This study assessed client characteristics, HIV testing history and results, and costs of four different approaches to providing HCT in Kenya. Although multiple approaches to HCT service delivery are used to provide access to different population groups and to meet HIV prevention, care, and treatment goals3,28,29
, past studies have primarily focused on describing the characteristics of traditional stand-alone HCT. This study compared stand-alone HCT with three alternative mobile HCT approaches: community-site mobile HCT, semi-mobile container HCT, and fully-mobile truck HCT. The findings demonstrate that mobile HCT approaches compare favorably with stand-alone HCT in terms of cost per client, and effectiveness for reaching key target population groups. This is consistent with the findings of another recent study, which showed that other non-traditional HCT approaches were less expensive than stand-alone HCT and were successful in reaching different populations23
Our data show great utilization of HCT using mobile HCT approaches, with more than three times as many clients accessing HCT via mobile approaches than at stand-alone HCT for the same time period. Although overall fewer women accessed HCT services than men, our data show comparatively higher utilization of women at community-site and semi-mobile container HCT than stand-alone. This may be related to the barriers women face in getting time away from domestic responsibilities, and cost of transport to attend distant stand-alone HCT sites. Mobile HCT approaches were also more successful than stand-alone HCT at reaching individuals who were learning their HIV status for the first time, with new clients representing more than 85% of clients at all mobile HCT approaches, compared to 58% at stand-alone HCT. Mobile HCT was introduced to improve access to HCT, to increase knowledge of HIV status in underserved communities3,8–10
and to identify new HIV positive individuals so that they may be referred for treatment and care services. These data indicate that mobile HCT achieved these objectives.
Our data indicate low utilization by couples at mobile HCT sites compared to stand-alone. Couples are a key target group for HCT, and couples HCT has been well-documented as an effective HIV prevention intervention, especially for discordant couples12–18
. In countries such as Kenya, rates of discordance among married couples can be as high as 45%7,30
. Targeting couples with HCT is a high priority in these countries, and more effort is needed to attract couples to receive HCT together, especially at mobile sites. The high rate of discordance among couples at fully-mobile truck HCT (20%) is likely explained by the high HIV prevalence in the geographic area in which this method was implemented, suggesting that HCT may be most effective at reaching discordant couples in areas known to have high HIV prevalence.
Other differences in utilization among couples may be explained by demographic differences as well as inherent differences in the various HCT approaches. Attending HCT as a couple requires planning, discussion, and preparation by partners. Stand-alone sites at permanent locations operate with fixed hours, allowing couples to plan for HCT services at their convenience, and they actively promote couples HCT through advertising and encouraging clients to return with their partners. Mobile services may be introduced to communities on short notices, giving partners little time to prepare for receiving couples HCT together. One exception is home-based mobile HCT, which has reported high utilization by couples and is also cost-effective compared to stand-alone HCT23
. This approach is now being scaled up rapidly in Kenya.
HCT contributes to HIV care, treatment, and prevention goals by identifying HIV-infected persons who are eligible for care and treatment, and who can prevent onward transmission to others31
. The HCT strategies studied here showed great variation in their effectiveness at serving HIV-infected clients. It was no surprise that mobile HCT approaches implemented in areas with higher HIV prevalence reached higher numbers of HIV-infected individuals. Similarly, low reported HIV prevalence at semi-mobile HCT is likely due to the lower background prevalence in communities where this approach was used (5–7%). Since one HIV control objective is to identify HIV-infected persons, mobile HCT approaches will be more effective at achieving this objective if they are implemented in areas with high HIV prevalence.
Overall, the addition of community-site mobile HCT services is more cost-effective than stand-alone services in this study, in terms of incremental cost per client tested and per new HCT client. This is not surprising, as transport and other costs are minimal with this ‘low-tech’ approach. HCT providers typically live in the same community where stand-alone HCT operates, and from there they may walk, bicycle, or use local transportation to get to each community-site mobile HCT. However, counselors report the burden of carrying bags and boxes with testing supplies, and utilizing often unreliable means of transportation such as public transportation or faulty rental cars. Due to the transportation difficulties of this method, HCT services are often provided close to main roads or nearby the central location of the stand-alone HCT center, and counselors also report challenges related to locating temporary facilities in communities that are accessible and visible to community members but also confidential, private, and clean. Still, the two programs using this approach saw high numbers of clients, reflecting the fact that lower costs of mobile HCT are also linked to higher numbers of clients seen using these approaches. For example, one implementing partner providing community outreach served ten times as many clients using this approach than at the stand-alone HCT, with comparable service times available. Furthermore, stand-alone HCT centers reported operating at low volume during conventional business hours, whereas the mobile HCT approaches assessed here reported a constant flow of clients throughout the day, and typically extended their hours into the evening in order to serve more clients.
Although client numbers were large and statistical tests reached significance, we were only able to evaluate a small number of projects in provinces with widely varying HIV prevalence rates. Only one fully-mobile HCT truck was functional at the time of the study, and this was based in Nyanza province in western Kenya with the highest HIV prevalence in the country (15%). Consequently, results related to HIV prevalence should be interpreted with caution. Cost per HIV-positive client and cost per new HIV-positive client were not reported for each mobile approach individually, given the possible bias from differences in background prevalence. In addition, while the prevention impact of HCT may be higher where services are targeted to HIV-positive individuals and discordant couples12–17
, the extent of behavioral risk reduction after HCT is unclear, particularly for new service delivery approaches such as mobile HCT. For this reason it was not possible to calculate outcomes estimating the number of HIV infections prevented by HCT, and more research in this area is needed.
This study demonstrates that the cost of providing HCT through the addition of mobile services is generally lower than the cost of stand-alone HCT across four different outcomes. Mobile HCT may be an effective strategy for improving HCT access in rural and underserved urban populations, and is a cost effective approach for expanding access to HCT services. Women and youth readily access mobile HCT, though based on our data more efforts are needed to attract couples to mobile HCT, such as advertising well in advance to give couples time to prepare for testing together. Although stand-alone HCT was more expensive than mobile HCT in this study, it is necessary to support the daily activities of mobile HCT, as the mobile HCT approaches studied here relied upon stand-alone HCT sites for operational support. Policymakers need to support a variety of HCT modalities, including stand-alone HCT and mobile HCT, to expand the reach of HIV counseling and testing to a diverse range of populations and meet HIV care, treatment, and prevention goals.