnosis of HIV

BACKGROUND

Human immunodeficiency virus (HIV) rapid diagnostic tests (RDTs) are widely used. However, buffer stockouts commonly lead to utilising non-approved liquids, resulting in errors. Our aim was to evaluate the diagnostic accuracy of an alternative buffer.

METHODS

Paired Determine HIV-1/2 rapid tests with commercial buffer and locally produced 0.01M phosphate-buffered saline (PBS) were performed on consecutive consenting individuals requiring HIV testing. Serum samples were sent for confirmation through the local gold-standard algorithm (Murex HIV Ag/Ab, Hexagon HIV with/without Geenius HIV 1/2). Test accuracy, κ and exact McNemar's test were also carried out.

RESULTS

Of 167 participants, 137 had confirmatory testing. The sensitivity of the Determine HIV-1/2 test using PBS compared with the gold standard was 100% (95% confidence interval [CI] 90.5 to 100) with a specificity of 98% (95% CI 92.9 to 99.8). The κ value was 0.94 compared with the gold standard and 0.92 compared with the Determine HIV-1/2 test using the commercial buffer. McNemar's test showed no evidence of differing sensitivities. Due to operational constraints, the study included 37 of the 49 positive cases as determined by the sample size calculation, resulting in an attained power of 80% instead of the intended 90%.

CONCLUSIONS

These results suggest that 0.01M PBS is an alternative solution for Determine HIV-1/2 when buffer stockouts occur.

Accuracy of point-of-care HIV and CD4 field testing by lay healthcare workers in the Botswana Combination Prevention Project

Accurate HIV and CD4 testing are critical in program implementation, with HIV misdiagnosis having serious consequences at both the client and/or community level. We implemented a comprehensive training and Quality Assurance (QA) program to ensure accuracy of point-of-care HIV and CD4 count testing by lay counsellors during the Botswana Combination Prevention Project (BCPP). We compared the performance of field testing by lay counsellors to results from an accredited laboratory to ascertain accuracy of testing. All trained lay counsellors passed competency assessments and performed satisfactorily in proficiency testing panel evaluations in 2013, 2014, and 2015. There was excellent agreement (99.6 %) between field and laboratory-based HIV test results; of the 3002 samples tested, 960 and 2030 were concordantly positive and negative respectively, with 12 misclassifications (kappa score 0.99, p < 0.0001). Of the 149 HIV-positive samples enumerated for CD4 count in the field using PIMA at a threshold of ≤ 350 cells/µl; there was 86 % agreement with laboratory testing, with only 21 misclassified. The mean difference between field and lab CD4 testing was - 16.16 cells/µl (95 % CI -5.4 to 26.9). Overall, there was excellent agreement between field and laboratory results for both HIV rapid test and PIMA CD4 results. A standard training package to train lay counsellors to accurately perform HIV and CD4 point-of-care testing in field settings was feasible, with point-of-care results obtained by lay counsellors comparable to laboratory-based testing.

Screening Antibodies Raised against the Spike Glycoprotein of SARS-CoV-2 to Support the Development of Rapid Antigen Assays

Severe acute respiratory coronavirus-2 (SARS-CoV-2) is a novel viral pathogen and therefore a challenge to accurately diagnose infection. Asymptomatic cases are common and so it is difficult to accurately identify infected cases to support surveillance and case detection. Diagnostic test developers are working to meet the global demand for accurate and rapid diagnostic tests to support disease management. However, the focus of many of these has been on molecular diagnostic tests, and more recently serologic tests, for use in primarily high-income countries. Low- and middle-income countries typically have very limited access to molecular diagnostic testing due to fewer resources. Serologic testing is an inappropriate surrogate as the early stages of infection are not detected and misdiagnosis will promote continued transmission. Detection of infection via direct antigen testing may allow for earlier diagnosis provided such a method is sensitive. Leading SARS-CoV-2 biomarkers include spike protein, nucleocapsid protein, envelope protein, and membrane protein. This research focuses on antibodies to SARS-CoV-2 spike protein due to the number of monoclonal antibodies that have been developed for therapeutic research but also have potential diagnostic value. In this study, we assessed the performance of antibodies to the spike glycoprotein, acquired from both commercial and private groups in multiplexed liquid immunoassays, with concurrent testing via a half-strip lateral flow assays (LFA) to indicate antibodies with potential in LFA development. These processes allow for the selection of pairs of high-affinity antispike antibodies that are suitable for liquid immunoassays and LFA, some of which with sensitivity into the low picogram range with the liquid immunoassay formats with no cross-reactivity to other coronavirus S antigens. Discrepancies in optimal ranking were observed with the top pairs used in the liquid and LFA formats. These findings can support the development of SARS-CoV-2 LFAs and diagnostic tools.

Screening Antibodies Raised against the Spike Glycoprotein of SARS-CoV-2 to Support the Development of Rapid Antigen Assays

Severe acute respiratory coronavirus-2 (SARS-CoV-2) is a novel viral pathogen and therefore a challenge to accurately diagnose infection. Asymptomatic cases are common and so it is difficult to accurately identify infected cases to support surveillance and case detection. Diagnostic test developers are working to meet the global demand for accurate and rapid diagnostic tests to support disease management. However, the focus of many of these has been on molecular diagnostic tests, and more recently serologic tests, for use in primarily high-income countries. Low- and middle-income countries typically have very limited access to molecular diagnostic testing due to fewer resources. Serologic testing is an inappropriate surrogate as the early stages of infection are not detected and misdiagnosis will promote continued transmission. Detection of infection via direct antigen testing may allow for earlier diagnosis provided such a method is sensitive. Leading SARS-CoV-2 biomarkers include spike protein, nucleocapsid protein, envelope protein, and membrane protein. This research focuses on antibodies to SARS-CoV-2 spike protein due to the number of monoclonal antibodies that have been developed for therapeutic research but also have potential diagnostic value. In this study, we assessed the performance of antibodies to the spike glycoprotein, acquired from both commercial and private groups in multiplexed liquid immunoassays, with concurrent testing via a half-strip lateral flow assays (LFA) to indicate antibodies with potential in LFA development. These processes allow for the selection of pairs of high-affinity antispike antibodies that are suitable for liquid immunoassays and LFA, some of which with sensitivity into the low picogram range with the liquid immunoassay formats with no cross-reactivity to other coronavirus S antigens. Discrepancies in optimal ranking were observed with the top pairs used in the liquid and LFA formats. These findings can support the development of SARS-CoV-2 LFAs and diagnostic tools.

Retesting for verification of HIV diagnosis before antiretroviral therapy initiation in Harare, Zimbabwe: Is there a gap between policy and practice?

BACKGROUND

WHO recommends retesting of HIV-positive patients before starting antiretroviral therapy (ART). There is no evidence on implementation of retesting guidelines from programmatic settings. We aimed to assess implementation of HIV retesting among clients diagnosed HIV-positive in the public health facilities of Harare, Zimbabwe, in June 2017.

METHODS

This cohort study involved analysis of secondary data collected routinely by the programme.

RESULTS

Of 1729 study participants, 639 (37%) were retested. Misdiagnosis of HIV was found in six (1%) of the patients retested-all were infants retested with DNA-PCR. There was no HIV misdiagnosis among adults. Among those retested, 95% were retested on the same day and two-thirds were tested by a different provider as per national guidelines. Among those retested and found positive, 95% were started on ART, while none of those with negative retest results were started on ART. Of those not retested, about half (51%) were started on ART. The median (IQR) time to ART initiation from diagnosis was 0 (0-1) d.

CONCLUSION

The implementation of HIV-retesting policy in Harare was poor. While most HIV retest positives were started on ART, only half non-retested received ART. Future research is needed to understand the reasons for non-retesting and non-initiation of ART among those not retested.

Does antiretroviral therapy use affect the accuracy of HIV rapid diagnostic assays? Experience from a demographic health and surveillance site in rural South Africa

Rapid diagnostic tests (RDTs) are the mainstay of HIV diagnosis in the developing world but might have poor sensitivity among individuals taking antiretroviral therapy (ART). We leveraged a home-based HIV testing program linked to clinical data to compare the sensitivity of RDTs between individuals using versus not using ART. Field workers tested 6802 individuals using 2 HIV RDTs, which were compared to a single HIV immunoassay tested on dried blood spots. Approximately 5% (371/6802) tested positive by immunoassay, of whom 157 (42%) were currently on ART. The sensitivity of the Abon RDT among those never versus currently on ART was 91.6% (95% CI 88.3–94.3) and 96.6% (95% CI 88.3–94.3), respectively, and 95.4% (95% CI 92.8–97.3) versus 99.3% (95% CI 95.2–99.7) for the Advanced Quality assay. We report similar sensitivity of RDTs in ART-naïve and ART-experienced individuals, which mitigates concerns about their use among treated individuals in population-based epidemiologic surveys and those transferring care.

