Client characteristics and acceptability of a home-based HIV counselling and testing intervention in rural South Africa

Factors influencing adolescent girls and young women's uptake of community-based PrEP services following home-based HIV testing in Eastern Cape, South Africa: a qualitative study

Home-based service delivery has been used to improve access to HIV testing and antiretroviral initiation across sub-Saharan Africa, but it has yet to be leveraged to improve pre-exposure prophylaxis (PrEP) uptake. We interviewed 37 adolescent girls and young women (AGYW) in Eastern Cape, South Africa to explore why they chose to initiate PrEP or not following home-based HIV testing and referral for PrEP, and what influenced time to PrEP initiation. Participants reported that home visits provided a source of trusted information and a way to involve family members in their PrEP initiation decisions, motivating some to start PrEP. AGYW who initiated PrEP were more likely to qualitatively perceive themselves to be at high risk for HIV compared with those who never initiated PrEP. Integrating home-based HIV testing with PrEP education and referral may be a valuable way to reduce familial barriers and boost PrEP uptake among AGYW in South Africa. Trial registration: NCT03977181. Retrospectively registered on June 6, 2019.

The effectiveness, feasibility and acceptability of HIV service delivery at private pharmacies in sub-Saharan Africa: a scoping review

INTRODUCTION

Private pharmacies are an understudied setting for differentiated delivery of HIV services that may address barriers to clinic-delivered services, such as stigma and long wait times. To understand the potential for pharmacy-delivered HIV services in sub-Saharan Africa, we conducted a scoping review of the published and grey literature.

METHODS

Using a modified Cochrane approach, we searched electronic databases through March 2022 and HIV conference abstracts in the past 5 years for studies that: (1) focused on the delivery of HIV testing, antiretroviral therapy (ART) and/or pre-exposure prophylaxis (PrEP) at private pharmacies in sub-Saharan Africa; (2) reported on effectiveness outcomes (e.g. HIV incidence) or implementation outcomes, specifically feasibility and/or acceptability; and (3) were published in English. Two authors identified studies and extracted data on study setting, population, design, outcomes and findings by HIV service type.

RESULTS AND DISCUSSION

Our search identified 1646 studies. After screening and review, we included 28 studies: seven on HIV testing, nine on ART delivery and 12 on PrEP delivery. Most studies (n = 16) were conducted in East Africa, primarily in Kenya. Only two studies evaluated effectiveness outcomes; the majority (n = 26) reported on feasibility and/or acceptability outcomes. The limited effectiveness data (n = 2 randomized trials) suggest that pharmacy-delivered HIV services can increase demand and result in comparable clinical outcomes (e.g. viral load suppression) to standard-of-care clinic-based models. Studies assessing implementation outcomes found actual and hypothetical models of pharmacy-delivered HIV services to be largely feasible (e.g. high initiation and continuation) and acceptable (e.g. preferable to facility-based models and high willingness to pay/provide) among stakeholders, providers and clients. Potential barriers to implementation included a lack of pharmacy provider training on HIV service delivery, costs to clients and providers, and perceived low quality of care.

CONCLUSIONS

The current evidence suggests that pharmacy-delivered HIV services may be feasible to implement and acceptable to clients and providers in parts of sub-Saharan Africa. However, limited evidence outside East Africa exists, as does limited evidence on the effectiveness of and costs associated with pharmacy-delivered HIV services. More research of this nature is needed to inform the scale-up of this new differentiated service delivery model throughout the region.

Acceptability of HIV oral self-test among truck drivers and youths: a qualitative investigation from Pune, Maharashtra

Background

Ending AIDS by 2030 is a global target, to which India is a signatory. HIV-self-test (HIVST) coupled with counselling and AIDS-care, including antiretroviral therapy, has the potential to achieve this. However, national programs are at varying stages of acceptance of HIVST, as discussions around its introduction spark controversy and debates. HIV-self-test, as yet, is not part of the AIDS control program in India. Against this backdrop, we explored acceptability of an HIV oral self-test (HIVOST) among truckers and young men and women.

Methods

A qualitative investigation with 41 in-depth-interviews and 15 group discussions were conducted in the district of Pune, in the western state of Maharashtra, India. These interactions were built around a prototype HIVOST kit, helped in taking the discussions forward. The software N-vivo (version 11.0) was used to manage the volumes of data generated through the aforementioned process. The study was conducted during June through December, 2019.

Results

While the truckers belonged to the age bracket 21–67 year, the youths were in the age group 18–24 year. ‘Ease of doing HIVOST’ and ‘fear of needle pricks’ were the reasons behind acceptance around HIVOST by both the study groups. Truckers felt that HIVOST would encourage one to know one’s HIV status and seek help as appropriate. Accuracy of HIVOST result and disposal of the kits following use were concerns of a few. Most of the participants preferred saliva over blood as the specimen of choice. Instructions in local language reportedly would enable test-use by self. The truck drivers preferred undertaking HIVOST at the truckers-friendly ‘Khushi clinics’ or in the vehicle, while youths preferred the privacy of home. Some of the young men mis-perceived the utility of HIVOST by referring to doing a test on a partner immediately prior to sexual encounter. On the other hand, a few truckers had wrong information on HIV cure.

Conclusions

Overall, the study communities expressed their acceptance towards HIV-self-test. The National AIDS Control Program, India would benefit by drawing upon the findings of the current investigation. Existing myths and misconceptions around HIV test and treatment require program attention.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-021-11963-7.

Implementing 'universal' access to antiretroviral treatment in South Africa: a scoping review on research priorities

‘Universal’ access to antiretroviral treatment (ART) has become the global standard for treating people living with HIV and achieving epidemic control; yet, findings from numerous ‘test and treat’ trials and implementation studies in sub-Saharan Africa suggest that bringing ‘universal' access to ART to scale is more complex than anticipated. Using South Africa as a case example, we describe the research priorities and foci in the literature on expanded ART access. To do so, we adapted Arksey and O’Malley’s six-stage scoping review framework to describe the peer-reviewed literature and opinion pieces on expanding access to ART in South Africa between 2000 and 2017. Data collection included systematic searches of two databases and hand-searching of a sub-sample of reference lists. We used an adapted socio-ecological thematic framework to categorize data according to where it located the challenges and opportunities of expanded ART eligibility: individual/client, health worker–client relationship, clinic/community context, health systems infrastructure and/or policy context. We included 194 research articles and 23 opinion pieces, of 1512 identified, addressing expanded ART access in South Africa. The peer-reviewed literature focused on the individual and health systems infrastructure; opinion pieces focused on changing roles of individuals, communities and health services implementers. We contextualized our findings through a consultative process with a group of researchers, HIV clinicians and programme managers to consider critical knowledge gaps. Unlike the published literature, the consultative process offered particular insights into the importance of researching and intervening in the relational aspects of HIV service delivery as South Africa’s HIV programme expands. An overwhelming focus on individual and health systems infrastructure factors in the published literature on expanded ART access in South Africa may skew understanding of HIV programme shortfalls away from the relational aspects of HIV services delivery and delay progress with finding ways to leverage non-medical modalities for achieving HIV epidemic control.

A systematic review of factors influencing participation in two types of malaria prevention intervention in Southeast Asia

Background

Multi-pronged malaria elimination strategies are increasingly being considered for accelerating efforts against malaria transmission in Southeast Asia. Two malaria prevention interventions used in in the region are insecticide-treated bed-nets (ITNs) and mass drug administration (MDA). Universal access to ITNs is recommended and high population coverage (e.g. above 80%) is needed during MDA initiatives to maximize the impact of these interventions. However, variability in ITN use and individual MDA participation exists. This systematic review aims to provide a summary and overview of literature discussing factors influencing uptake of these two malaria control strategies in Southeast Asian countries.

Methods

A search of OVID Embase, OVID MEDLINE, Cochrane Central Register of Controlled Trials, Web of Science, OpenGrey, ProQuest, and Google Scholar was undertaken in February 2020. English-language publications with any study design using data from any of the ten member countries of the Association of Southeast Asian Nations were eligible for inclusion. In addition, reference lists of identified articles were manually searched. Websites for relevant international agencies were also searched to identify related grey literature.

Results

The review identified thirty publications that met the inclusion and exclusion criteria. Most discussed ITN use (n = 18) and were relevant to populations in Myanmar (n = 14). All MDA studies were published after 2016, whereas included ITN studies spanned from 1998 to 2020. Seven main themes emerged across the studies. Knowledge of malaria and attitudes towards ITNs were emphasized as key factors associated with ITN use. For MDA participation, key factors included the importance of positive attitudes towards the program, the influence of indirect costs and incentives, and the tendency for group decision-making.

Conclusions

As countries in Southeast Asia continue to work towards becoming malaria-free by 2030, the knowledge and attitudes of local population sub-groups should be assessed and incorporated into the planning and implementation of malaria prevention activities. The role of incentives and group decision making should also be considered particularly as they relate to MDA. There is need for ongoing involvement of health educators, the continuation of implementation research and the prioritization of community engagement efforts alongside malaria interventions in the region.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12936-021-03733-y.

"I got tested at home, the help came to me": acceptability and feasibility of home-based TB testing of household contacts using portable molecular diagnostics in South Africa

OBJECTIVE

The effectiveness of household contact investigations is limited by low referral uptake for clinic-based TB testing by symptomatic household contacts. We qualitatively investigated the acceptability and perceived benefits of home-based TB testing using a portable GeneXpert-I instrument (GX-I) in an urban South African township.

