We piloted household HIV testing as a platform for combination HIV prevention in southwestern Uganda and demonstrated very high levels of HIV testing. Monthly follow-up visits over three months for HIV infected persons and for higher-risk uncircumcised HIV seronegative men facilitated very high uptake of HIV care and medical male circumcision referrals and addressed barriers to linkages. Half of HIV seropositive persons identified were unaware of their serostatus, and identified at an early stage (median CD4 count of 467 cells/µL) when they could benefit from counseling and engagement in HIV care.
Prior studies have shown that community-wide HBCT strategies can successfully test thousands of persons, with high acceptance, in multiple countries and in both rural and urban settings 
, and with high accuracy of results using rapid HIV serologic tests 
. Our study found high uptake of HIV testing after community mobilization: 81.8% of those living in households were at home on the day of testing and 98.1% accepted testing received their results. The acceptability of mobile electronic data capture with HBCT was very high, and facilitated an integrated counseling and referral algorithm for referrals of HIV seropositive persons to HIV care and higher risk HIV seronegative men to male circumcision.
We found an HIV prevalence of 9.8%, comparable to the 9% HIV prevalence observed in southwestern Uganda from the 2011 Uganda AIDS Indicator Survey. A high proportion (50%) of those found to be HIV seropositive were unaware of their serostatus, however, only 25% were eligible for ART by Ugandan guidelines at the time of the HBCT visit and 11% of those who knew their HIV serostatus were not engaged in any HIV care and approximately 40% had not had a CD4 count in the prior year. A challenge of HIV testing programs, including HBCT programs, has been effective early engagement in HIV care. In a district-wide HBCT study from southwestern Uganda in 2004–7, only 11% initiated ART, most of whom had symptomatic HIV disease 
. In recent HBCT projects in rural and urban Kenya, 42–54% of HIV-seropositive persons visited an HIV clinic within one month after HBCT 
. HIV testing, even when done in a home-based setting, may not be sufficient to motivate early engagement in care, and follow-up visits may be needed to facilitate linkages to care. Challenges in linkage to HIV care occur at key transitions, such as from HIV testing to CD4 measurement or clinical staging to ART initiation, and need to be addressed to maximize the benefit of identifying HIV seropositive persons through HBCT 
. Earlier initiation of ART results in improved survival 
, and ART initiation is accompanied by a substantial decrease in HIV infectiousness 
. Recently, implementation of ART according to South African guidelines was associated with a reduction in population HIV incidence in rural KwaZulu-Natal 
, emphasizing the dual treatment and prevention potential of identification of HIV seropositive persons through testing with effective linkage to care and ART.
WHO guidelines recommend ART initiation at CD4 counts ≤350 cells/µL; however, in many African settings, the average CD4 count at the time of HIV diagnosis is significantly below 200 cells/µL 
, indicating substantial missed opportunities for HIV testing, diagnosis, and linkage to care. HBCT identifies HIV seropositive persons with higher CD4 counts and asymptomatic disease 
, median CD4 count was 467 cells/µL in our HBCT study. For HIV seropositive persons in our population who had CD4 counts <250 cells/µL, not taking ART at baseline, and eligible for ART under Ugandan guidelines at the time of the study, 71% initiated ART during the 3 months of study follow-up, and >85% of those who were HIV seropositive, regardless of CD4 count, were linked to HIV care. Thus, HBCT, by permitting identification of HIV seropositive persons earlier in the course of infection and coupled with lay counselor follow-up, offers a strategy for effective linkages to HIV care in order to realize the benefits of ART and other clinical and prevention interventions, including co-trimoxazole prophylaxis, isoniazid prophylaxis in areas with high tuberculosis prevalence, provision of bednets in malaria-endemic settings, risk reduction counseling, and condom promotion.
We provided referrals for HIV seronegative uncircumcised men in HBCT to medical MC services. Of the 123 men (22%) in HBCT who met our high risk criteria for targeted follow-up to assess uptake of MC, 62% reported having been circumcised by three months after HBCT () with 40% uptake in circumcision one month after HBCT. HBCT provides an opportunity to stimulate demand, facilitate referrals, and address men’s concerns about male circumcision. The high uptake of MC in this pilot is notable in a population where 85% of the HIV seronegative men are uncircumcised and given the challenges in achieving high levels of MC in subSaharan Africa including settings where MC trials were conducted 
The public health benefits of HBCT also include behavior change from learning one’s HIV status and their partner’s serostatus. We demonstrated the feasibility of couples HIV testing and counseling (CHTC) in the context of HBCT. Notably, 21% were tested as couples, 99% mutually disclosed their results, and 10% of couples were HIV serodiscordant, who are a priority for HIV prevention interventions, 
. However, approximately one-third of the adults tested reported that their partner did not live in the household, for whom visits for HIV testing were not attempted. Additional CHTC strategies will be needed in parallel with HBCT in order to increase the proportion of couples who know and have disclosed their HIV serostatus to each other, as recommended by WHO 
The limitations of our study include that the study was conducted in a geographically small area and HBCT had been conducted in this area five years earlier. We did not independently verify self-reported outcomes of visiting an HIV clinic or MC provider. We did not have resources to randomize communities to HBCT versus standard HIV testing strategies to be able to directly compare linkage to HIV care and MC rates through HBCT with other testing strategies. The questionnaire did not fully capture HIV disclosure to partners who did not reside within the household. Follow-up in this pilot was limited to three months; future work should assess longer-term impact, particularly ongoing engagement in HIV care and treatment. Our study was limited to adults and therefore cannot address acceptability of HBCT and follow-up in those younger than 18 years of age, an important population at risk in sub-Saharan Africa.
In summary, this pilot evaluation from rural southwestern Uganda demonstrates that HBCT achieves high levels of knowledge of HIV serostatus and is an acceptable, effective platform for identifying at-risk persons and achieving high uptake of linkages to HIV care and MC services through targeted referrals with rare social harms reported. Future studies in larger populations from diverse settings are necessary to assess the generalizability and potential impact of this combination HIV prevention strategy.