Using mHealth to Deliver a Home-Based Testing and Counseling Program to Improve Linkage to Care and ART Adherence in Rural South Africa

Community-based HIV testing and counseling (HTC) programs have become an important part of the healthcare system in South Africa and other low- and middle-income countries with a high HIV prevalence and strained primary healthcare system. Current HTC programs excel at identifying people living with HIV (PLH) but leave gaps in linkage to care and antiretroviral therapy (ART) as most HTC programs do not have the capacity to ensure that linkage has occurred. This article presents the protocol for an mHealth study, that is, pilot testing a mobile platform in KwaZulu-Natal (KZN), South Africa, to improve linkage to care and ART adherence after home-based HTC. Testing data are shared with designated clinics. PLH are identified using fingerprint scans, mobile numbers, or South African IDs. If PLH do not present at a designated clinic after testing HIV positive, study field staff are sent SMS alerts to prompt follow-up visits. Similarly, if PLH do not refill ART prescriptions after their initial 1-month dose runs out, SMS alerts that are sent to field staff. This paper presents the mHealth study protocol and baseline sample characteristics (N = 101 PLH). Analyses will summarize rates of linkage to care and ART prescription refills. Cost-effectiveness analyses will examine the costs and benefits of linkage and ART adherence using our mHealth system. Linkage to care rates will be compared between our study and a historical control, that is, provided by a prior HTC program that was conducted in KZN without our mHealth system (n = 615).

Feasibility of home-based HIV counselling and testing and linking to HIV services among women delivering at home in Geita, Tanzania: a household longitudinal survey

Background

Substantial number of women who deliver at home (WDH) are not captured in prevention of mother-to-child transmission (PMTCT) services. This delays HIV infection detection that negatively impacts endeavours to fight the HIV pandemic and the health of mothers and children. The study objective was to determine the feasibility of home-based HIV testing and linking to care for HIV services among WDH in Geita District Council, Tanzania.

Methods

A longitudinal household survey was conducted. The study involved all mentally-able women who delivered within 2 years (WDTY) preceding the survey and their children under the age of two. The study was conducted in Geita District Council in Geita Region, Tanzania from June to July 2017. Geita is among the region with high HIV prevalence and proportion of women delivering at home.

Results

Of the 993 women who participated in the study, 981 (98.8%) accepted household-based HIV counselling and testing (HBHCT) from the research team. HIV prevalence was 5.3% (52 women). HBHCT identified 26 (2.7%) new HIV infections; 23 (23.4%) were those tested negative at ANC and the remaining three (0.3%) were those who had no HIV test during the ANC visit. Among the 51 HIV+ women, 21 (40.4%) were enrolled in PMTCT services. Of the 32 HIV+ participants who delivered at home, eight (25.8%) were enrolled in the PMTCT compared to 100% (13/13) of the women who delivered at a health facility.

Conclusion

HBHCT uptake was high. HBHCT detected new HIV infection among WDH as well as seroconversion among women with previously negative HIV tests. The study findings emphasize the importance of extending re-testing to women who breastfeed. HBHCT is feasible and can be used to improve PMTCT services among WDH.

Effect and cost of two successive home visits to increase HIV testing coverage: a prospective study in Lesotho, Southern Africa

BACKGROUND

Home-based HIV testing and counselling (HB-HTC) is frequently used to increase awareness of HIV status in sub-Saharan Africa. Whereas acceptance of HB-HTC is usually high, testing coverage may remain low due to household members being absent during the home visits. This study assessed whether two consecutive visits, one during the week, one on the weekend, increase coverage.

METHODS

The study was a predefined nested-study of the CASCADE-trial protocol and conducted in 62 randomly selected villages and 17 urban areas in Butha-Buthe district, Lesotho. HB-HTC teams visited each village/urban area twice: first during a weekday, followed by a weekend visit to catch-up for household members absent during the week. Primary outcome was HTC coverage after first and second visit. Coverage was defined as all individuals who knew their HIV status out of all household members (present and absent).

RESULTS

HB-HTC teams visited 6665 households with 18,286 household members. At first visit, 69.2 and 75.4% of household members were encountered in rural and urban households respectively (p < 0.001) and acceptance for testing was 88.5% in rural and 79.5% in urban areas (p < 0.001), resulting in a coverage of 61.8 and 61.5%, respectively. After catch-up visit, the HTC coverage increased to 71.9% in rural and 69.4% in urban areas. The number of first time testers was higher at the second visit (47% versus 35%, p < 0.001). Direct cost per person tested and per person tested HIV positive were lower during weekdays (10.50 and 335 USD) than during weekends (20 and 1056 USD).

CONCLUSIONS

A catch-up visit on weekends increased the proportion of persons knowing their HIV status from 62 to 71% and reached more first-time testers. However, cost per person tested during catch-up visits was nearly twice the cost during first visit.

TRIAL REGISTRATION

NCT02692027 (prospectively registered on February 21, 2016).

Methods, outcomes, and costs of a 2.5 year comprehensive facility-and community-based HIV testing intervention in Bukoba Municipal Council, Tanzania, 2014-2017

To diagnose ≥90% HIV-infected residents (diagnostic coverage), the Bukoba Combination Prevention Evaluation (BCPE) implemented provider-initiated (PITC), home- (HBHTC), and venue-based (VBHTC) HIV testing and counseling (HTC) intervention in Bukoba Municipal Council, a mixed urban and rural lake zone community of 150,000 residents in Tanzania. This paper describes the methods, outcomes, and incremental costs of these HTC interventions. PITC was implemented in outpatient department clinics in all eight public and three faith-based health facilities. In clinics, lay counselors routinely screened and referred eligible patients for HIV testing conducted by HTC-dedicated healthcare workers. In all 14 wards, community teams offered HTC to eligible persons encountered at 31,293 home visits and at 79 male- and youth-frequented venues. HTC was recommended for persons who were not in HIV care or had not tested in the prior 90 days. BCPE conducted 133,695 HIV tests during the 2.5 year intervention (PITC: 88,813, 66%; HBHTC: 27,407, 21%; VBHTC: 17,475, 13%). Compared with other strategies, PITC conducted proportionally more tests among females (65%), and VBHTC conducted proportionally more tests among males (69%) and young-adults aged 15-24 years (42%). Of 5,550 (4.2% of all tests) HIV-positive tests, 4,143 (75%) clients were newly HIV diagnosed, including 1,583 males and 881 young adults aged 15-24 years. Of HIV tests conducted 3.7%, 1.8%, and 2.1% of PITC, HBHTC, and VBHTC clients, respectively, were newly HIV diagnosed; PITC accounted for 79% of all new diagnoses. Cost per test (per new diagnosis) was $4.55 ($123.66), $6.45 ($354.44), and $7.98 ($372.67) for PITC, HBHTC, and VBHTC, respectively. In a task-shifting analysis in which lay counselors replaced healthcare workers, estimated costs per test (per new diagnosis) would have been $3.06 ($83.15), $ 4.81 ($264.04), and $5.45 ($254.52), for PITC, HBHTC, and VBHTC, respectively. BCPE models reached different target groups, including men and young adults, two groups with consistently low coverage. Implementation of multiple models is likely necessary to achieve ≥90% diagnostic coverage.

Provision of HIV services by community health workers should be strengthened to achieve full programme potential: a cross-sectional analysis in rural South Africa

OBJECTIVE

South Africa's community health workers (CHWs) provide a bridge between the primary healthcare (PHC) facility and its community. We conducted a cross-sectional analysis to determine the contribution of the community-based HIV programme (CBHP) to the overall HIV programme.

METHODS

We collected service provision data from the daily activity register of CHWs attached to 12 PHC facilities in rural Mopani District, South Africa. Personal identifiers of individuals referred to the facility for HIV services were recorded and verified against facility routine patient registers to determine the effectiveness of referral.

RESULTS

HIV services were provided on 18 927 occasions; 30% of the total activities performed by CHWs during the study period. CHWs assessed 12 159 individuals for HIV risk (13% coverage of the study population); only 290 (2%) were referred for HIV testing services. Referral was effective in 213 (73%) individuals; evidence of an HIV-positive status was found for 38 (18%) individuals. However, 30 (79%) of these individuals were referred by CHWs despite being on ART. Adherence support was provided during 5657 visits; only one individual was referred for complications. Finally, of the 864 individuals lost to the ART programme, CHWs managed to find 452 (52%) for referral back to the facility; only 241 (53%) of these were (re)initiated on ART.

CONCLUSIONS

Provision of HIV services by CHWs should be strengthened to fully deliver on the programme's potential. Human resource investment, home-based HIV testing and improved tracing models constitute potential strategies to enhance CHWs impact on the HIV programme.

Lay provider HIV testing: A promising strategy to reach the undiagnosed key populations in Vietnam

Background

In Vietnam, reaching the remaining one-third of undiagnosed people living with HIV and facilitating their antiretroviral therapy (ART) enrollment requires breakthrough approaches. We piloted lay provider HIV testing as an innovative approach to reach at-risk populations that never or infrequently HIV test at facility-based services.

Methods

We conducted a cross-sectional survey and analysis of routine program data in two urban provinces (Hanoi and Ho Chi Minh City) and two rural mountainous provinces (Nghe An and Dien Bien) from October 2015 through September 2017. Acceptability of lay provider testing was defined as the proportion of first-time HIV testers utilizing the service, and effectiveness was measured by HIV positivity and ART initiation rates. Univariate and multivariate analyses were used to determine lay provider testing preference and factors associated with that preference.

Results

Among 1,230 individuals recruited for face-to-face interviews, 74% belonged to key populations: people who inject drugs accounted for 31.4%; men who have sex with men, 60.4%; and female sex workers, 8.2%. Most clients (67%) reported being first-time HIV testers, and the majority (85.8%) preferred lay provider testing to facility-based testing. Multivariate analysis found that clients in urban areas (adjusted odds ratio [aOR] = 2.50; 95% confidence interval [CI]: 1.30–4.90) and those who had a university or higher education (aOR = 1.83; 95% CI: 1.05–3.20) were more likely to prefer lay provider testing. Lay provider testing yielded a higher HIV positivity rate (4.1%), particularly among first-time testers (6.8%), compared to facility-based testing (nationally estimated at 1.6% in 2016) and had a high ART initiation rate (91%).