METHODS

In-depth interviews were conducted with household contacts tested and those that observed testing. Semi-structured interviews explored household contact's understanding of TB, perceptions of the GX-I device and testing procedures, confidentiality, willingness to refer others, and views on home- vs. clinic-based testing. Focus group discussions with home-based TB testing implementing staff assessed operational considerations for scale-up. Data were analysed using a constant comparison approach to qualitatively evaluate the acceptability and feasibility of home-based TB testing.

RESULTS

Thirty in-depth interviews and two focus group discussions were conducted. Observing one's own sputum being tested resulted in an emergent trust in home-based TB testing, the GX-I device and one's test results. Home-based TB testing was considered convenient, helped to overcome apathy towards testing and mitigated barriers to clinic-based testing. Perceptions that home-based TB testing contributes to improved household and community health resulted in an emergent theme of alleviation of health insecurities. Operational concerns regarding inadvertent disclosure of one's diagnosis to household members and time spent in people's homes were identified.

CONCLUSIONS

Home-based TB testing was acceptable and feasible. Individuals expressed belief in the machine by being able to witness the testing process. Though most themes mirrored qualitative studies of home-based HIV testing, the alleviation of health insecurities theme is unique to home-based TB testing. Future research must evaluate the impact of home-based TB testing on case finding yield, time-to-treatment initiation and household outcomes.

"They haven't asked me. I haven't told them either": fertility plan discussions between women living with HIV and healthcare providers in western Ethiopia

Background

Despite the importance of women living with HIV (WLHIV) engaging in fertility plan discussions with their healthcare providers (HCPs), little research exists. This study explored perceptions surrounding fertility plan discussions between WLHIV and their HCPs in western Ethiopia, from the perspectives of both women and providers.

Methods

Thirty-one interviews (27 with WLHIV and 4 with HCPs) were conducted at four healthcare facilities in western Ethiopia in 2018. Data were transcribed verbatim and translated into English. Codes and themes were identified using inductive thematic analysis.

Results

There was a discordance between HCPs and WLHIV’s perception regarding the delivery of fertility plan discussions. Only nine of the 27 WLHIV reported they had discussed their personal fertility plans with their HCPs. When discussions did occur, safer conception and contraceptive use were the primary focus. Referrals to mother support groups, adherence counsellors as well as family planning clinics (where they can access reproductive counselling) facilitated fertility discussions. However, lack of initiating discussions by either HCPs or women, high client load and insufficient staffing, and a poor referral system were barriers to discussing fertility plans. Where discussions did occur, barriers to good quality interactions were: (a) lack of recognizing women’s fertility needs; (b) a lack of time and being overworked; (c) mismatched fertility desire among couples; (d) non-disclosure of HIV-positive status to a partner; (e) poor partner involvement; (f) fear of repercussions of disclosing fertility desires to a HCP; and (g) HCPs fear of seroconversion.

Conclusions

Our findings highlight the need for policies and guidelines to support fertility plan discussions. Training of HCPs, provision of non-judgmental and client-centered fertility counselling, improving integration of services along with increased human resources are crucial to counselling provision. Enhancing partner involvement, and supporting and training mother support groups and adherence counsellors in providing fertility plan discussions are crucial to improving safer conception and effective contraceptive use, which helps in having healthy babies and reducing HIV transmission.

Rates and Correlates of HIV Incidence in Namibia's Zambezi Region From 2014 to 2016: Sentinel, Community-Based Cohort Study

BACKGROUND

Direct measures of HIV incidence are needed to assess the population-level impact of prevention programs but are scarcely available in the subnational epidemic hotspots of sub-Saharan Africa. We created a sentinel HIV incidence cohort within a community-based program that provided home-based HIV testing to all residents of Namibia's Zambezi region, where approximately 24% of the adult population was estimated to be living with HIV.

OBJECTIVE

The aim of this study was to estimate HIV incidence, detect correlates of HIV acquisition, and assess the feasibility of the sentinel, community-based approach to HIV incidence surveillance in a subnational epidemic hotspot.

METHODS

Following the program's initial home-based testing (December 2014-July 2015), we purposefully selected 10 clusters of 60 to 70 households each and invited residents who were HIV negative and aged ≥15 years to participate in the cohort. Consenting participants completed behavioral interviews and a second HIV test approximately 1 year later (March-September 2016). We used Poisson models to calculate HIV incidence rates between baseline and follow-up and multivariable Cox proportional hazard models to assess the correlates of seroconversion.

RESULTS

Among 1742 HIV-negative participants, 1624 (93.23%) completed follow-up. We observed 26 seroconversions in 1954 person-years (PY) of follow-up, equating to an overall incidence rate of 1.33 per 100 PY (95% CI 0.91-1.95). Among women, the incidence was 1.55 per 100 PY (95% CI 1.12-2.17) and significantly higher among those aged 15 to 24 years and residing in rural areas (adjusted hazard ratio [aHR] 4.26, 95% CI 1.39-13.13; P=.01), residing in the Ngweze suburb of Katima Mulilo city (aHR 2.34, 95% CI 1.25-4.40; P=.01), who had no prior HIV testing in the year before cohort enrollment (aHR 3.38, 95% CI 1.04-10.95; P=.05), and who had engaged in transactional sex (aHR 17.64, 95% CI 2.88-108.14; P=.02). Among men, HIV incidence was 1.05 per 100 PY (95% CI 0.54-2.31) and significantly higher among those aged 40 to 44 years (aHR 13.04, 95% CI 5.98-28.41; P<.001) and had sought HIV testing outside the study between baseline and follow-up (aHR 8.28, 95% CI 1.39-49.38; P=.02). No seroconversions occurred among persons with HIV-positive partners on antiretroviral treatment.

CONCLUSIONS

Nearly three decades into Namibia's generalized HIV epidemic, these are the first estimates of HIV incidence for its highest prevalence region. By creating a sentinel incidence cohort from the infrastructure of an existing community-based testing program, we were able to characterize current transmission patterns, corroborate known risk factors for HIV acquisition, and provide insight into the efficacy of prevention interventions in a subnational epidemic hotspot. This study demonstrates an efficient and scalable framework for longitudinal HIV incidence surveillance that can be implemented in diverse sentinel sites and populations.

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).

Social franchising of community-based HIV counselling and testing services to increase HIV testing and linkage to care in Tshwane, South Africa: study protocol for a non-randomised implementation trial

BACKGROUND

Meeting the ambitious UN 90-90-90 HIV testing, treatment and viral load suppression targets requires innovative strategies and approaches in Sub-Saharan Africa. To date no known interventions have been tested with community health workers (counsellors) as social franchisees or owner-managed businesses in Community-based HIV counselling and testing (CBCT) work. The aim of this methods paper is to describe a Social franchise (SF) CBCT implementation trial to increase HIV testing and linkage to care for individuals at community levels in comparison with an existing CBCT programme methods.

METHODS/DESIGN

This is a two arm non-randomised community implementation trial with a once off round of post-test follow-up per HIV positive participant to assess linkage to care in low income communities. The intervention arm is a social franchise CBCT in which unemployed, self-employed or employed community members are recruited, contracted and incentivised to test at least 100 people per month, identifying at least 5 HIV positive tests and linking to care at least 4 of them. Social franchisees receive approximately $3.20 per HIV test and $8 per client linked to care. In the control arm, full-time employed HIV counsellors conduct CBCT on a fixed monthly salary. Primary study outcomes are HIV testing uptake rate, HIV positivity, Linkage to care and treatment rate and average counsellors' remuneration cost. Data collection will be conducted using both paper-based and electronic data applications by CBCT or SF counsellors. Data analysis will compare proportions of HIV testing, positivity, linkage to HIV care and treatment rates and counsellors' cost in the two study arms.

DISCUSSION

The study will provide important insight into whether the SF-delivered CBCT programme increases testing coverage and linkage to care as well as reducing CBCT cost per HIV test and per HIV positive person linked to care.

TRIAL REGISTRATION

Pan African Clinical Trial Registry PACTR201809873079121. The trial was retrospectively registered on 11 September 2018.

Results of a Couples-Based Randomized Controlled Trial Aimed to Increase Testing for HIV

BACKGROUND

Although couples HIV testing and counseling (CHTC) is effective for facilitating mutual disclosure and linkage to HIV care, uptake remains low. Using a randomized controlled design, we tested the efficacy of a behavioral couples-based intervention aimed to increase CHTC.

SETTING

The Vulindlela district of KwaZulu-Natal, South Africa.

METHODS

Couples were recruited from the community (eg, markets and community events). Couples were excluded if mutual HIV serostatus disclosure had occurred. Both partners had to report being each other's primary partner and relationship length was at least 6 months. Assessments occurred at baseline, and 3, 6, and 9 months after intervention. Eligible couples attended a group session (3-4 hours) after which randomization occurred. Intervention couples additionally received: one couples-based group session followed by 4 couples' counseling sessions (1-2 hours). Intervention topics included communication skills, intimate partner violence, and HIV prevention. Our primary outcomes were CHTC and sexual risk behavior.

RESULTS

Overall, 334 couples were enrolled. Intervention couples were significantly more likely to have participated in CHTC [42% vs. 12% (P ≤ 0.001)]. In addition, their time to participate in CHTC was significantly shorter (logrank P ≤ 0.0001) (N = 332 couples). By group, 59% of those who tested HIV-positive in intervention and 40% of those who tested in control were new HIV diagnoses (P = 0.18). There were no group differences in unprotected sex.

