Our study documents that residents of households in the lowest income quartile were significantly less likely to have ever used facility-based HTC services than the rest of the population of Likoma (Malawi). These disparities in access to facility-based HTC were particularly severe among women: women in the poorest households were only half as likely to have ever been tested for HIV at a health-care facility than women in more affluent households. Several factors potentially contribute to this inequality in HTC uptake at health-care facilities. This may be due, for example, to the lower burden of HIV and associated infections among the poorest (section 2.3). Among respondents tested during home-based HTC, the prevalence of HIV was significantly lower among members of the poorest households. This pattern of HIV infection has been reported elsewhere.26,27
In addition, poorer women may be more dependent on their husband's approval to attend facility-based HTC testing services because they need to seek money for transport.10
Women are also often tested for HIV in the context of antenatal care (ANC), and ANC attendance is lower among women in poor households.1
Independent of the underlying causes, the inability of facility-based HTC services to reach the poorest has potentially far-reaching implications, which may turn HIV into a “disease of the poor”.27
By constraining access to HIV prevention and treatment services that effectively mitigate the transmission and the impact of the disease, low HTC uptake at health facilities among the poorest may lead to increased incidence of the virus and lower survival rates. It may also broaden economic inequalities and further jeopardize already fragile livelihoods in the poorest households.
The Likoma Network Study provided, for the first time on the island, home-based HTC services as part of a broader study on sexual networks and HIV transmission.21,22
Despite the fact that less than one quarter of the study population had previously participated in facility-based HTC, the home-based provision of HTC was very well accepted in this population: when present at home at the time of the HTC team's visit, more than 75% of respondents accepted to be tested and immediately retrieved their HIV test results at home. Uptake was even higher among the poorest, suggesting a strong unmet need for HTC among the most disadvantaged subgroups of the population. Home-based HTC thus has the potential to increase access of under-served populations to a series of services (e.g., ARV treatment) that may help the poorest households cope with the consequences of AIDS.
Participation in home-based HTC was also associated with several risk factors for HIV transmission/acquisition: inhabitants of Likoma with multiple sex partners over the last 3 years and inhabitants who presented recent symptoms of sexually transmitted infections were more likely to participate in home-based HTC. These findings suggest that the “yield” (i.e., the number of newly identified HIV cases) of a home-based HTC intervention might be high. Respondents involved in multiple concurrent partnerships at the time of the survey, however, were less likely to participate in home-based HTC in multivariate models. Such partnerships play a key role in HIV transmission,28
thus even though home-based HTC may significantly enhance case finding for HIV its impact on the onward transmission of HIV during non-marital partnerships may be more limited.
There are several limitations to our study. First, our assessment of prior use of facility-based HTC services is admittedly somewhat crude: we have no information about the last time a respondent got tested (recently or not), in which context testing was conducted (e.g., voluntary counseling and testing versus diagnostic testing), or whether the respondent retrieved his/her test results. Second, our measure of household poverty (household income in the lower quartile) is also crude. More precise measures of poverty often rely on detailed accounts of household expenditure, for example. Unfortunately such data were not available in our study. Third, our measures of sexual activity were limited to a small number of variables. As such, they may not have captured important differences in sexual behaviors between members of the poorest households and the rest of the population. Fourth, the provision of home-based HTC services during our study was limited to a narrow age range (ages 18–35), preventing this study to investigate the acceptability of home-based HTC among younger and older age groups. Fifth, our study is also not able to assess the potential impact of home-based HTC on the identification of cases of paediatric HIV,19
and it did not investigate the effect of home-based HTC on the communication of HIV test results among couples, which could lead to lower infection risks in discordant couples.15
Finally, the provision of a small bar of soap as a token of appreciation for participation in HTC may have provided stronger incentives for the individuals in the poorest households to participate in home-based HTC as compared to individuals in more affluent households. However, if the remuneration—rather than the ability to learn one's HIV status—had provided the primary motivation for HTC participation among the poorest individuals, one would have expected a higher rate of stopping HTC after the pre-test counseling among the poorest individuals. This was not the case.
In summary, the analyses presented in this paper confirm earlier studies showing large socioeconomic differences in uptake of HIV testing and counseling services provided at health facilities (e.g., hospitals, health centers). For the first time, however, this study documents that the home-based provision of HTC services has the potential of not only increasing the uptake of HTC services among the general population, but also to substantially reduce the socioeconomic gradient in HTC utilization observed in several African countries. While the logistical issues associated with large-scale home-based provision of HTC services are important,10
the home-based provision of HTC thus has the potential to satisfy a strong unmet need for testing and counseling among the poorest segments of sub-Saharan populations. It may also subsequently allow the poorest to gain greater access to life-extending ARV treatment, as well as to other prevention, care and support services. The impact of home-based HTC on uptake of testing and counseling, socioeconomic inequalities in access to treatment and HIV transmission should thus be tested rigorously, through controlled trials in which local communities are randomly assigned to facility-based or home-based schemes of HTC provision29