Conclusions

Our findings suggest that lay provider HIV testing is an effective approach to reach previously unreached at-risk populations, and, therefore, a critical addition to accelerating Vietnam’s attainment of the Joint United Nations Programme on HIV/AIDS 90-90-90 goals.

Misdiagnosis of HIV infection during a South African community-based survey: implications for rapid HIV testing

Introduction: We describe the overall accuracy and performance of a serial rapid HIV testing algorithm used in community-based HIV testing in the context of a population-based household survey conducted in two sub-districts of uMgungundlovu district, KwaZulu-Natal, South Africa, against reference fourth-generation HIV-1/2 antibody and p24 antigen combination immunoassays. We discuss implications of the findings on rapid HIV testing programmes.

Methods: Cross-sectional design: Following enrolment into the survey, questionnaires were administered to eligible and consenting participants in order to obtain demographic and HIV-related data. Peripheral blood samples were collected for HIV-related testing. Participants were offered community-based HIV testing in the home by trained field workers using a serial algorithm with two rapid diagnostic tests (RDTs) in series. In the laboratory, reference HIV testing was conducted using two fourth-generation immunoassays with all positives in the confirmatory test considered true positives. Accuracy, sensitivity, specificity, positive predictive value, negative predictive value and false-positive and false-negative rates were determined.

Results: Of 10,236 individuals enrolled in the survey, 3740 were tested in the home (median age 24 years (interquartile range 19–31 years), 42.1% males and HIV positivity on RDT algorithm 8.0%). From those tested, 3729 (99.7%) had a definitive RDT result as well as a laboratory immunoassay result. The overall accuracy of the RDT when compared to the fourth-generation immunoassays was 98.8% (95% confidence interval (CI) 98.5–99.2). The sensitivity, specificity, positive predictive value and negative predictive value were 91.1% (95% CI 87.5–93.7), 99.9% (95% CI 99.8–100), 99.3% (95% CI 97.4–99.8) and 99.1% (95% CI 98.8–99.4) respectively. The false-positive and false-negative rates were 0.06% (95% CI 0.01–0.24) and 8.9% (95% CI 6.3–12.53). Compared to true positives, false negatives were more likely to be recently infected on limited antigen avidity assay and to report antiretroviral therapy (ART) use.

Conclusions: The overall accuracy of the RDT algorithm was high. However, there were few false positives, and the sensitivity was lower than expected with high false negatives, despite implementation of quality assurance measures. False negatives were associated with recent (early) infection and ART exposure. The RDT algorithm was able to correctly identify the majority of HIV infections in community-based HIV testing. Messaging on the potential for false positives and false negatives should be included in these programmes.

Identification of misdiagnosed HIV clients in an Early Access to ART for All implementation study in Swaziland

Introduction: Rapid diagnostic testing has made HIV diagnosis and subsequent treatment more accessible. However, multiple factors, including improper implementation of testing strategies and clerical errors, have been reported to lead to HIV misdiagnosis. The World Health Organization has recommended HIV retesting prior to antiretroviral therapy (ART) initiation which has become pertinent with scaling up of Early Access to ART for All (EAAA). In this analysis, misdiagnosed clients are identified from a subgroup of clients enrolled in EAAA implementation study in Swaziland.

Methods: The subgroup to assess misdiagnosis was identified from enrolled EAAA study clients, who had an undetectable viral load prior to ART initiation between September 1, 2014 and May 31, 2016. One hundred and five of 2533 (4%) clients had an undetectable viral load prior to initiation to ART (pre-ART). The HIV status of clients was confirmed using the Determine HIV 1/2 and Uni-Gold HIV 1/2 rapid tests performed serially as recommended by the national testing algorithm. The status of clients on ART was additionally confirmed by fourth-generation HIV Ag/Ab combo tests, Architect and Genscreen Ultra.

Results: Fourteen of the 105 (13%) clients were false positive (HIV negative) on confirmation testing, of whom five (36%) were still in pre-ART care, while nine (64%) were in ART care. Overall, proportion of false positive was 0.6% (14/2533). The false-positive clients had a median CD4 of 791 cells/ml (interquartile range (IQR): 628, 967) compared to 549 cells/ml (IQR: 387, 791) for true positives (HIV positive) (p = 0.0081) and were nearly 20 years older (p = 0.0008).

Conclusions: Overall 0.6% of all enrolled EAAA clients were misdiagnosed, and 64% of misdiagnosed clients were initiated on ART. With adoption of EAAA guidelines by national governments, ART initiation regardless of immunological criteria, strengthening of proficiency testing and adoption of retesting prior to ART initiation would allow identification of misdiagnosed clients and further reduce potential of initiating misdiagnosed clients on ART.

Understanding low sensitivity of community-based HIV rapid testing: experiences from the HPTN 071 (PopART) trial in Zambia and South Africa

Introduction: Population-wide HIV testing services (HTS) must be delivered in order to achieve universal antiretroviral treatment (ART) coverage. To accurately deliver HTS at such scale, non-facility-based HIV point-of-care testing (HIV-POCT) is necessary but requires rigorous quality assurance (QA). This study assessed the performance of community-wide HTS in Zambia and South Africa (SA) as part of the HPTN 071 (PopART) study and explores the impact of quality improvement interventions on HTS performance.

Methods: Between 2014 and 2016, HIV-POCT was undertaken within households both as part of the randomly selected HPTN 071 research cohort (Population Cohort [PC]) and as part of the intervention provided by community HIV-care providers. HIV-POCT followed national algorithms in both countries. Consenting PC participants provided a venous blood sample in addition to being offered HIV-POCT. We compared results obtained in the PC using a laboratory-based gold standard (GS) testing algorithm and HIV-POCT. Comprehensive QA mechanisms were put in place to support the community-wide testing. Participants who were identified as having a false negative or false positive HIV rapid test were revisited and offered retesting.

Results: We initially observed poor sensitivity (45–54%, 95% confidence interval [CI] 31–69) of HIV-POCT in the PC in SA compared to sensitivity in Zambia for the same time period of 95.8% (95% CI 93–98). In both countries, specificity of HIV-POCT was >98%. With enhanced QA interventions and adoption of the same HIV-POCT algorithm, sensitivity in SA improved to a similar level as in Zambia.

Conclusions: This is one of the first reports of HIV-POCT performance during wide-scale delivery of HTS compared to a GS laboratory algorithm. HIV-POCT in a real-world setting had a lower sensitivity than anticipated. Appropriate choice of HIV-POCT algorithms, intensive training and supervision, and robust QA mechanisms are necessary to optimize HIV-POCT test performance when testing is delivered at a community level. HIV-POCT in clients who did not disclose that they were on ART may have contributed to false negative HIV-POCT results and should be the topic of future research.

HIV rapid diagnostic testing by lay providers in a key population-led health service programme in Thailand

Introduction: Rapid diagnostic testing (RDT) for HIV has a quick turn-around time, which increases the proportion of people testing who receive their result. HIV RDT in Thailand has traditionally been performed only by medical technologists (MTs), which is a barrier to its being scaled up. We evaluated the performance of HIV RDT conducted by trained lay providers who were members of, or worked closely with, a group of men who have sex with men (MSM) and with transgender women (TG) communities, and compared it to tests conducted by MTs. Methods: Lay providers received a 3-day intensive training course on how to perform a finger-prick blood collection and an HIV RDT as part of the Key Population-led Health Services (KPLHS) programme among MSM and TG. All the samples were tested by lay providers using Alere Determine HIV 1/2. HIV-reactive samples were confirmed by DoubleCheckGold Ultra HIV 1&2 and SD Bioline HIV 1/2. All HIV-positive and 10% of HIV-negative samples were re-tested by MTs using Serodia HIV 1/2. Results: Of 1680 finger-prick blood samples collected and tested using HIV RDT by lay providers in six drop-in centres in Bangkok, Chiang Mai, Chonburi and Songkhla, 252 (15%) were HIV-positive. MTs re-tested these HIV-positive samples and 143 randomly selected HIV-negative samples with 100% concordant test results. Conclusion: Lay providers in Thailand can be trained and empowered to perform HIV RDT as they were found to achieve comparable results in sample testing with MTs. Based on the task-shifting concept, this rapid HIV testing performed by lay providers as part of the KPLHS programme has great potential to enhance HIV prevention and treatment programmes among key at-risk populations.

To err is human, to correct is public health: a systematic review examining poor quality testing and misdiagnosis of HIV status

INTRODUCTION

In accordance with global testing and treatment targets, many countries are seeking ways to reach the "90-90-90" goals, starting with diagnosing 90% of all people with HIV. Quality HIV testing services are needed to enable people with HIV to be diagnosed and linked to treatment as early as possible. It is essential that opportunities to reach people with undiagnosed HIV are not missed, diagnoses are correct and HIV-negative individuals are not inadvertently initiated on life-long treatment. We conducted this systematic review to assess the magnitude of misdiagnosis and to describe poor HIV testing practices using rapid diagnostic tests.