CONCLUSIONS

Our intervention improved CHTC uptake-a vehicle for mutual serostatus disclosure and entrée into HIV treatment, both of which exert a significant public health impact on communities substantially burdened by HIV.

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

BACKGROUND

Integrating home-based HIV counseling and testing (HCT) with tuberculosis (TB) evaluation could improve the uptake of HIV testing among household contacts of patients with active TB. We sought to identify the facilitators of and barriers to HCT during household contact investigation for TB in Kampala, Uganda.

METHODS

We nested semi-structured interviews with 28 household contacts who were offered home-based HCT in a household-randomized trial of home-based strategies for TB contact investigation. Respondents reflected on their experiences of the home visit, the social context of the household, and their decision to accept or decline HIV testing. We used content analysis to identify and evaluate facilitators of and barriers to testing, then categorized the emergent themes using the Capability, Opportunity, Motivation, and Behavior (COM-B) model.

RESULTS

Facilitators included a preexisting desire to confirm HIV status or to show support for the index TB patient; a perception that home-based services are convenient; and positive perceptions of lay health workers. Key barriers included fear of results and feeling psychologically unprepared to receive results. The social influence of other household members operated as both a facilitator and a barrier.

CONCLUSIONS

Preexisting motivation, psychological readiness to test, and the social context of the household are major contributors to the decision to test for HIV at home. Uptake might be improved by providing normalizing information about HCT before the visit, by offering a second HCT opportunity, by offering self-tests with follow-up counseling, or by introducing HCT using "opt-out" language.

Linkage to care of HIV positive clients in a community based HIV counselling and testing programme: A success story of non-governmental organisations in a South African district

Introduction

Although current data projects South Africa potentially meeting the UN target to test 90% of all people living with HIV by 2020, linking them to HIV care remains a big challenge. In an effort to increase linkage to care (LTC) of HIV positive clients an innovative collaborative intervention between two non-governmental organisations was developed and implemented between 2016 and 2017. This paper investigated the outcome of this collaborative intervention.

Methods

We used a mixed methods approach to assess the outcome of the innovative relationship. This was done by analysing routine programmatic quantitative data on LTC between 2015 and 2017 and qualitatively interviewing five programme managers, four programme implementers and five HIV positive clients on their perceived success/failure factors. Qualitative data were analysed using thematic content analysis while LTC rates were descriptively analysed. Two consultative meetings presented draft findings to programme managers (n = 7) and implementers (n = 10) for feedback, results verification and confirmation.

Results

In 2015 cumulative LTC rate was 27% and it rose to 85% two years post-intervention in 2017. Six themes emerged as success factors at the health system and structural levels and these include: provision of client escort services, health facility human resource capacity strengthening, inter and intra-organisational teamwork, onsite LTC, facilitated and expedited jumping of queues and shifting administrative tasks to non-clinical staff to protect nurses’ time on ART initiation. These measures in turn ensured increased, affordable and swift ART initiation of clients while strengthening client support.

Conclusions

We concluded that multi-faceted interventions that target both health system challenges including staff shortages, efficiencies, and extended facility opening times, and structural inadequacies, including client time and resource limitations due to poverty or nature of jobs, can help to increase LTC.

Social franchising of community-based HIV testing and linkage to HIV care and treatment services: an evaluation of a pilot study in Tshwane, South Africa

INTRODUCTION

Although HIV testing services (HTS) have been successfully task-shifted to lay counsellors, no model has tested the franchising of HTS to lay counsellors as independent small-scale business owners. This paper evaluates the effectiveness of a social franchisee (SF) HTS-managed pilot project compared to the Foundation for Professional Development (FPD) employee-managed HTS programme in testing and linking clients to care.

METHODS

Unemployed, formally employed or own business individuals were engaged as franchisees, trained and supported to deliver HTS services under a common brand in high HIV-prevalent communities in Tshwane district between 2016 and 2017. SFs were remunerated per-HIV test and received larger payments per-HIV-positive client linked to care. In the standard HTS, FPD employed counsellors received similar training and observed similar standards as in the SF HTS, but were remunerated through the normal payroll. We assessed the proportion of clients tested, HIV positivity, linkage to care and per-counsellor cost of HIV test and linkage to care in the two HTS groups.

RESULTS

The SF HTS had 19 HIV counsellors while FPD HTS employed 20. A combined total of 84,556 clients were tested by SFs (50.5%: 95% confidence interval (CI) 50.2 to 50.8)) and FPD (49.5%: 49.2 to 49.8). SFs tested more females than FPD (54.1%: 53.6 to 54.6 vs. 48%: 47.7 to 48.7). SFs identified more first-time testers than FPD (21.5%: 21.1 to 21.9 vs. 8.9%: 8.6 to 9.1). Overall, 8%: 7.9 to 8.2 tested positive with more clients testing positive in the SF (10.2%: 9.9 to 10.5) than FPD (5.9%: 5.6 to 6.1) group. The SFs identified more female HIV-positive clients (11.1%: 10.7 to 11.6) than FPD (6.5%: 6.2 to 6.9). The SFs linked fewer clients to HIV care and treatment (60.0%: 58.5 to 61.5) than FPD (80.3%: 78.7 to 81.9%). It cost four times less to conduct an HIV test using SFs ($3.90 per SF HIV test) than FPD ($13.98) and five times less to link a client to care with SFs ($62.74) than FPD ($303.13).

CONCLUSIONS

SF HTS was effective in identifying more clients, first-time HIV testers and more HIV-positive people, but less effective in linking clients to care than FPD HTS. The SF HTS model was cheaper than the FPD-employee model. We recommend strengthening SFs particularly their linkage to care activities.

"If you are here at the clinic, you do not know how many people need help in the community": Perspectives of home-based HIV services from health care workers in rural KwaZulu-Natal, South Africa in the era of universal test-and-treat

Background

Limited engagement in clinic-based care is affecting the HIV response. We explored the field experiences and perceptions of local health care workers regarding home-based strategies as opportunities to improve the cascade of care of people living with HIV in rural South Africa as part of a Universal Test-and-Treat approach.

Methods

In Hlabisa sub-district, home-based HIV services, including rapid HIV testing and counselling, and support for linkage to and retention in clinic-based HIV care, were implemented by health care workers within the ANRS 12249 Treatment-as-Prevention (TasP) trial. From April to July 2016, we conducted a mixed-methods study among health care workers from the TasP trial and from local government clinics, using self-administrated questionnaires (n = 90 in the TasP trial, n = 56 in government clinics), semi-structured interviews (n = 13 in the TasP trial, n = 5 in government clinics) and three focus group discussions (n = 6–10 health care workers of the TasP trial per group). Descriptive statistics were used for quantitative data and qualitative data were analysed thematically.

Results

More than 90% of health care workers assessed home-based testing and support for linkage to care as feasible and acceptable by the population they serve. Many health care workers underlined how home visits could facilitate reaching people who had slipped through the cracks of the clinic-based health care system and encourage them to successfully access care. Health care workers however expressed concerns about the ability of home-based services to answer the HIV care needs of all community members, including people working outside their home during the day or those who fear HIV-related stigmatization. Overall, health care workers encouraged policy-makers to more formally integrate home-based services in the local health system. They promoted reshaping the disease-specific and care-oriented services towards more comprehensive goals.

Conclusion

Because home-based services allow identification of people early during their infection and encourage them to take actions leading to viral suppression, HCWs assessed them as valuable components within the panel of UTT interventions, aiming to reach the 90-90-90 UNAIDS targets, especially in the rural Southern African region.

Trial registration

The registration number of the ANRS 12249 TasP trial on ClinicalTrials.gov is NCT01509508.

Feasibility and acceptability of home-based HIV testing among refugees: a pilot study in Nakivale refugee settlement in southwestern Uganda

Background

Refugees in sub-Saharan Africa face both the risk of HIV infection and barriers to HIV testing. We conducted a pilot study to determine the feasibility and acceptability of home-based HIV testing in Nakivale Refugee Settlement in Uganda and to compare home-based and clinic-based testing participants in Nakivale.

Methods

From February–March 2014, we visited homes in 3 villages in Nakivale up to 3 times and offered HIV testing. We enrolled adults who spoke English, Kiswahili, Kinyarwanda, or Runyankore; some were refugees and some Ugandan nationals. We surveyed them about their socio-demographic characteristics. We evaluated the proportion of individuals encountered (feasibility) and assessed participation in HIV testing among those encountered (acceptability). We compared characteristics of home-based and clinic-based testers (from a prior study in Nakivale) using Wilcoxon rank sum and Pearson’s chi-square tests. We examined the relationship between a limited number of factors (time of visit, sex, and number of individuals at home) on willingness to test, using logistic regression models with the generalized estimating equations approach to account for clustering.

Results

Of 566 adults living in 319 homes, we encountered 507 (feasibility = 90%): 353 (62%) were present at visit one, 127 (22%) additional people at visit two, and 27 (5%) additional people at visit three. Home-based HIV testing participants totaled 378 (acceptability = 75%). Compared to clinic-based testers, home-based testers were older (median age 30 [IQR 24–40] vs 28 [IQR 22–37], p < 0.001), more likely refugee than Ugandan national (93% vs 79%, < 0.001), and more likely to live ≥1 h from clinic (74% vs 52%, < 0.001). The HIV prevalence was lower, but not significantly, in home-based compared to clinic-based testing participants (1.9 vs 3.4% respectively, p = 0.27). Testing was not associated with time of visit (p = 0.50) or sex (p = 0.66), but for each additional person at home, the odds of accepting HIV testing increased by over 50% (OR 1.52, 95%CI 1.12–2.06, p = 0.007).