METHODS

We systematically searched peer-reviewed articles, abstracts and grey literature published from 1 January 1990 to 19 April 2017. Studies were included if they used at least two rapid diagnostic tests and reported on HIV misdiagnosis, factors related to potential misdiagnosis or described quality issues and errors related to HIV testing.

RESULTS

Sixty-four studies were included in this review. A small proportion of false positive (median 3.1%, interquartile range (IQR): 0.4-5.2%) and false negative (median: 0.4%, IQR: 0-3.9%) diagnoses were identified. Suboptimal testing strategies were the most common factor in studies reporting misdiagnoses, particularly false positive diagnoses due to using a "tiebreaker" test to resolve discrepant test results. A substantial proportion of false negative diagnoses were related to retesting among people on antiretroviral therapy. Conclusions HIV testing errors and poor practices, particularly those resulting in false positive or false negative diagnoses, do occur but are preventable. Efforts to accelerate HIV diagnosis and linkage to treatment should be complemented by efforts to improve the quality of HIV testing services and strengthen the quality management systems, particularly the use of validated testing algorithms and strategies, retesting people diagnosed with HIV before initiating treatment and providing clear messages to people with HIV on treatment on the risk of a "false negative" test result.

HIV point of care diagnosis: preventing misdiagnosis experience from a pilot of rapid test algorithm implementation in selected communes in Vietnam

INTRODUCTION

In Vietnam, HIV testing services had been available only at provincial and district health facilities, but not at the primary health facilities. Consequently, access to HIV testing services had been limited especially in rural areas. In 2012, Vietnam piloted decentralization and integration of HIV services at commune health stations (CHSs). As a part of this pilot, a three-rapid test algorithm was introduced at CHSs. The objective of this study was to assess the performance of a three-rapid test algorithm and the implementation of quality assurance measures to prevent misdiagnosis, at primary health facilities.

METHODS

The three-rapid test algorithm (Determine HIV-1/2, followed by ACON HIV 1/2 and DoubleCheckGold HIV 1&2 in parallel) was piloted at CHSs from August 2012 to December 2013. Commune health staff were trained to perform HIV testing. Specimens from CHSs were sent to the provincial confirmatory laboratory (PCL) for confirmatory and validation testing. Quality assurance measures were undertaken including training, competency assessment, field technical assistance, supervision and monitoring and external quality assessment (EQA). Data on HIV testing were collected from the testing logbooks at commune and provincial facilities. Descriptive analysis was conducted. Sensitivity and specificity of the rapid testing algorithm were calculated.

RESULTS

A total of 1,373 people received HIV testing and counselling (HTC) at CHSs. Eighty people were diagnosed with HIV infection (5.8%). The 755/1244 specimens reported as HIV negative at the CHS were sent to PCL and confirmed as negative, and all 80 specimens reported as HIV positive at CHS were confirmed as positive at the PCL. Forty-nine specimens that were reactive with Determine but negative with ACON and DoubleCheckGold at the CHSs were confirmed negative at the PCL. The results show this rapid test algorithm to be 100% sensitive and 100% specific. Of 21 CHSs that received two rounds of EQA panels, 20 CHSs submitted accurate results.

CONCLUSIONS

Decentralization of HIV confirmatory testing to CHS is feasible in Vietnam. The results obtained from this pilot provided strong evidence of the feasibility of HIV testing at primary health facilities. Quality assurance measures including training, competency assessment, regular monitoring and supervision and an EQA scheme are essential for prevention of misdiagnosis.

Changes in Fertility at the Population Level in the Era of ART in Rural Malawi

Introduction:

HIV reduces fertility through biological and social pathways, and antiretroviral treatment (ART) can ameliorate these effects. In northern Malawi, ART has been available since 2007 and lifelong ART is offered to all pregnant or breastfeeding HIV-positive women.

Methods:

Using data from the Karonga Health and Demographic Surveillance Site in Malawi from 2005 to 2014, we used total and age-specific fertility rates and Cox regression to assess associations between HIV and ART use and fertility. We also assessed temporal trends in in utero and breastfeeding HIV and ART exposure among live births.

Results:

From 2005 to 2014, there were 13,583 live births during approximately 78,000 person years of follow-up of women aged 15–49 years. The total fertility rate in HIV-negative women decreased from 6.1 [95% confidence interval (CI): 5.5 to 6.8] in 2005–2006 to 5.1 (4.8–5.5) in 2011–2014. In HIV-positive women, the total fertility rate was more stable, although lower, at 4.4 (3.2–6.1) in 2011–2014. In 2011–2014, compared with HIV-negative women, the adjusted (age, marital status, and education) hazard ratio was 0.7 (95% CI: 0.6 to 0.9) and 0.8 (95% CI: 0.6 to 1.0) for women on ART for at least 9 months and not (yet) on ART, respectively. The crude fertility rate increased with duration on ART up to 3 years before declining. The proportion of HIV-exposed infants decreased, but the proportion of ART-exposed infants increased from 2.4% in 2007–2010 to 3.5% in 2011–2014.

Conclusions:

Fertility rates in HIV-positive women are stable in the context of generally decreasing fertility. Despite a decrease in HIV-exposed infants, there has been an increase in ART-exposed infants.

Implementation and Operational Research: Cost and Efficiency of a Hybrid Mobile Multidisease Testing Approach With High HIV Testing Coverage in East Africa

BACKGROUND

In 2013-2014, we achieved 89% adult HIV testing coverage using a hybrid testing approach in 32 communities in Uganda and Kenya (SEARCH: NCT01864603). To inform scalability, we sought to determine: (1) overall cost and efficiency of this approach; and (2) costs associated with point-of-care (POC) CD4 testing, multidisease services, and community mobilization.

METHODS

We applied microcosting methods to estimate costs of population-wide HIV testing in 12 SEARCH trial communities. Main intervention components of the hybrid approach are census, multidisease community health campaigns (CHC), and home-based testing for CHC nonattendees. POC CD4 tests were provided for all HIV-infected participants. Data were extracted from expenditure records, activity registers, staff interviews, and time and motion logs.

RESULTS

The mean cost per adult tested for HIV was $20.5 (range: $17.1-$32.1) (2014 US$), including a POC CD4 test at $16 per HIV+ person identified. Cost per adult tested for HIV was $13.8 at CHC vs. $31.7 by home-based testing. The cost per HIV+ adult identified was $231 ($87-$1245), with variability due mainly to HIV prevalence among persons tested (ie, HIV positivity rate). The marginal costs of multidisease testing at CHCs were $1.16/person for hypertension and diabetes, and $0.90 for malaria. Community mobilization constituted 15.3% of total costs.

CONCLUSIONS

The hybrid testing approach achieved very high HIV testing coverage, with POC CD4, at costs similar to previously reported mobile, home-based, or venue-based HIV testing approaches in sub-Saharan Africa. By leveraging HIV infrastructure, multidisease services were offered at low marginal costs.

Should trained lay providers perform HIV testing? A systematic review to inform World Health Organization guidelines

New strategies for HIV testing services (HTS) are needed to achieve UN 90-90-90 targets, including diagnosis of 90% of people living with HIV. Task-sharing HTS to trained lay providers may alleviate health worker shortages and better reach target groups. We conducted a systematic review of studies evaluating HTS by lay providers using rapid diagnostic tests (RDTs). Peer-reviewed articles were included if they compared HTS using RDTs performed by trained lay providers to HTS by health professionals, or to no intervention. We also reviewed data on end-users' values and preferences around lay providers preforming HTS. Searching was conducted through 10 online databases, reviewing reference lists, and contacting experts. Screening and data abstraction were conducted in duplicate using systematic methods. Of 6113 unique citations identified, 5 studies were included in the effectiveness review and 6 in the values and preferences review. One US-based randomized trial found patients' uptake of HTS doubled with lay providers (57% vs. 27%, percent difference: 30, 95% confidence interval: 27-32, p < 0.001). In Malawi, a pre/post study showed increases in HTS sites and tests after delegation to lay providers. Studies from Cambodia, Malawi, and South Africa comparing testing quality between lay providers and laboratory staff found little discordance and high sensitivity and specificity (≥98%). Values and preferences studies generally found support for lay providers conducting HTS, particularly in non-hypothetical scenarios. Based on evidence supporting using trained lay providers, a WHO expert panel recommended lay providers be allowed to conduct HTS using HIV RDTs. Uptake of this recommendation could expand HIV testing to more people globally.

Human immunodeficiency virus: Diagnostic approach

First descriptions of acquired immunodeficiency syndrome appeared in 1981. Four years later the causative agent was cultured which lead to development and production of tests that helped healthcare providers to identify persons living with HIV. Currently, diagnosis of HIV is performed with fourth generation immunoassays (those that detect p24 antigen together with IgM and IgG antibodies to HIV-1 and -2) which if positive need to be followed by an assay that can differentiate between HIV-1 and HIV-2 viruses. The Western blot is no longer used to confirm HIV infections per CDC guidelines. In case there is a positive fourth generation assay but negative differentiation assay, nucleic acid testing for HIV-1 should be performed. This algorithm allows for detection of acute infections. Alternatively, the World Health Organization has algorithms that use rapid testing for diagnosis of HIV infections. This review will describe the evolution of tests and diagnostic algorithms from the 1980s to the current state. Special situations regarding diagnosis will also be discussed.

Can trained lay providers perform HIV testing services? A review of national HIV testing policies

BACKGROUND

Only an estimated 54% of people living with HIV are aware of their status. Despite progress scaling up HIV testing services (HTS), a testing gap remains. Delivery of HTS by lay providers may help close this testing gap, while also increasing uptake and acceptability of HIV testing among key populations and other priority groups.

METHODS

50 National HIV testing policies were collated from WHO country intelligence databases, contacts and testing program websites. Data regarding lay provider use for HTS was extracted and collated. Our search had no geographical or language restrictions. This data was then compared with reported data from the Global AIDS Response Progress Reporting (GARPR) from July 2015.

RESULTS

Forty-two percent of countries permit lay providers to perform HIV testing and 56% permit lay providers to administer pre-and post-test counseling. Comparative analysis with GARPR found that less than half (46%) of reported data from countries were consistent with their corresponding national HIV testing policy.

CONCLUSIONS

Given the low uptake of lay provider use globally and their proven use in increasing HIV testing, countries should consider revising policies to support lay provider testing using rapid diagnostic tests.

Multi-centre field evaluation of the performance of the Trinity Biotech Uni-Gold HIV 1/2 rapid test as a first-line screening assay for gay and bisexual men compared with 4th generation laboratory immunoassays

BACKGROUND

The Trinity Biotech Uni-Gold HIV test (Uni-Gold) is often used as a supplementary rapid test in testing algorithms.

OBJECTIVE

To evaluate the operational performance of the Uni-Gold as a first-line screening test among gay and bisexual men (GBM) in a setting where 4th generation HIV laboratory assays are routinely used.

STUDY DESIGN

We compared the performance of Uni-Gold with conventional HIV serology conducted in parallel among GBM attending 22 testing sites. Sensitivity was calculated separately for acute and established infection, defined using 4th generation screening Ag/Ab immunoassay (EIA) and Western blot results. Previous HIV testing history and results of supplementary 3rd generation HIV Ab EIA, and p24 antigen EIA were used to further characterise cases of acute infection.

RESULTS

Of 10,793 specimens tested with Uni-Gold and conventional serology, 94 (0.90%, 95%CI:0.70-1.07) were confirmed as HIV-positive by conventional serology, and 37 (39.4%) were classified as acute infection. Uni-Gold sensitivity was 81.9% overall (77/94, 95%CI:72.6-89.1); 56.8% for acute infection (21/37, 95%CI:39.5-72.9) and 98.2% for established infection (56/57, 95%CI:90.6-100.0). Of 17 false non-reactive Uni-Gold results, 16 were acute infections, and of these seven were p24 antigen reactive but antibody negative. Uni-Gold specificity was 99.9% (10,692/10,699, 95%CI:99.9-100.0), PPV was 91.7% (95%CI:83.6-96.6) and NPV was 99.8% (95%CI:99.7-99.9), respectively.

CONCLUSIONS

In this population, Uni-Gold had good specificity and sensitivity was high for established infections when compared to 4th generation laboratory assays, however sensitivity was lower in acute infections. Where rapid tests are used in populations with a high proportion of acute infections, additional testing strategies are needed to detect acute infections.

Clinical outcomes of routine opt-out antenatal human immunodeficiency virus screening: a systematic review

AIMS AND OBJECTIVES

To evaluate the clinical outcome of routine screening of human immunodeficiency virus in antenatal clinic settings.

BACKGROUND

Despite the growing advances in human immunodeficiency virus management, nearly 30% of the estimated 1·5 million seropositive pregnant women are undiagnosed. Routine opt-out testing is a strategy endorsed by the World Health Organization in to increase testing rates in clinical settings.

DESIGN

A systematic review of relevant published literature.

METHODS

A comprehensive electronic search for relevant studies in Science Direct, MEDLINE, SCOPUS, CINAHL and PubMed was conducted with search terms (Box 2). Hand searches were also conducted for additional resources. There were no geographical restrictions. Searches were restricted to English language and studies conducted between 1998-2015; totaling 1097 were retrieved and carefully appraised for review. Eighteen studies were eligible for review: eight from Africa, five from the United States, three from Europe, one from Australia and one from Asia.

RESULTS

Fourteen studies reported increases in human immunodeficiency virus testing rate. Following the introduction of routine testing, human immunodeficiency virus testing rates increased from values ranging from 68-99·9% with median value of 88%. The comparison studies reported testing uptake of 22-93·5% with median value of 59%. Maternal human immunodeficiency virus case detection rates nearly doubled following adoption of routine testing at values of 99 and 45% during opt-in. Linkage to treatment and care for prevention of vertical transmission was reported on six studies, and results ranged between 12·9-77·2%.

CONCLUSION

The findings show that irrespective of human immunodeficiency virus epidemiological scenarios, routine testing gave more women opportunity to learn their human immunodeficiency virus status and take measures for prevention of mother-to-child transmission of human immunodeficiency virus. Future studies should focus on identifying strategies to improving linkages to treatment and care for prevention of vertical transmission.

RELEVANCE TO CLINICAL PRACTICE

Understanding the contributions of Routine opt-out testing in antenatal clinic would help practitioners adopt the novel testing model for more mothers to learn their human immunodeficiency virus status for prevention of mother-to-child transmission.

Taking HIV Testing to Families: Designing a Family-Based Intervention to Facilitate HIV Testing, Disclosure, and Intergenerational Communication

INTRODUCTION

Facility-based HIV testing does not capture many adults and children who are at risk of HIV in South Africa. This underscores the need to provide targeted, age-appropriate HIV testing for children, adolescents, and adults who are not accessing health facilities. While home-based counseling and testing has been successfully delivered in multiple settings, it also often fails to engage adolescents. To date, the full potential for testing entire families and linking them to treatment has not been evaluated.

METHODS

The steps to expand a successful home-based counseling and testing model to a family-based counseling and testing approach in a high HIV prevalence context in rural South Africa are described. The primary aim of this family-based model is to increase uptake of HIV testing and linkage to care for all family members, through promoting family cohesion and intergenerational communication, increasing HIV disclosure in the family, and improving antiretroviral treatment uptake, adherence, and retention. We discuss the three-phased research approach that led to the development of the family-based counseling and testing intervention.

RESULTS

The family-based intervention is designed with a maximum of five sessions, depending on the configuration of the family (young, mixed, and older families). There is an optional additional session for high-risk or vulnerable family situations. These sessions encourage HIV testing of adults, children, and adolescents and disclosure of HIV status. Families with adolescents receive an intensive training session on intergenerational communication, identified as the key causal pathway to improve testing, linkage to care, disclosure, and reduced stigma for this group. The rationale for the focus on intergenerational communication is described in relation to our formative work as well as previous literature, and potential challenges with pilot testing the intervention are explored.

CONCLUSION

This paper maps the process for adapting a novel and largely successful home-based counseling and testing intervention for use with families. Expanding the successful home-based counseling and testing model to capture children, adolescents, and men could have significant impact, if the pilot is successful and scaled-up.

Accuracy in HIV Rapid Testing among Laboratory and Non-laboratory Personnel in Zambia: Observations from the National HIV Proficiency Testing System

Background

Despite rapid task-shifting and scale-up of HIV testing services in high HIV prevalence countries, studies evaluating accuracy remain limited. This study aimed to assess overall accuracy level and factors associated with accuracy in HIV rapid testing in Zambia.

Methods

Accuracy was investigated among rural and urban HIV testing sites participating in two annual national HIV proficiency testing (PT) exercises conducted in 2009 (n = 282 sites) and 2010 (n = 488 sites). Testers included lay counselors, nurses, laboratory personnel and others. PT panels of five dry tube specimens (DTS) were issued to testing sites by the national reference laboratory (NRL). Site accuracy level was assessed by comparison of reported results to the expected results. Non-parametric rank tests and multiple linear regression models were used to assess variation in accuracy between PT cycles and between tester groups, and to examine factors associated with accuracy respectively.

Results

Overall accuracy level was 93.1% (95% CI: 91.2–94.9) in 2009 and 96.9% (95% CI: 96.1–97.8) in 2010. Differences in accuracy were seen between the tester groups in 2009 with laboratory personnel being more accurate than non-laboratory personnel, while in 2010 no differences were seen. In both PT exercises, lay counselors and nurses had more difficulties interpreting results, with more occurrences of false-negative, false-positive and indeterminate results. Having received the standard HIV rapid testing training and adherence to the national HIV testing algorithm were positively associated with accuracy.

Conclusion

The study showed an improvement in tester group and overall accuracy from the first PT exercise to the next. Average number of incorrect test results per 1000 tests performed was reduced from 69 to 31. Further improvement is needed, however, and the national HIV proficiency testing system seems to be an important tool in this regard, which should be continued and needs to be urgently strengthened.