Conclusions

Home-based HIV testing in Nakivale Refugee Settlement was feasible, with 90% of eligible individuals encountered within 3 visits, and acceptable with 75% willing to test for HIV, with a yield of nearly 2% individuals tested identified as HIV-positive.

Is home-based HIV testing universally acceptable? Findings from a case-control study nested within the HPTN 071 (PopART) trial

OBJECTIVE

The HPTN 071 (PopART) trial is examining the impact of a package including universal testing and treatment on community-level HIV incidence in Zambia and South Africa. We conducted a nested case-control study to examine factors associated with acceptance of home-based HIV testing and counselling (HB-HTC) delivered by community HIV-care providers (CHiPs) in PopART intervention communities.

METHODS

Of 295 447 individuals who were offered testing, random samples of individuals who declined HB-HTC (cases) and accepted HB-HTC (controls), stratified by gender and community, were selected. Odds ratios comparing cases and controls were estimated using multivariable logistic regression.

RESULTS

Data from 642 participants (313 cases, 329 controls) were analysed. There were no differences between cases and controls by demographic or behavioural characteristics including age, marital or socio-economic position. Participants who felt they could be open with CHiPs (AOR: 0.46, 95% CI: 0.30-0.71, P < 0.001); self-reported as not previously tested (AOR: 0.64; 95% CI: 0.43-0.95, P = 0.03); considered HTC at home to be convenient (AOR: 0.38, 95% CI: 0.27-0.54, P = 0.001); knowing others who had accepted HB-HTC from the CHiPs (AOR: 0.49, 95% CI: 0.31-0.77, P = 0.002); or were motivated to get treatment without delay (AOR: 0.60, 95% CI: 0.43-0.85, P = 0.004) were less likely to decline the offer of HB-HCT. Those who self-reported high-risk sexual behaviour were also less likely to decline HB-HCT (AOR: 0.61, 95% CI: 0.39-0.93, P = 0.02). Having stigmatising attitudes about HB-HTC was not an important barrier to HB-HCT uptake. Men who reported fear of HIV were more likely to decline HB-HCT (AOR: 2.68, 95% CI: 1.33-5.38, P = 0.005).

CONCLUSION

Acceptance of HB-HTC was associated with lack of previous HIV testing, positive attitudes about HIV services/treatment and perception of high sexual risk. Uptake of HB-HCT among those offered it was similar across a range of demographic and behavioural subgroups suggesting it was 'universally' acceptable.

"I was referred from the other side": Gender and HIV testing among older South Africans living with HIV

South Africa has a Universal Test and Treat (UTT) policy in place to ensure that everyone tests for HIV and can access treatment if they test positive. The aim of this study is to document the pathways that older South Africans who are living with HIV take to access testing and treatment in this context. Despite the aging of the HIV epidemic in South Africa and clear evidence that testing older persons (over age 50) is necessary, very little is known about the circumstances under which older persons test for HIV or their motivations for doing so. In this study, we analyze 21 qualitative, in-depth interviews with women and men aged 50 and over who are living with HIV from two townships outside of Cape Town. Using grounded theory to specify emerging themes, we find similarities and differences between older men and women in their pathways to testing. Men primarily test for HIV when their spouse is diagnosed or in connection with TB testing and treatment. Older women, who are more likely to be widowed or divorced, often test for HIV only when they are symptomatic or not responding appropriately to care for non-communicable diseases. Most importantly, we find that older South Africans do not seek testing as a response to risk. Instead, older men and women test only once they are symptomatic and referred by a provider, or as a result of a partner's status. Our respondents, particularly the women, expressed "shock" and confusion at learning they were HIV-positive because they do not see themselves as at risk of acquiring HIV. Because the benefits of UTT are greatest with early detection and treatment, older persons' tendency to test at such a late stage of illness decreases the individual and population level advantages of UTT. More research is needed to understand older persons' risk and testing behavior so that policy and programs include HIV testing messages that reach this population.

Acceptability and performance of a directly assisted oral HIV self-testing intervention in adolescents in rural Mozambique

INTRODUCTION

Whereas progress in HIV testing and treatment has been made globally, the UNAIDS goal of "90 90 90" is still out of sight in rural northern Mozambique. New strategies that promote testing in hard to reach groups will aid Mozambique's response to the HIV epidemic. HIV self-testing (HIVST) is recommended by the WHO as an additional approach to augment the HIV testing services available to adolescents. This study evaluates acceptability and performance of a directly assisted oral HIVST intervention for adolescents in rural Mozambique.

METHODS

Adolescents aged 16-20 years were included at schools and invited to attend the local hospital's youth friendly service for directly assisted oral HIVST. Baseline and post-test questionnaires were obtained. OraQuick Rapid HIV-1/2 Anti body test® was used. Results were read by the participant and by a nurse. Results were confirmed by finger prick HIV test (Determine® HIV 1/2 Alere and Unigold™ HIV Trinity Biotech) according to the Mozambican national standard.

RESULTS

Between September and November 2016, 496 adolescents were included, of which 299 performed an oral HIV self-test. 70% were first time testers. The positivity rate was 1.7%. The inter-rater agreement between adolescent and nurse was 99.6% (kappa 0.93); there were no false negative or false positive results of the oral HIV self-test. Five tests were invalid. 7.1% found the test difficult to use. Over 80% preferred directly assisted HIVST compared to the standard finger prick testing. While 20% thought it would be good to do HIVST at home, 76% preferred to do HIVST at the health centre, for reasons including increased security, privacy, and the presence of a counsellor.

CONCLUSIONS

Directly assisted oral HIVST is a feasible intervention for adolescents in rural Mozambique and showed encouraging results for first time HIV testers.

What Influences Linkage to Care After Home-Based HIV Counseling and Testing?

To maximize the benefits of test and treat strategies that utilize community-based HIV testing, clients who test positive must link to care in a timely manner. However, linkage rates across the HIV treatment cascade are typically low and little is known about what might facilitate or hinder care-seeking behavior. This qualitative study was conducted within a home-based HIV counseling and testing (HBHCT) intervention in South Africa. In-depth interviews were conducted with 30 HBHCT clients who tested HIV positive to explore what influenced their care-seeking behavior. A set of field notes for 196 additional HBHCT clients who tested HIV positive at home were also reviewed and analyzed. Content analysis showed that linkage to care is influenced by a myriad of factors at the individual, relationship, community, and health system levels. These factors subtly interact and at times reinforce each other. While some factors such as belief in test results, coping ability, social support, and prior experiences with the health system affect clients’ desire and motivation to seek care, others such as limited time and resources affect their agency to do so. To ensure that the benefits of community-based testing models are realized through timely linkage to care, programs and interventions must take into account and address clients’ emotions, motivation levels, living situations, relationship dynamics, responsibilities, and personal resources.

Going door-to-door to reach men and young people with HIV testing services to achieve the 90-90-90 treatment targets

Setting: Mulanje District, Malawi. Objective: To examine the effectiveness of door-to-door (DtD) testing in reaching young people and men in a remote, rural area with a high prevalence of human immunodeficiency virus (HIV) infection. Design: This was a retrospective analysis of data collected for a pilot DtD program. HIV testing services (HTS) visited targeted villages for 1-2 weeks. All current residents aged ⩾2 years not known to be HIV-positive were offered testing. Results: Ninety per cent (13 783/15 391) of individuals eligible for testing accepted. Forty-one per cent (n = 5693) of those tested were males and 56% (n = 7752) were aged <20 years. The overall proportion who tested positive was 4% (n = 524), with half as many males as females testing positive (OR 0.49, 95%CI 0.40-0.60, P < 0.001). There was a higher positive yield rate for those aged ⩾20 years (6% for men and 8% for women). Two thirds were first-time testers; males were half as likely as females to have been previously tested (OR 0.43, 95%CI 0.40-0.47, P < 0.001). Conclusion: DtD-HTS can be an effective way to reach populations in remote, rural high-prevalence areas where access to fixed facilities is inadequate. It has the potential to reach young people and men better than facility-based testing or other community strategies, and can identify young HIV-positive children who may have been missed by other methods.

Who Needs to Be Targeted for HIV Testing and Treatment in KwaZulu-Natal? Results From a Population-Based Survey

Supplemental Digital Content is Available in the Text.

Introduction:

Identifying gaps in HIV testing and treatment is essential to design specific strategies targeting those not accessing HIV services. We assessed the prevalence and factors associated with being HIV untested, unaware, untreated, and virally unsuppressed in KwaZulu-Natal, South Africa.

Methods:

Cross-sectional population-based survey. People aged 15–59 years were eligible. Interviews, HIV testing, and blood collection for antiretroviral drug presence test, CD4, and viral load were done at the participants' home.

Results:

Of the 5649 individuals included, 81.4% (95% CI: 79.8 to 82.9) had previously been tested. HIV prevalence was 25.2%. HIV-positivity awareness rate was 75.2% (95% CI: 72.9 to 77.4). Of all unaware, 73.3% of people were aged <35 years and 68.7% were women. Antiretroviral therapy coverage was 75.0% (95% CI: 72.0 to 77.8) among those eligible for treatment (CD4 < 350, PMTCT-B) and 53.1% (95% CI: 50.4 to 55.7) among all HIV-positive individuals. Viral load was <1000 copies per milliliter in 57.1% of all HIV-positive individuals. Although 66.3% and 71.7% of people with viral load ≥1000 copies per milliliter were people aged <35 years and women respectively, men had 4.4, 1.8, 1.6, and 1.7 times the odds of being untested, unaware, untreated, and virally unsuppressed. In addition, people with more than 1 sexual partner had 1.3, 2.2, and 1.9 times the odds of being untested, unaware, and untreated.

Conclusions:

The majority of HIV-positive people unaware of their status, untreated, and virally unsuppressed were individuals aged <35 years and women. However, men were disproportionately untested, unaware HIV positivity, untreated, and virally unsuppressed. In this context, HIV testing and treatment should be prioritized to target young people and women, whereas novel strategies are necessary to reach men.

Patient and provider attitudes to emergency department-based HIV counselling and testing in South Africa

Background

The national South African HIV Counselling and Testing (HCT) guidelines mandate that voluntary counselling and testing (VCT) should be offered in all healthcare facilities. Emergency departments (EDs) are at the forefront of many healthcare facilities, yet VCT is not routinely implemented in this setting.

Methods

We conducted a cross-sectional study that surveyed patients and healthcare providers at a tertiary care ED in the spring and summer of 2016 to ascertain their attitudes to VCT in the ED. We also used two previously validated survey instruments to gather data on patients’ HIV knowledge and providers’ stigma against patients living with HIV, as we anticipated that these may have an impact on providers’ and patients’ attitudes to the provision of HIV testing within the ED, and may offer insights for future intervention development.

Results

A total of 104 patients and 26 providers were enrolled in the study. Overall, patients responded more favourably to ED-based HIV testing (92.3%) compared to providers (only 40% responded favourably). When asked about potential barriers to receiving or providing HIV testing, 16.4% of patients and 24% of providers felt that the subject of HIV was too sensitive and 58.7% of patients and 80% of providers indicated that privacy and confidentiality issues would pose major barriers to implementing ED-based HIV testing.

Conclusion

This study shows that while ED-based HIV testing is overall highly acceptable to patients, providers seem less willing to provide this service. The survey data also suggest that future development of ED-based testing strategies should take into consideration privacy and confidentiality concerns that may arise within a busy emergency care setting. Furthermore, every effort should be made to tackle HIV stigma among providers to improve overall attitudes towards HIV-positive individuals that present for care in the ED.

Perceived mHealth barriers and benefits for home-based HIV testing and counseling and other care: Qualitative findings from health officials, community health workers, and persons living with HIV in South Africa

mHealth has been proposed to address inefficiencies in the current South African healthcare system, including home-based HIV testing and counseling (HTC) programs. Yet wide-scale adoption of mHealth has not occurred. Even as infrastructure barriers decrease, a need to better understand perceived adoption barriers by stakeholders remains. We conducted focus group discussions (FGD) in South Africa in 2016 with 10 home-based HTC field staff, 12 community health workers (CHWs) and 10 persons living with HIV (PLH). Key informant (KI) interviews were conducted with five health officials. Perceptions about current home-based HTC practices, future mHealth systems and the use of biometrics for patient identification were discussed, recorded and transcribed for qualitative analysis. Themes were based on a conceptual model for perceived mHealth service quality. Stakeholders brought up a lack of communication in sharing patient health information between clinics, between clinics and CHWs, and between clinics and patients as major barriers to care that mHealth can address. CHWs need better patient information from clinics in terms of physical location and health status to plan visitation routes and address patient needs. CHWs perceive that communication barriers create distrust towards them by clinic staff. PLH want automated appointment and medication reminders. KI see mHealth as a way to improve health information transfer to government officials to better allocate healthcare resources. Stakeholders are also optimistic about the ability for biometrics to improve patient identification but disagreed as to which biometrics would be acceptable, especially in older patients. All stakeholders provided useful information towards the development of mHealth systems. Hospitals are adopting patient-centered approaches that solicit feedback from patients and incorporate them into decision-making processes. A similar approach is needed in the development of mHealth systems. Further, such systems are critical to the successful extension of the health system from health facilities into people's homes.

Willingness by people living with HIV/AIDS to utilize HIV services provided by Village Health team workers in Kalungu district, central Uganda

BACKGROUND

Less than one quarter of people in need have access to HIV services in Uganda. This study assessed willingness of people living with HIV/AIDS (PLWHAs) to utilize HIV services provided by Village Health Teams (VHTs) in Kalungu district, central Uganda.

METHODS

A cross-sectional study conducted in two health facilities providing anti-retroviral therapy enrolled 312 PLWHAs. Pre-tested semi-structured questionnaires were administered to participants at household level. A forward fitting logistic regression model computed the predictors of willingness of PLWHAs to utilize services provided by VHTs.

RESULTS

Overall, 49% were willing to utilize HIV services provided by VHTs increasing to 75.6% if the VHT member was HIV positive. PLWHAs who resided in urban areas were more likely to utilize HIV services provided by VHTs (AOR 0.24, 95%CI 0.06-0.87). Barriers to utilizing HIV services provided by VHTs were: income level > 40 USD (AOR 6.43 95%CI 1.19-34.68), being a business person (AOR 8.71 95%CI 1.23-61.72), peasant (AOR 7.95 95%CI 1.37-46.19), lack of encouragement from: peers (AOR 6.33 95%CI 1.43-28.09), spouses (AOR 4.93 95%CI 1.23-19.82) and community leader (AOR 9.67 95%CI 3.35-27.92).

CONCLUSION

Social support could improve willingness by PLWHAs to utilize HIV services provided by VHTs for increased access to HIV services by PLWHA.

Cascade of Refusal-What Does It Mean for the Future of Treatment as Prevention in Sub-Saharan Africa?

Recent recommendations by the World Health Organization support treatment for all people living with HIV (PLWH) globally to be initiated at the point of testing. While there has been marked success in efforts to identify and expand treatment for PLWH throughout sub-Saharan Africa, the goal of universal treatment may prove challenging to achieve. The pre-ART phase of the care cascade from HIV testing to HIV treatment initiation includes several social and structural barriers. One such barrier is antiretroviral therapy (ART) treatment refusal, a phenomenon in which HIV-infected individuals choose not to start treatment upon learning their ART eligibility. Our goal is to provide further understanding of why treatment-eligible adults may choose to present for HIV testing but not initiate ART when indicated. In this article, we will discuss factors driving pre-ART loss and present a framework for understanding the impact of decision-making on early losses in the care cascade, with a focus on ART refusal.

An assessment of quality of home-based HIV counseling and testing performed by lay counselors in a rural sub-district of KwaZulu-Natal, South Africa

HIV counseling and testing (HCT) has been prioritized as one of the prevention strategies for HIV/AIDS, and promoted as an essential tool in scaling up and improving access to treatment, care and support especially in community settings. Home-based HCT (HBHCT) is a model that has consistently been found to be highly acceptable and has improved HCT coverage and uptake in low- and middle-income countries since 2002. It involves trained lay counselors going door-to-door offering pre-test counseling and providing HCT services to consenting eligible household members. Currently, there are few studies reporting on the quality of HBHCT services offered by lay counselors especially in Sub-Saharan Africa, including South Africa. This is a quantitative descriptive sub-study of a community randomized trial (Good Start HBHCT trial) which describes the quality of HBHCT provided by lay counselors. Quality of HBHCT was measured as scores comparing observed practice to prescribed protocols using direct observation. Data were collected through periodic observations of HCT sessions and exit interviews with clients. Counselor quality scores for pre-test counseling and post-test counseling sessions were created to determine the level of quality. For the client exit interviews a continuous score was created to assess how satisfied the clients were with the counseling session. A total of 196 (3%) observational assessments and 406 (6%) client exit interviews were completed. Overall, median scores for quality of counseling and testing were high for both HIV-negative and HIV-positive clients. For exit interviews all 406 (100%) clients had overall satisfaction with the counseling and testing services they received, however 11% were concerned about the counselor keeping their discussion confidential. Of all 406 clients, 393 (96.8%) intended to recommend the service to other people. In ensuring good quality HCT services, ongoing quality assessments are important to monitor quality of HCT after training.

Factors associated with HIV status awareness and Linkage to Care following home based testing in rural Malawi

OBJECTIVE

HIV diagnosis and linkage to care are the main barriers in Africa to achieving the UNAIDS 90-90-90 targets. We assessed HIV-positive status awareness and linkage to care among survey participants in Chiradzulu District, Malawi.

METHOD

Nested cohort study within a population-based survey of persons aged 15-59 years between February and May 2013. Participants were interviewed and tested for HIV (and CD4 if found HIV-positive) in their homes. Multivariable regression was used to determine factors associated with HIV-positive status awareness prior to the survey and subsequent linkage to care.

RESULTS

Of 8277 individuals eligible for the survey, 7270 (87.8%) participated and were tested for HIV. The overall HIV prevalence was 17.0%. Among HIV-positive participants, 77.0% knew their status and 72.8% were in care. Women (adjusted odds ratio [aOR] 6.5, 95% CI 3.2-13.1) and older participants (40-59 vs. 15-29 years, aOR 10.1, 95% CI 4.0-25.9) were more likely to be aware of their positive status. Of those newly diagnosed, 47.5% were linked to care within 3 months. Linkage to care was higher among older participants (40-59 vs. 15-29, adjusted hazard ratio [aHR] 3.39, 95% CI 1.83-6.26), women (aHR 1.73, 95% CI 1.12-2.67) and those eligible for ART (aHR 1.61, 95% CI 1.03-2.52).