Systematic review and meta-analysis of community and facility-based HIV testing to address linkage to care gaps in sub-Saharan Africa

HIV testing and counselling is the first crucial step for linkage to HIV treatment and prevention. However, despite high HIV burden in sub-Saharan Africa, testing coverage is low, particularly among young adults and men. Community-based HIV testing and counselling (testing outside of health facilities) has the potential to reduce coverage gaps, but the relative impact of different modalities is not well assessed. We conducted a systematic review of HIV testing modalities, characterizing community (home, mobile, index, key populations, campaign, workplace and self-testing) and facility approaches by population reached, HIV positivity, CD4 count at diagnosis and linkage. Of 2,520 abstracts screened, 126 met eligibility criteria. Community HIV testing and counselling had high coverage and uptake and identified HIV-positive people at higher CD4 counts than facility testing. Mobile HIV testing reached the highest proportion of men of all modalities examined (50%, 95% confidence interval (CI) = 47-54%) and home with self-testing reached the highest proportion of young adults (66%, 95% CI = 65-67%). Few studies evaluated HIV testing for key populations (commercial sex workers and men who have sex with men), but these interventions yielded high HIV positivity (38%, 95% CI = 19-62%) combined with the highest proportion of first-time testers (78%, 95% CI = 63-88%), indicating service gaps. Community testing with facilitated linkage (for example, counsellor follow-up to support linkage) achieved high linkage to care (95%, 95% CI = 87-98%) and antiretroviral initiation (75%, 95% CI = 68-82%). Expanding home and mobile testing, self-testing and outreach to key populations with facilitated linkage can increase the proportion of men, young adults and high-risk individuals linked to HIV treatment and prevention, and decrease HIV burden.

Human Immunodeficiency Virus, Antiretroviral Therapy and Markers of Lymphatic Filariasis Infection: A Cross-sectional Study in Rural Northern Malawi

Background

Lymphatic filariasis (LF) and human immunodeficiency virus (HIV) are major public health problems. Individuals may be co-infected, raising the possibility of important interactions between these two pathogens with consequences for LF elimination through annual mass drug administration (MDA).

Methodology and Principal Findings

We analysed circulating filarial antigenaemia (CFA) by HIV infection status among adults in two sites in northern Malawi, a region endemic for both LF and HIV. Stored blood samples and data from two geographically separate studies were used: one a recruitment phase of a clinical trial of anti-filarial agent dosing regimens, and the other a whole population annual HIV sero-survey. In study one, 1,851 consecutive adult volunteers were screened for HIV and LF infection. CFA prevalence was 25.4% (43/169) in HIV-positive and 23.6% (351/1487) in HIV-negative participants (p=0.57). Geometric mean CFA concentrations were 859 and 1660 antigen units per ml of blood (Ag/ml) respectively, geometric mean ratio (GMR) 0.85, 95%CI 0.49-1.50. In 7,863 adults in study two, CFA prevalence was 20.9% (86/411) in HIV-positive and 24.0% (1789/7452) in HIV–negative participants (p=0.15). Geometric mean CFA concentrations were 630 and 839 Ag/ml respectively (GMR 0.75, 95%CI 0.60-0.94). In the HIV-positive group, antiretroviral therapy (ART) use was associated with a lower CFA prevalence, 12.7% (18/142) vs. 25.3% (67/265), (OR 0.43, 95%CI 0.24-0.76). Prevalence of CFA decreased with duration of ART use, 15.2% 0-1 year (n=59), 13.6% >1-2 years (n=44), 10.0% >2-3 years (n=30) and 0% >3-4 years treatment (n=9), p<0.01 χ² for linear trend.

Conclusions/Significance

In this large cross-sectional study of two distinct LF-exposed populations, there is no evidence that HIV infection has an impact on LF epidemiology that will interfere with LF control measures. A significant association of ART use with lower CFA prevalence merits further investigation to understand this apparent beneficial impact of ART.

Lymphatic filariasis (LF) and HIV are both major public health problems worldwide and where they co-exist have the potential to interact. The main strategy for LF elimination is annual mass drug administration (MDA). A particular concern is whether HIV, through its impact on the immune system, will interfere with the effectiveness of this approach to control and eliminate LF. We report findings from cross-sectional studies in two separate populations in northern Malawi where both HIV and LF are common. One group (1,851 individuals) were studied at enrolment into a trial of anti-LF treatments, whilst the other study used samples stored from adult participants in a whole population HIV survey (7,863 individuals). Between 5–10% of the study participants were HIV-positive and 24% were LF-infected. We found no evidence that LF infection was more or less common in HIV-positive adults in either population. However, we identified robust evidence that antiretroviral therapy use was associated with lower LF prevalence rates. We have no evidence to suggest HIV will have a detrimental effect on LF control. On the contrary, the evidence suggests that antiretroviral therapy may have beneficial effects and merits further careful evaluation of the anti-filarial properties of these compounds.

Performance of rapid HIV testing by lay counselors in the field during the behavioral and biological surveillance survey among female sex workers and men who have sex with men in Botswana

: The study assessed the performance of rapid HIV testing with whole blood using Kehua Bio-engineering HIV (1 + 2) and Uni-Gold HIV test kits by trained and certified lay counselors, offered to female sex workers and men who have sex with men during the 2012 survey fieldwork. The results of rapid HIV testing were compared with enzyme-linked immunosorbent assay testing performed in a parallel algorithm at the HIV Reference Laboratory. The sensitivity and the specificity of rapid HIV testing were high for men who have sex with men and female sex workers, with 98.1% and 100%, and 98.2% and 98.5%, respectively. Misclassifications occurred with rapid testing.

Cost-effectiveness of community-based strategies to strengthen the continuum of HIV care in rural South Africa: a health economic modelling analysis

BACKGROUND

Home HIV counselling and testing (HTC) achieves high coverage of testing and linkage to care compared with existing facility-based approaches, particularly among asymptomatic individuals. In a modelling analysis we aimed to assess the effect on population-level health and cost-effectiveness of a community-based package of home HTC in KwaZulu-Natal, South Africa.

METHODS

We parameterised an individual-based model with data from home HTC and linkage field studies that achieved high coverage (91%) and linkage to antiretroviral therapy (80%) in rural KwaZulu-Natal, South Africa. Costs were derived from a linked microcosting study. The model simulated 10,000 individuals over 10 years and incremental cost-effectiveness ratios were calculated for the intervention relative to the existing status quo of facility-based testing, with costs discounted at 3% annually.

FINDINGS

The model predicted implementation of home HTC in addition to current practice to decrease HIV-associated morbidity by 10–22% and HIV infections by 9–48% with increasing CD4 cell count thresholds for antiretroviral therapy initiation. Incremental programme costs were US$2·7 million to $4·4 million higher in the intervention scenarios than at baseline, and costs increased with higher CD4 cell count thresholds for antiretroviral therapy initiation; antiretroviral therapy accounted for 48–87% of total costs. Incremental cost-effectiveness ratios per disability-adjusted life-year averted were $1340 at an antiretroviral therapy threshold of CD4 count lower than 200 cells per μL, $1090 at lower than 350 cells per μL, $1150 at lower than 500 cells per μL, and $1360 at universal access to antiretroviral therapy.

INTERPRETATION

Community-based HTC with enhanced linkage to care can result in increased HIV testing coverage and treatment uptake, decreasing the population burden of HIV-associated morbidity and mortality. The incremental cost-effectiveness ratios are less than 20% of South Africa's gross domestic product per person, and are therefore classed as very cost effective. Home HTC can be a viable means to achieve UNAIDS' ambitious new targets for HIV treatment coverage.

FUNDING

National Institutes of Health, Bill & Melinda Gates Foundation, Wellcome Trust.

HIV testing service awareness and service uptake among female heads of household in rural Mozambique: results from a province-wide survey

Background

HIV voluntary counseling and testing (VCT) utilization remains low in many sub-Saharan African countries, particularly in remote rural settings. We sought to identify factors associated with service awareness and service uptake of VCT among female heads of household in rural Zambézia Province of north-central Mozambique which is characterized by high HIV prevalence (12.6%), poverty, and suboptimal health service access and utilization.

Methods

Our population-based survey of female heads of household was administered to a representative two-stage cluster sample using a sampling frame created for use on all national surveys and based on census results. The data served as a baseline measure for the Ogumaniha project initiated in 2009. Survey domains included poverty, health, education, income, HIV stigma, health service access, and empowerment. Descriptive statistics and logistic regression were used to describe service awareness and service uptake of VCT.

Results

Of 3708 women surveyed, 2546 (69%) were unaware of available VCT services. Among 1162 women who were aware of VCT, 673 (58%) reported no prior testing. In the VCT aware group, VCT awareness was associated with higher education (aOR = 2.88; 95% CI = 1.61, 5.16), higher income (aOR = 1.41, 95% CI = 1.06, 1.86), higher numeracy (aOR = 1.05, CI 1.03, 1.08), more children < age 5 in the home (aOR = 1.53; 95% CI = 1.07, 2.18), closer proximity to a health facility (aOR = 1.05; 95% CI = 1.03, 1.07), and mobile phone ownership (aOR = 1.37; 95% CI = 1.03, 1.84) (all p-values < 0.04). Having a higher HIV-associated stigma score was the factor most strongly associated with being less likely to test. (aOR = 0.41; 95% CI = 0.23, 0.71; p<0.001).

Conclusions

Most women were unaware of available VCT services. Even women who were aware of services were unlikely to have been tested. Expanded VCT and social marketing of VCT are needed in rural Mozambique with special attention to issues of community-level stigma reduction.

Initiation of antiretroviral therapy and viral suppression after home HIV testing and counselling in KwaZulu-Natal, South Africa, and Mbarara district, Uganda: a prospective, observational intervention study

OBJECTIVE

Antiretroviral therapy (ART) significantly decreases HIV-associated morbidity, mortality, and HIV transmission through HIV viral load suppression. In high HIV prevalence settings, outreach strategies are needed to find asymptomatic HIV positive persons, link them to HIV care and ART, and achieve viral suppression.