CONCLUSIONS

In settings with high levels of HIV awareness, home-based testing remains an efficient strategy to diagnose and link to care. Men were less likely to be diagnosed, and when diagnosed to link to care, underscoring the need for a gender focus in order to achieve the 90-90-90 targets.

African Breast Cancer-Disparities in Outcomes (ABC-DO): protocol of a multicountry mobile health prospective study of breast cancer survival in sub-Saharan Africa

INTRODUCTION

Sub-Saharan African (SSA) women with breast cancer (BC) have low survival rates from this potentially treatable disease. An understanding of context-specific societal, health-systems and woman-level barriers to BC early detection, diagnosis and treatment are needed.

METHODS

The African Breast Cancer-Disparities in Outcomes (ABC-DO) is a prospective hospital-based study of overall survival, impact on quality of life (QOL) and delays along the journey to diagnosis and treatment of BC in SSA. ABC-DO is currently recruiting in Namibia, Nigeria, South Africa, Uganda and Zambia. Women aged 18 years or older who present at participating secondary and tertiary hospitals with a new clinical or histocytological diagnosis of primary BC are invited to participate. For consented women, tumour characteristics, specimen and treatment data are obtained. Over a 2-year enrolment period, we aim to recruit 2000 women who, in the first instance, will be followed for between 1 and 3 years. A face-to-face baseline interview obtains information on socioeconomic, cultural and demographic factors, QOL, health and BC attitudes/knowledge, and timing of all prediagnostic contacts with caregivers in orthodox health, traditional and spiritual systems. Responses are immediately captured on mobile devices that are fed into a tailored mobile health (mHealth) study management system. This system implements the study protocol, by prompting study researchers to phone women on her mobile phone every 3 months and, failing to reach her, prompts contact with her next-of-kin. At follow-up calls, women provide updated information on QOL, care received and disease impacts on family and working life; date of death is asked of her next-of-kin when relevant.

ETHICS AND DISSEMINATION

The study was approved by ethics committees of all involved institutions. All participants provide written informed consent. The findings from the study will be published in peer-reviewed scientific journals, presented to funders and relevant local organisations and at scientific conferences.

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.

Home-Based HIV Testing Among Pregnant Couples Increases Partner Testing and Identification of Serodiscordant Partnerships

INTRODUCTION

Male partner HIV testing has been recognized as an important component of prevention of mother-to-child HIV transmission. Scheduled home-based couple HIV testing may be an effective strategy to reach men.

METHODS

Women attending their first antenatal visit at Kisumu County Hospital in Kenya were randomized to home-based education and HIV testing within 2 weeks of enrollment (HOPE) or to written invitations for male partners to attend clinic (INVITE). Male partner HIV testing and maternal child health outcomes were compared at 6 months postpartum.

RESULTS

Of 1101 women screened, 620 were eligible and 601 were randomized to HOPE (n = 306) or INVITE (n = 295). At 6 months postpartum, male partners were more than twice as likely [relative risk (RR) = 2.10; 95% CI (CI): 1.81 to 2.42] to have been HIV tested in the HOPE arm [233 (87%)] compared with the INVITE arm [108 (39%)]. Couples in the HOPE arm [192 (77%)] were 3 times as likely (RR = 3.17; 95% CI: 2.53 to 3.98) to have been tested as a couple as the INVITE arm [62 (24%)] and women in the HOPE arm [217 (88%)] were also twice as likely (RR = 2.27; 95% CI: 1.93 to 2.67) to know their partner's HIV status as the INVITE arm [98 (39%)]. More serodiscordant couples were identified in the HOPE arm [33 (13%)] than in the INVITE arm [10 (4%)] (RR = 3.38; 95% CI: 1.70 to 6.71). Maternal child health outcomes of facility delivery, postpartum family planning, and exclusive breastfeeding did not vary by arm.

CONCLUSIONS

Home-based HIV testing for pregnant couples resulted in higher uptake of male partner and couple testing, as well as higher rates of HIV status disclosure and identification of serodiscordant couples. However, the intervention did not result in higher uptake of maternal child health outcomes, because facility delivery and postpartum family planning were high in both arms, whereas exclusive breastfeeding was low. The HOPE intervention was successful at its primary aim to increase HIV testing and disclosure among pregnant couples and was able to find more serodiscordant couples compared with the invitation-only strategy.

TRIAL REGISTRATION

Clinicaltrials.gov registry: NCT01784783.

Access to HIV care in the context of universal test and treat: challenges within the ANRS 12249 TasP cluster-randomized trial in rural South Africa

Introduction

We aimed to quantify and identify associated factors of linkage to HIV care following home-based HIV counselling and testing (HBHCT) in the ongoing ANRS 12249 treatment-as-prevention (TasP) cluster-randomized trial in rural KwaZulu-Natal, South Africa.

Methods

Individuals ≥16 years were offered HBHCT; those who were identified HIV positive were referred to cluster-based TasP clinics and offered antiretroviral treatment (ART) immediately (five clusters) or according to national guidelines (five clusters). HIV care was also available in the local Department of Health (DoH) clinics. Linkage to HIV care was defined as TasP or DoH clinic attendance within three months of referral among adults not in HIV care at referral. Associated factors were identified using multivariable logistic regression adjusted for trial arm.

Results

Overall, 1323 HIV-positive adults (72.9% women) not in HIV care at referral were included, of whom 36.9% (n=488) linked to care <3 months of referral (similar by sex). In adjusted analyses (n=1222), individuals who had never been in HIV care before referral were significantly less likely to link to care than those who had previously been in care (<33% vs. >42%, p<0.001). Linkage to care was lower in students (adjusted odds-ratio [aOR]=0.47; 95% confidence interval [CI] 0.24–0.92) than in employed adults, in adults who completed secondary school (aOR=0.68; CI 0.49–0.96) or at least some secondary school (aOR=0.59; CI 0.41–0.84) versus ≤ primary school, in those who lived at 1 to 2 km (aOR=0.58; CI 0.44–0.78) or 2–5 km from the nearest TasP clinic (aOR=0.57; CI 0.41–0.77) versus <1 km, and in those who were referred to clinic after ≥2 contacts (aOR=0.75; CI 0.58–0.97) versus those referred at the first contact. Linkage to care was higher in adults who reported knowing an HIV-positive family member (aOR=1.45; CI 1.12–1.86) versus not, and in those who said that they would take ART as soon as possible if they were diagnosed HIV positive (aOR=2.16; CI 1.13–4.10) versus not.

Conclusions

Fewer than 40% of HIV-positive adults not in care at referral were linked to HIV care within three months of HBHCT in the TasP trial. Achieving universal test and treat coverage will require innovative interventions to support linkage to HIV care.

How equitable are community health worker programmes and which programme features influence equity of community health worker services? A systematic review

BACKGROUND

Community health workers (CHWs) are uniquely placed to link communities with the health system, playing a role in improving the reach of health systems and bringing health services closer to hard-to-reach and marginalised groups. A systematic review was conducted to determine the extent of equity of CHW programmes and to identify intervention design factors which influence equity of health outcomes.

METHODS

In accordance with our published protocol, we systematically searched eight databases from 2004 to 2014 for quantitative and qualitative studies which assessed access, utilisation, quality or community empowerment following introduction of a CHW programme according to equity stratifiers (place of residence, gender, socio-economic position and disability). Thirty four papers met inclusion criteria. A thematic framework was applied and data extracted and managed, prior to charting and thematic analysis.

RESULTS

To our knowledge this is the first systematic review that describes the extent of equity within CHW programmes and identifies CHW intervention design features which influence equity. CHW programmes were found to promote equity of access and utilisation for community health by reducing inequities relating to place of residence, gender, education and socio-economic position. CHWs can also contribute towards more equitable uptake of referrals at health facility level. There was no clear evidence for equitable quality of services provided by CHWs and limited information regarding the role of the CHW in generating community empowerment to respond to social determinants of health. Factors promoting greater equity of CHW services include recruitment of most poor community members as CHWs, close proximity of services to households, pre-existing social relationship with CHW, provision of home-based services, free service delivery, targeting of poor households, strengthened referral to facility, sensitisation and mobilisation of community. However, if CHW programmes are not well planned some of the barriers faced by clients at health facility level can replicate at community level.

CONCLUSIONS

CHWs promote equitable access to health promotion, disease prevention and use of curative services at household level. However, care must be taken by policymakers and implementers to take into account factors which can influence the equity of services during planning and implementation of CHW programmes.

Review of Developments in Electronic, Clinical Data Collection, and Documentation Systems over the Last Decade - Are We Ready for Big Data in Routine Health Care?

Recently, information availability has become more elaborate and widespread, and treatment decisions are based on a multitude of factors, including imaging, molecular or pathological markers, surgical results, and patient’s preference. In this context, the term “Big Data” evolved also in health care. The “hype” is heavily discussed in literature. In interdisciplinary medical specialties, such as radiation oncology, not only heterogeneous and voluminous amount of data must be evaluated but also spread in different styles across various information systems. Exactly this problem is also referred to in many ongoing discussions about Big Data – the “three V’s”: volume, velocity, and variety. We reviewed 895 articles extracted from the NCBI databases about current developments in electronic clinical data management systems and their further analysis or postprocessing procedures. Few articles show first ideas and ways to immediately make use of collected data, particularly imaging data. Many developments can be noticed in the field of clinical trial or analysis documentation, mobile devices for documentation, and genomics research. Using Big Data to advance medical research is definitely on the rise. Health care is perhaps the most comprehensive, important, and economically viable field of application.

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.

Uptake and yield of HIV testing and counselling among children and adolescents in sub-Saharan Africa: a systematic review

INTRODUCTION

In recent years children and adolescents have emerged as a priority for HIV prevention and care services. We conducted a systematic review to investigate the acceptability, yield and prevalence of HIV testing and counselling (HTC) strategies in children and adolescents (5 to 19 years) in sub-Saharan Africa.

METHODS

An electronic search was conducted in MEDLINE, EMBASE, Global Health and conference abstract databases. Studies reporting on HTC acceptability, yield and prevalence and published between January 2004 and September 2014 were included. Pooled proportions for these three outcomes were estimated using a random effects model. A quality assessment was conducted on included studies.

RESULTS AND DISCUSSION

A total of 16,380 potential citations were identified, of which 21 studies (23 entries) were included. Most studies were conducted in Kenya (n=5) and Uganda (n=5) and judged to provide moderate (n=15) to low quality (n=7) evidence, with data not disaggregated by age. Seven studies reported on provider-initiated testing and counselling (PITC), with the remainder reporting on family-centred (n=5), home-based (n=5), outreach (n=5) and school-linked HTC among primary schoolchildren (n=1). PITC among inpatients had the highest acceptability (86.3%; 95% confidence interval [CI]: 65.5 to 100%), yield (12.2%; 95% CI: 6.1 to 18.3%) and prevalence (15.4%; 95% CI: 5.0 to 25.7%). Family-centred HTC had lower acceptance compared to home-based HTC (51.7%; 95% CI: 10.4 to 92.9% vs. 84.9%; 95% CI: 74.4 to 95.4%) yet higher prevalence (8.4%; 95% CI: 3.4 to 13.5% vs. 3.0%; 95% CI: 1.0 to 4.9%). School-linked HTC showed poor acceptance and low prevalence.

CONCLUSIONS

While PITC may have high test acceptability priority should be given to evaluating strategies beyond healthcare settings (e.g. home-based HTC among families) to identify individuals earlier in their disease progression. Data on linkage to care and cost-effectiveness of HTC strategies are needed to strengthen policies.

A Cost-Effectiveness Analysis of a Home-Based HIV Counselling and Testing Intervention versus the Standard (Facility Based) HIV Testing Strategy in Rural South Africa

INTRODUCTION

There is growing evidence concerning the acceptability and feasibility of home-based HIV testing. However, less is known about the cost-effectiveness of the approach yet it is a critical component to guide decisions about scaling up access to HIV testing. This study examined the cost-effectiveness of a home-based HIV testing intervention in rural South Africa.

METHODS

Two alternatives: clinic and home-based HIV counselling and testing were compared. Costs were analysed from a provider's perspective for the period of January to December 2010. The outcome, HIV counselling and testing (HCT) uptake was obtained from the Good Start home-based HIV counselling and testing (HBHCT) cluster randomised control trial undertaken in KwaZulu-Natal province. Cost-effectiveness was estimated for a target population of 22,099 versus 23,864 people for intervention and control communities respectively. Average costs were calculated as the cost per client tested, while cost-effectiveness was calculated as the cost per additional client tested through HBHCT.

RESULTS

Based on effectiveness of 37% in the intervention (HBHCT) arm compared to 16% in control arm, home based testing costs US$29 compared to US$38 per person for clinic HCT. The incremental cost effectiveness per client tested using HBHCT was $19.

CONCLUSIONS

HBHCT was less costly and more effective. Home-based HCT could present a cost-effective alternative for rural 'hard to reach' populations depending on affordability by the health system, and should be considered as part of community outreach programs.

Rates of HIV testing and diagnosis in South Africa: successes and challenges

BACKGROUND

UNAIDS aims for 90% of HIV-positive individuals to be diagnosed by 2020, but few attempts have been made in developing countries to estimate the fraction of the HIV-positive population that has been diagnosed.

METHODS

To estimate the rate of HIV diagnosis in South Africa, reported numbers of HIV tests performed in the South African public and private health sectors were aggregated, and estimates of HIV prevalence in individuals tested for HIV were combined. The data were integrated into a mathematical model of the South African HIV epidemic, which was additionally calibrated to estimates of the fraction of the population ever tested for HIV, as reported in three national household surveys.

RESULTS

The fraction of HIV-positive adults who were undiagnosed declined from more than 80% in the early 2000s to 23.7% [95% confidence interval (95% CI) 23.1-24.3] in 2012. The undiagnosed proportion in 2012 was substantially higher in men (31.9%, 95% CI 29.7-34.3) than in women (19.0%, 95% CI 17.9-19.9). Projected probabilities of experiencing disease progression (CD4 cell count <350 cells/μl) without diagnosis are more than 50% for most HIV-positive adults over the age of 40. The fraction of HIV-positive adults who are undiagnosed is projected to decline to 8.9% by 2020 if current targets (10 million tests per annum) are met.

CONCLUSION

South Africa has made significant progress in expanding access to HIV testing, and at current testing rates, the target of 90% of HIV-positive adults diagnosed by 2020 is likely to be reached. However, uptake is relatively low in men and older adults.

Linkage to care following a home-based HIV counselling and testing intervention in rural South Africa

Introduction

Efforts to increase awareness of HIV status have led to growing interest in community-based models of HIV testing. Maximizing the benefits of such programmes requires timely linkage to care and treatment. Thus, an understanding of linkage and its potential barriers is imperative for scale-up.

Methods

This study was conducted in rural South Africa. HIV-positive clients (n=492) identified through home-based HIV counselling and testing (HBHCT) were followed up to assess linkage to care, defined as obtaining a CD4 count. Among 359 eligible clients, we calculated the proportion that linked to care within three months. For 226 clients with available data, we calculated the median CD4. To determine factors associated with the rate of linkage, Cox regression was performed on a subsample of 196 clients with additional data on socio-demographic factors and personal characteristics.

Results

We found that 62.1% (95% CI: 55.7 to 68.5%) of clients from the primary sample (n=359) linked to care within three months of HBHCT. Among those who linked, the median CD4 count was 341 cells/mm³ (interquartile range [IQR] 224 to 542 cells/mm³). In the subsample of 196 clients, factors predictive of increased linkage included the following: believing that drugs/supplies were available at the health facility (adjusted hazard ratio [aHR] 1.78; 95% CI: 1.07 to 2.96); experiencing three or more depression symptoms (aHR 2.09; 95% CI: 1.24 to 3.53); being a caregiver for four or more people (aHR 1.93; 95% CI: 1.07 to 3.47); and knowing someone who died of HIV/AIDS (aHR 1.68; 95% CI: 1.13 to 2.49). Factors predictive of decreased linkage included the following: younger age – 15 to 24 years (aHR 0.50; 95% CI: 0.28 to 0.91); living with two or more adults (aHR 0.52; 95% CI: 0.35 to 0.77); not believing or being unsure about the test results (aHR 0.48; 95% CI: 0.30 to 0.77); difficulty finding time to seek health care (aHR 0.40; 95% CI: 0.24 to 0.67); believing that antiretroviral treatment can make you sick (aHR 0.56; 95% CI: 0.35 to 0.89); and drinking alcohol (aHR 0.52; 95% CI: 0.34 to 0.80).

Conclusions

The findings highlight barriers to linkage following an increasingly popular model of HIV testing. Further, they draw attention to ways in which practical interventions and health education strategies could be used to improve linkage to care.

Empowering patients to link to care and treatment: qualitative findings about the role of a home-based HIV counselling, testing and linkage intervention in South Africa

To explore the barriers and facilitators of linkage to and retention in care amongst persons who tested positive for HIV, qualitative research was conducted in a home-based HIV counselling and testing (HBCT) project with interventions to facilitate linkages to HIV care in rural KwaZulu-Natal, South Africa. The intervention tested 1272 adults for HIV in Vulindlela of whom 32% were HIV positive, received point-of-care (POC) CD4 testing and referral to local HIV clinics. Those testing positive also received follow-up visits from a counsellor to evaluate linkages to care. The study employed a qualitative methodology collecting data through in-depth semi-structured interviews. Respondents included 25 HIV-positive persons who had tested as part of HBCT project, 4 intervention research counsellors who delivered the HBCT intervention and 9 government clinic staff who received referrals for care. The results show that HBCT helped to facilitate linkage to care through providing education and support to help overcome fears of stigma and discrimination. The results show the perceived value of receiving a POC CD4 result during post-test counselling, both for those newly diagnosed and those previously diagnosed as HIV positive. The results also demonstrate that in-depth counselling creates an "educated consumer" facilitating engagement with clinical services. The study provides qualitative insights into the acceptability of confidential HBCT with same day POC CD4 testing and counselling as factors that influenced HIV-positive persons' decisions to link to care. This model warrants further evaluation in non-research settings to determine impact and cost-effectiveness relative to other HIV testing and referral strategies.

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.