METHODS

We conducted a prospective intervention study in two rural communities in KwaZulu-Natal, South Africa, and Mbabara district, Uganda. The intervention included home HIV testing and counseling (HTC), point-of-care CD4 count testing for HIV positive persons, referral to care, and one month then quarterly lay counselor follow-up visits. The outcomes at 12 months were linkage to care, and ART initiation and viral suppression among HIV positive persons eligible for ART (CD4≤350 cells/μL).

FINDINGS

3,393 adults were tested for HIV (96% coverage), of whom 635 (19%) were HIV positive. At baseline, 36% of HIV positive persons were newly identified (64% were previously known to be HIV positive) and 40% were taking ART. By month 12, 619 (97%) of HIV positive persons visited an HIV clinic, and of 123 ART eligible participants, 94 (76%) initiated ART by 12 months. Of the 77 participants on ART by month 9, 59 (77%) achieved viral suppression by month 12. Among all HIV positive persons, the proportion with viral suppression (<1,000 copies/mL) increased from 50% to 65% (p=<0.001) at 12 months.

INTERPRETATION

Community-based HTC in rural South Africa and Uganda achieved high testing coverage and linkage to care. Among those eligible for ART, a high proportion initiated ART and achieved viral suppression, indicating high adherence. Implementation of this HTC approach by existing community health workers in Africa should be evaluated to determine effectiveness and costs.

Case finding advantage of HIV rapid tests in community settings: men who have sex with men in 12 programme areas in China, 2011

We sought to describe the advantage of rapid tests over ELISA tests in community-based screening for HIV among men who have sex with men (MSM) in urban areas of China. Data of 31,406 screening tests conducted over six months in 2011 among MSM across 12 areas were analyzed to compare the differences between those receiving rapid testing and ELISA. Rapid tests accounted for 45.8% of these screening tests. The rate of being screened positive was 7.2% among rapid tests and 5.3% for ELISA tests (χ(2 )= 49.161, p < 0.001). This advantage of rapid test in HIV case finding persisted even when socio-demographic, behavioural, screening recruitment channel and city were controlled for in logistic regression (exp[beta] = 1.42, p < 0.001, 95% CI = 1.27,1.59). MSM who received rapid tests, compared with those tested by ELISA, were less likely to use condoms during last anal sex (50.8% vs. 72.3%, χ(2 )= 1706.146, p < 0.001), more likely to have multiple sex partners (55.7% vs. 49.5%, χ(2 )= 238.188, p < 0.001) and less likely to have previously undergone HIV testing (38.8% vs. 54.7%, χ(2 )= 798.476, p < 0.001). These results demonstrate the robustness of the advantage of rapid tests over traditional ELISA tests in screening for MSM with HIV infection in cooperation with community-based organizations in urban settings in China.

Measuring causes of adult mortality in rural northern Malawi over a decade of change

BACKGROUND

Verbal autopsy could be more widely used if interpretation by computer algorithm could be relied on. We assessed how InterVA-4 results compared with clinician review in diagnosing HIV/AIDS-related deaths over the period of antiretroviral (ART) roll-out.

DESIGN

In the Karonga Prevention Study demographic surveillance site in northern Malawi, all deaths are followed by verbal autopsy using a semi-structured questionnaire. Cause of death is assigned by two clinicians with a third as a tie-breaker. The clinician review diagnosis was compared with the InterVA diagnosis using the same questionnaire data, including all adult deaths from late 2002 to 2012. For both methods data on HIV status were used. ART was first available in the district from 2005, and within the demographic surveillance area from 2006.

RESULTS

There were 1,637 adult deaths, with verbal autopsy data for 1,615. Adult mortality and the proportion of deaths attributable to HIV/AIDS fell dramatically following ART introduction, but for each year the proportion attributed to HIV/AIDS by InterVA was lower than that attributed by clinician review. This was partly explained by the handling of TB cases. Using clinician review as the best available 'gold standard', for those aged 15-59, the sensitivity of InterVA for HIV/AIDS deaths was 59% and specificity 88%. Grouping HIV/AIDS/TB sensitivity was 78% and specificity 83%. Sensitivity was lower after widespread ART use.

CONCLUSIONS

InterVA underestimates the proportion of deaths due to HIV/AIDS. Accepting that it is unrealistic to try and differentiate TB and AIDS deaths would improve the estimates. Caution is needed in interpreting trends in causes of death as ART use may affect the performance of the algorithm.

Earlier menarche is associated with a higher prevalence of Herpes simplex type-2 (HSV-2) in young women in rural Malawi

Remarkably little is known about associations between age at menarche and sexually transmitted infections, although girls with earlier menarche tend to have earlier sexual debut and school drop-out, so an association might be expected. In a population-based survey of >3000 women aged 15-30 in northern Malawi we show that those with earlier menarche had earlier sexual debut, earlier marriage and were more often Herpes simplex type-2 (HSV-2) positive. Compared to those with menarche aged <14, the age-adjusted odds ratios for HSV-2 were 0.89 (95%CI 0.71-1.1), 0.71 (0.57-0.89) and 0.69 (0.54-0.89) for menarche aged 14, 15 and 16+ respectively. This association persisted after adjusting for socio-economic factors, including schooling, and for sexual behaviour. No such association was seen with HIV infection, which is much less common and less uniformly distributed than HSV-2 in this population. The extra vulnerability of girls with earlier menarche needs to be recognised. DOI: http://dx.doi.org/10.7554/eLife.01604.001.

Antiretroviral therapy for prevention is a combination strategy

In the past several years, the debate of "treatment vs prevention" has shifted with the introduction of the concept of "treatment as prevention," (TasP), stemming from a series of compelling observational, ecological, and modeling studies as well as HPTN 052, a randomized clinical trial, demonstrating that use of ART is associated with a decrease in HIV transmission. In addition to TasP being viewed as 1 intervention in a combination strategy for HIV Prevention, TasP is, in and of itself, a combination of multiple interventions that need to be implemented with high coverage in order to achieve its potential impact.

Quality of home-based rapid HIV testing by community lay counsellors in a rural district of South Africa

Introduction

Lack of universal, annual testing for human immunodeficiency virus (HIV) in health facilities suggests that expansion of HIV testing and counselling (HTC) to non-clinical settings is critical to the achievement of national goals for prevention, care and treatment. Consideration should be given to the ability of lay counsellors to perform home-based HTC in community settings.

Methods

We implemented a community cluster randomized controlled trial of home-based HTC in Sisonke District, South Africa. Trained lay counsellors conducted door-to-door HIV testing using the same rapid tests used by the local health department at the time of the study (SD Bioline and Sensa). To monitor testing quality and counsellor skill, additional dry blood spots were taken and sent for laboratory-based enzyme-linked immunosorbent assay (ELISA) testing. Sensitivity and specificity were calculated using the laboratory result as the gold standard.

Results and discussion

From 3986 samples, the counsellor and laboratory results matched in all but 23 cases. In 18 cases, the counsellor judged the result as indeterminate, whereas the laboratory judged 10 positive, eight negative and three indeterminate, indicating that the counsellor may have erred on the side of caution. Sensitivity was 98.0% (95% CI: 96.3–98.9%), and specificity 99.6% (95% CI: 99.4–99.7%), for the lay counsellor field-based rapid tests. Both measures are high, and the lower confidence bound for specificity meets the international standard for assessing HIV rapid tests.

Conclusions

These findings indicate that adequately trained lay counsellors are capable of safely conducting high-quality rapid HIV tests and interpreting the results as per the kit guidelines. These findings are important given the likely expansion of community and home-based testing models and the shortage of clinically trained professional staff.

High HIV testing uptake and linkage to care in a novel program of home-based HIV counseling and testing with facilitated referral in KwaZulu-Natal, South Africa

OBJECTIVE

For antiretroviral therapy (ART) to have a population-level HIV prevention impact, high levels of HIV testing and effective linkages to HIV care among HIV-infected persons are required.

METHODS

We piloted home-based counseling and testing (HBCT) with point-of-care CD4 count testing and follow-up visits to facilitate linkage of HIV-infected persons to local HIV clinics and uptake of ART in rural KwaZulu-Natal, South Africa. Lay counselor follow-up visits at months one, three and six evaluated the primary outcome of linkage to care. Plasma viral load was measured at baseline and month six.

RESULTS

671 adults were tested for HIV (91% coverage) and 201 (30%) were HIV-infected, of which 73 (36%) were new diagnoses. By month three, 90% of HIV-infected persons not on ART at baseline had visited an HIV clinic and 80% of those eligible for ART at baseline by South African guidelines (CD4≤200 cells/μL at the time of the study) had initiated ART. Among HIV-infected participants who were eligible for ART at baseline, mean viral load decreased by 3.23 log10 copies/mL (p<0.001) and the proportion with viral load suppression increased from 20% to 80% between baseline and month six.

CONCLUSIONS

In this pilot of HBCT and linkages to care in KwaZulu-Natal, 91% of adults were tested for HIV. Linkage to care was ∼90% both among newly-identified HIV-infected persons as well as known HIVinfected persons who were not engaged in care. Among those eligible for ART, a high proportion initiated ART and achieved viral suppression, indicating high adherence and reduced infectiousness.

Towards universal voluntary HIV testing and counselling: a systematic review and meta-analysis of community-based approaches

BACKGROUND

Effective national and global HIV responses require a significant expansion of HIV testing and counselling (HTC) to expand access to prevention and care. Facility-based HTC, while essential, is unlikely to meet national and global targets on its own. This article systematically reviews the evidence for community-based HTC.

METHODS AND FINDINGS

PubMed was searched on 4 March 2013, clinical trial registries were searched on 3 September 2012, and Embase and the World Health Organization Global Index Medicus were searched on 10 April 2012 for studies including community-based HTC (i.e., HTC outside of health facilities). Randomised controlled trials, and observational studies were eligible if they included a community-based testing approach and reported one or more of the following outcomes: uptake, proportion receiving their first HIV test, CD4 value at diagnosis, linkage to care, HIV positivity rate, HTC coverage, HIV incidence, or cost per person tested (outcomes are defined fully in the text). The following community-based HTC approaches were reviewed: (1) door-to-door testing (systematically offering HTC to homes in a catchment area), (2) mobile testing for the general population (offering HTC via a mobile HTC service), (3) index testing (offering HTC to household members of people with HIV and persons who may have been exposed to HIV), (4) mobile testing for men who have sex with men, (5) mobile testing for people who inject drugs, (6) mobile testing for female sex workers, (7) mobile testing for adolescents, (8) self-testing, (9) workplace HTC, (10) church-based HTC, and (11) school-based HTC. The Newcastle-Ottawa Quality Assessment Scale and the Cochrane Collaboration's "risk of bias" tool were used to assess the risk of bias in studies with a comparator arm included in pooled estimates. 117 studies, including 864,651 participants completing HTC, met the inclusion criteria. The percentage of people offered community-based HTC who accepted HTC was as follows: index testing, 88% of 12,052 participants; self-testing, 87% of 1,839 participants; mobile testing, 87% of 79,475 participants; door-to-door testing, 80% of 555,267 participants; workplace testing, 67% of 62,406 participants; and school-based testing, 62% of 2,593 participants. Mobile HTC uptake among key populations (men who have sex with men, people who inject drugs, female sex workers, and adolescents) ranged from 9% to 100% (among 41,110 participants across studies), with heterogeneity related to how testing was offered. Community-based approaches increased HTC uptake (relative risk [RR] 10.65, 95% confidence interval [CI] 6.27-18.08), the proportion of first-time testers (RR 1.23, 95% CI 1.06-1.42), and the proportion of participants with CD4 counts above 350 cells/µl (RR 1.42, 95% CI 1.16-1.74), and obtained a lower positivity rate (RR 0.59, 95% CI 0.37-0.96), relative to facility-based approaches. 80% (95% CI 75%-85%) of 5,832 community-based HTC participants obtained a CD4 measurement following HIV diagnosis, and 73% (95% CI 61%-85%) of 527 community-based HTC participants initiated antiretroviral therapy following a CD4 measurement indicating eligibility. The data on linking participants without HIV to prevention services were limited. In low- and middle-income countries, the cost per person tested ranged from US$2-US$126. At the population level, community-based HTC increased HTC coverage (RR 7.07, 95% CI 3.52-14.22) and reduced HIV incidence (RR 0.86, 95% CI 0.73-1.02), although the incidence reduction lacked statistical significance. No studies reported any harm arising as a result of having been tested.

CONCLUSIONS

Community-based HTC achieved high rates of HTC uptake, reached people with high CD4 counts, and linked people to care. It also obtained a lower HIV positivity rate relative to facility-based approaches. Further research is needed to further improve acceptability of community-based HTC for key populations. HIV programmes should offer community-based HTC linked to prevention and care, in addition to facility-based HTC, to support increased access to HIV prevention, care, and treatment.

REVIEW REGISTRATION

International Prospective Register of Systematic Reviews CRD42012002554 Please see later in the article for the Editors' Summary.

Underestimation of HIV prevalence in surveys when some people already know their status, and ways to reduce the bias

OBJECTIVE

To quantify refusal bias due to prior HIV testing, and its effect on HIV prevalence estimates, in general-population surveys.

DESIGN

Four annual, cross-sectional, house-to-house HIV serosurveys conducted during 2006-2010 within a demographic surveillance population of 33 000 in northern Malawi.

METHODS

The effect of prior knowledge of HIV status on test acceptance in subsequent surveys was analysed. HIV prevalence was then estimated using ten adjustment methods, including age-standardization; multiple imputation of missing data; a conditional probability equations approach incorporating refusal bias; using longitudinal data on previous and subsequent HIV results; including self-reported HIV status; and including linked antiretroviral therapy clinic data.

RESULTS

HIV test acceptance was 55-65% in each serosurvey. By 2009/2010 79% of men and 85% of women had tested at least once. Known HIV-positive individuals were more likely to be absent, and refuse interviewing and testing. Using longitudinal data, and adjusting for refusal bias, the best estimate of HIV prevalence was 7% in men and 9% in women in 2008/2009. Estimates using multiple imputations were 4.8 and 6.4%, respectively. Using the conditional probability approach gave good estimates using the refusal risk ratio of HIV-positive to HIV-negative individuals observed in this study, but not when using the only previously published estimate of this ratio, even though this was also from Malawi.

CONCLUSION

As the proportion of the population who know their HIV-status increases, survey-based prevalence estimates become increasingly biased. As an adjustment method for cross-sectional data remains elusive, sources of data with high coverage, such as antenatal clinics surveillance, remain important.

Fertility intentions and use of contraception among monogamous couples in northern Malawi in the context of HIV testing: a cross-sectional analysis

CONTEXT

Knowledge of HIV status may influence fertility desires of married men and women. There is little knowledge about the importance of this influence among monogamously married couples and how knowledge of HIV status influences use of contraception among these couples.

METHODOLOGY

We carried out a cross-sectional analysis of interview data collected between October 2008 and September 2009 on men aged 15-59 years and women aged 15-49 years who formed 1766 monogamously married couples within the Karonga Prevention Study demographic surveillance study in northern Malawi.

RESULTS

5% of men and 4% of women knew that they were HIV positive at the time of interview and 81% of men and 89% of women knew that they were HIV negative. 73% of men and 83% of women who knew that they were HIV positive stated that they did not want more children, compared to 35% of men and 38% of women who knew they were HIV negative. Concordant HIV positive couples were more likely than concordant negative couples to desire to stop child bearing (odds ratio 11.5, 95%CI 4.3-30.7, after adjusting for other factors) but only slightly more likely to use contraceptives (adjusted odds ratio 1.5 (95%CI 0.8-3.3).

CONCLUSION

Knowledge of HIV positive status is associated with an increase in the reported desire to cease childbearing but there was limited evidence that this desire led to higher use of contraception. More efforts directed towards assisting HIV positive couples to access and use reproductive health services and limit HIV transmission among couples are recommended.

Household-based HIV counseling and testing as a platform for referral to HIV care and medical male circumcision in Uganda: a pilot evaluation

Background

Combination HIV prevention initiatives incorporate evidence-based, biomedical and behavioral interventions appropriate and acceptable to specific populations, aiming to significantly reduce population-level HIV incidence. Knowledge of HIV serostatus is key to linkages to HIV care and prevention. Household-based HIV counseling and testing (HBCT) can achieve high HIV testing rates. We evaluated HBCT as a platform for delivery of combination HIV prevention services in sub-Saharan Africa.

Methods

We conducted HBCT in a semi-urban area in southwestern Uganda. All adults received standard HIV prevention messaging. Real-time electronic data collection included a brief risk assessment and prevention triage algorithm for referrals of HIV seropositive persons to HIV care and uncircumcised HIV seronegative men with multiple sex partners to male circumcision. Monthly follow-up visits for 3 months were conducted to promote uptake of HIV care and male circumcision.

Results

855 households received HBCT; 1587 of 1941 (81.8%) adults were present at the HBCT visit, 1557 (98.1% of those present) were tested and received HIV results, of whom, 46.5% were men. A total of 152 (9.8%) were HIV seropositive, for whom the median CD4 count was 456 cells/µL, and 50.7% were newly-identified as HIV seropositive. Three months after HBCT, 88.5% of HIV seropositive persons had attended an HIV care clinic; among those with CD4 counts <250 cells/µL, 71.4% initiated antiretroviral therapy. Among 123 HIV seronegative men with an HIV+ partner or multiple partners, 62.0% were circumcised by month 3.

Conclusions

HBCT achieves high levels of knowledge of HIV serostatus and is an effective platform for identifying at-risk persons and achieving higher uptake of HIV prevention and care services through referrals and targeted follow-up than has been accomplished through other single focus strategies.

Community-based rapid oral human immunodeficiency virus testing for tuberculosis patients in Lima, Peru

Among tuberculosis patients, timely diagnosis of human immunodeficiency virus (HIV) co-infection and early antiretroviral treatment are crucial, but are hampered by a myriad of individual and structural barriers. Community-based models to provide counseling and rapid HIV testing are few but offer promise. During November 2009-April 2010, community health workers offered and performed HIV counseling and testing by using the OraQuick Rapid HIV-1/2 Antibody Test to new tuberculosis cases in 22 Ministry of Health establishments and their household contacts (n = 130) in Lima, Peru. Refusal of HIV testing or study participation was low (4.7%). Intervention strengths included community-based approach with participant preference for testing site, use of a rapid, non-invasive test, and accompaniment to facilitate HIV care and family disclosure. We will expand the intervention under programmatic auspices for rapid community-based testing for new tuberculosis cases in high incidence establishments. Other potential target populations include contacts of HIV-positive persons and pregnant women.