Pilot study of home-based delivery of HIV testing and counseling and contraceptive services to couples in Malawi

Background

HIV counseling and testing for couples is an important component of HIV prevention strategies, particularly in Sub Saharan Africa. The purpose of this pilot study is to estimate the uptake of couple HIV counseling and testing (CHCT) and couple family planning (CFP) services in a single home visit in peri-urban Malawi and to assess related factors.

Methods

This study involved offering CHCT and CFP services to couples in their homes; 180 couples were sampled from households in a peri-urban area of Blantyre. Baseline data were collected from both partners and follow-up data were collected one week later. A pair of male and female counselors approached each partner separately about HIV testing and counseling and contraceptive services and then, if both consented, CHCT and CFP services (pills, condoms and referrals for other methods) were given. Bivariate and multivariate logistic regression analyses were done to examine the relationship between individual partner characteristics and acceptance of the services. Selected behaviors reported pre- and post-intervention, particularly couple reports on contraceptive use and condom use at last sex, were also tested for differences.

Results

89% of couples accepted at least one of the services (58% CHCT-only, 29% CHCT + CFP, 2% CFP-only). Among women, prior testing experience (p < 0.05), parity (p < 0.01), and emotional closeness to partner (p < 0.01) had significant bivariate associations with acceptance of at least one service. Reported condom use at last sex increased from 6% to 25% among couples receiving any intervention. First-ever HIV testing was delivered to 25 women and 69 men, resulting, respectively, in 4 and 11 newly detected infections.

Conclusions

Home-based CHCT and CFP were very successful in this pilot study with high proportions of previously untested husbands and wives accepting CHCT and there were virtually no negative outcomes within one week. This study supports the need for further research and testing of home- and couple-based approaches to expand access to HCT and contraceptive services to prevent the undesired consequences of sexually transmitted infection and unintended pregnancy via unprotected sex.

Facilitators and barriers related to voluntary counseling and testing for HIV among young adults in Bo, Sierra Leone

In 2012, we interviewed a population-based sample of 285 young adult residents (age 18-35 years) of the city of Bo, Sierra Leone, about their attitudes toward and experience with voluntary testing and counseling (VCT) for HIV. In total, 33% of the participants (44% of women and 25% of men) reported having been tested for HIV at least once. More than 85% of those not previously tested indicated a willingness to be tested in the near future, but untested participants were nearly twice as likely as tested participants to report fears about family/partner rejection, job loss, and other potential consequences of testing. More than 90% of participants expressed a high desire for testing privacy, and the majority reported a preference for VCT at a facility far from home where no one would know them. Social barriers to HIV testing remain a challenge for HIV prevention in Sierra Leone.

Factors contributing to home-based acceptability of rapid testing for HIV infection among the inner city commuter population in Johannesburg, South Africa

BACKGROUND

The study aimed to determine factors contributing to the acceptability of home-based HIV counselling and testing (HBHCT) among commuters in Johannesburg inner city.

METHODS

Simple random sampling was used to select participants in a venue based intercept survey at Noord Street taxi rank in Johannesburg central business district. A total of 1146 individuals were interviewed and logistic regression analysis assessed factors associated with HBHCT acceptability.

RESULTS

HBHCT acceptability was 64%. Home testing was preferred as an alternative to testing at a health facility. High school education (adjusted odds ratio [aOR] 0.61, CI: 0.46-0.85), inner city residence aOR 0.70, CI: 0.52-0.94), previous HIV testing in the hospital (aOR 0.22, CI: 0.15-0.32) and at home (aOR 0.18, CI: 0.11-0.27) were significantly less likely associated with HBHCT acceptability. Being married (aOR 1.64, CI: 1.15-2.32), recent HIV testing (aOR 1.85, CI: 1.15-2.99) and having experienced negative health worker attitude (aOR 2.41, CI: 1.66-3.48) were significantly more likely associated with HBHCT acceptability.

CONCLUSIONS

High acceptability of HBHCT among urban-based commuters plus factors that would deter HBHCT acceptability were identified. Further research to identify strategies to improve HBHCT acceptability among commuter populations is needed.

Four models of HIV counseling and testing: utilization and test results in South Africa

BACKGROUND

HIV Counseling and Testing (HCT) is the point-of-entry for pathways of HIV care and prevention. However, HCT is not reaching many who are HIV infected and this may be related to the HCT provision model. We describe HCT utilization and HIV diagnosis using four models of HCT delivery: clinic-based, urban mobile, rural mobile, and stand-alone.

METHODS

Using cross-sectional data from routine HCT provided in South Africa, we described client characteristics and HIV test results from information collected during service delivery between January 2009 and June 2012.

RESULTS

118,358 clients received services at clinic-based units, 18,597; stand-alone, 28,937; urban mobile, 38,840; and rural mobile, 31,984. By unit, clients were similar in terms of median age (range 28-31), but differed in sex distribution, employment status, prior testing, and perceived HIV risk. Urban mobile units had the highest proportion of male clients (52%). Rural mobile units reached the highest proportion of clients with no prior HCT (61%) and reporting no perceived HIV risk (64%). Overall, 10,862 clients (9.3%) tested HIV-positive.

CONCLUSIONS

Client characteristics varied by HCT model. Importantly, rural and urban mobile units reached more men, first-time testers, and clients who considered themselves to be at low risk for HIV.

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

HIV testing has the potential to reduce HIV transmission by identifying and counseling individuals with HIV, reducing risk behaviors, linking persons with HIV to care and earlier treatment, and reducing perinatal transmission. In Lesotho, a high HIV prevalence country in which a large proportion of the population has never tested for HIV, home-based testing (HBT) may be an important strategy to increase HIV testing. We identified factors influencing acceptability of HIV prevention strategies among a convenience sample of 200 pregnant or post-partum Basotho women and 30 Basotho men. We first conducted cross-sectional surveys, followed by key informant interviews with all 30 men and focus group discussions with a sub-set of 62 women. In total, 82% of women reported positive perceptions of HBT; women and men viewed HBT as a potential way to increase testing among men and saw the home as a comfortable, supportive environment for testing and counseling couples and families together. Potential barriers to HBT uptake included concerns about confidentiality, privacy, coercion to test, conflict within the family and fear of HIV/AIDS-associated stigma. Participants emphasized community mobilization and education as important elements of HBT.

Optimizing lay counsellor services for chronic care in South Africa: a qualitative systematic review

OBJECTIVE

To conduct a qualitative systematic review on the use of lay counsellors in South Africa to provide lessons on optimizing their use for psychological and behavioural change counselling for chronic long-term care in scare-resource contexts.

METHOD

A qualitative systematic review of the literature on lay counsellor services in South Africa.

RESULTS

Twenty-nine studies met the inclusion criteria. Five randomized control trials and two cohort studies reported that lay counsellors can provide behaviour change counselling with good outcomes. One multi-centre cohort study provided promising evidence of improved anti-retroviral treatment adherence and one non-randomized controlled study provided promising results for counselling for depression. Six studies found low fidelity of lay counsellor-delivered interventions in routine care. Reasons for low fidelity include poor role definition, inconsistent remuneration, lack of standardized training, and poor supervision and logistical support.

CONCLUSION

Within resource-constrained settings, adjunct behaviour change and psychological services provided by lay counsellors can be harnessed to promote chronic care at primary health care level.

PRACTICE IMPLICATIONS

Optimizing lay counsellor services requires interventions at an organizational level that provide a clear role definition and scope of practice; in-service training and formal supervision; and sensitization of health managers to the importance and logistical requirements of counselling.

Uthando Lwethu ('our love'): a protocol for a couples-based intervention to increase testing for HIV: a randomized controlled trial in rural KwaZulu-Natal, South Africa

Background

Couples-based HIV counseling and testing (CHCT) is a proven strategy to reduce the risk of HIV transmission between partners, but uptake of CHCT is low. We describe the study design of a randomized controlled trial (RCT) aimed to increase participation in CHCT and reduce sexual risk behavior for HIV among heterosexual couples in rural KwaZulu-Natal, South Africa. We hypothesize that the rate of participation in CHCT will be higher and sexual risk behavior will be lower in the intervention group as compared to the control.

Methods/design

Heterosexual couples (N = 350 couples, 700 individuals) are being recruited to participate in a randomized trial of a couples-based intervention comprising two group sessions (one mixed gender, one single gender) and four couples’ counseling sessions. Couples must have been in a relationship together for at least 6 months. Quantitative assessments are conducted via mobile phones by gender-matched interviewers at baseline, 3, 6, and 9 months post-randomization. Intervention content is aimed to improve relationship dynamics, and includes communication skills and setting goals regarding CHCT.

Discussion

The Uthando Lwethu (‘our love’) intervention is the first couples-based intervention to have CHCT as its outcome. We are also targeting reductions in unprotected sex. CHCT necessitates the testing and mutual disclosure of both partners, conditions that are essential for improving subsequent outcomes such as disclosure of HIV status, sexual risk reduction, and improving treatment outcomes. Thus, improving rates of CHCT has the potential to improve health outcomes for heterosexual couples in a rural area of South Africa that is highly impacted by HIV. The results of our ongoing clinical trial will provide much needed information regarding whether a relationship-focused approach is effective in increasing rates of participation in CHCT. Our intervention represents an attempt to move away from individual-level conceptualizations, to a more integrated approach for HIV prevention.

Trial registration

Study Name: Couples in Context: An RCT of a Couples-based HIV Prevention Intervention

ClinicalTrials.gov identifier: NCT01953133.

South African clinical trial registration number: DOH-27-0212-3937