Niklaus Labhardt and colleagues investigate how different HIV testing and counseling strategies, based on home visits or mobile clinics, reach different populations in a rural African setting.
Please see later in the article for the Editors' Summary
The success of HIV programs relies on widely accessible HIV testing and counseling (HTC) services at health facilities as well as in the community. Home-based HTC (HB-HTC) is a popular community-based approach to reach persons who do not test at health facilities. Data comparing HB-HTC to other community-based HTC approaches are very limited. This trial compares HB-HTC to mobile clinic HTC (MC-HTC).
Methods and Findings
The trial was powered to test the hypothesis of higher HTC uptake in HB-HTC campaigns than in MC-HTC campaigns. Twelve clusters were randomly allocated to HB-HTC or MC-HTC. The six clusters in the HB-HTC group received 30 1-d multi-disease campaigns (five villages per cluster) that delivered services by going door-to-door, whereas the six clusters in MC-HTC group received campaigns involving community gatherings in the 30 villages with subsequent service provision in mobile clinics. Time allocation and human resources were standardized and equal in both groups. All individuals accessing the campaigns with unknown HIV status or whose last HIV test was >12 wk ago and was negative were eligible. All outcomes were assessed at the individual level. Statistical analysis used multivariable logistic regression. Odds ratios and p-values were adjusted for gender, age, and cluster effect.
Out of 3,197 participants from the 12 clusters, 2,563 (80.2%) were eligible (HB-HTC: 1,171; MC-HTC: 1,392). The results for the primary outcomes were as follows. Overall HTC uptake was higher in the HB-HTC group than in the MC-HTC group (92.5% versus 86.7%; adjusted odds ratio [aOR]: 2.06; 95% CI: 1.18–3.60; p = 0. 011). Among adolescents and adults ≥12 y, HTC uptake did not differ significantly between the two groups; however, in children <12 y, HTC uptake was higher in the HB-HTC arm (87.5% versus 58.7%; aOR: 4.91; 95% CI: 2.41–10.0; p<0.001). Out of those who took up HTC, 114 (4.9%) tested HIV-positive, 39 (3.6%) in the HB-HTC arm and 75 (6.2%) in the MC-HTC arm (aOR: 0.64; 95% CI: 0.48–0.86; p = 0.002). Ten (25.6%) and 19 (25.3%) individuals in the HB-HTC and in the MC-HTC arms, respectively, linked to HIV care within 1 mo after testing positive. Findings for secondary outcomes were as follows: HB-HTC reached more first-time testers, particularly among adolescents and young adults, and had a higher proportion of men among participants. However, after adjusting for clustering, the difference in male participation was not significant anymore.
Age distribution among participants and immunological and clinical stages among persons newly diagnosed HIV-positive did not differ significantly between the two groups. Major study limitations included the campaigns' restriction to weekdays and a relatively low HIV prevalence among participants, the latter indicating that both arms may have reached an underexposed population.
This study demonstrates that both HB-HTC and MC-HTC can achieve high uptake of HTC. The choice between these two community-based strategies will depend on the objective of the activity: HB-HTC was better in reaching children, individuals who had never tested before, and men, while MC-HTC detected more new HIV infections. The low rate of linkage to care after a positive HIV test warrants future consideration of combining community-based HTC approaches with strategies to improve linkage to care for persons who test HIV-positive.
Please see later in the article for the Editors' Summary
Annually, about 2.3 million people become newly infected with HIV, the virus that causes AIDS by gradually destroying CD4 cells and other immune system cells, thereby leaving HIV-infected individuals susceptible to other serious infections. HIV can be transmitted through unprotected sex with an infected partner, from an HIV-positive mother to her unborn child, or through the injection of drugs with shared needles. Infection with HIV is usually diagnosed by looking for antibodies to HIV in the blood or saliva. After diagnosis, the progression of HIV infection is monitored by regularly counting the number of CD4 cells in the blood. Initiation of antiretroviral therapy (ART)—a combination of drugs that keeps HIV replication in check but that does not cure the infection—is recommended when an individual's CD4 count falls below 500 cells/µl or when he or she develops signs of advanced or severe disease, such as unusual infections.
Why Was This Study Done?
To control HIV/AIDS, HIV transmission needs to be reduced, and ART delivery needs to be increased. In settings of high HIV prevalence, universal coverage of HIV testing and counseling (HTC) is essential if these goals are to be met. Unfortunately, many people refuse “facility-based” HTC (HTC delivered at health care facilities) because they fear stigmatization and discrimination. Moreover, many people in resource-limited settings rarely visit health care facilities. Community-based HTC may be one way to increase the uptake of HTC, particularly among populations that are hard to reach, such as men and first-time testers, but which form of community-based HTC will be most effective? In this cluster-randomized trial, the researchers ask whether home-based HTC (HB-HTC)—community-based HTC in which health care workers go door-to-door to offer HTC to people in their own home—results in a higher uptake of HTC than HTC delivered through community gatherings and mobile clinics (MC-HTC) in two rural areas in Lesotho. Nearly a quarter of adults are HIV-positive in Lesotho, but only 61% of people who need ART currently receive treatment. A cluster-randomized trial compares outcomes in groups (clusters) of people chosen at random to receive different interventions.
What Did the Researchers Do and Find?
The researchers allocated 12 clusters, each comprising a health center and its catchment area, to the HB-HTC or MC-HTC intervention. In the HB-HTC arm (1,171 participants), HTC teams going door-to-door delivered a multi-disease campaign that included HTC to five villages in each cluster. In the MC-HTC arm (1,392 participants), the multi-disease campaign was delivered at community gatherings with subsequent service provision in mobile clinics. Overall, HTC uptake was higher in the HB-HTC arm than in the MC-HTC arm (92.5% and 86.7% uptake, respectively). Among participants aged ≥12 years, there was no significant difference in HTC uptake between the arms, whereas among children aged <12 years, HTC uptake was significantly higher in the HB-HTC arm than in the MC-HTC arm (87.5% versus 58.7%; a significant difference is a difference unlikely to have happened by chance). Among individuals who took up HTC, 3.6% and 6.2% tested positive for HIV in the HB-HTC arm and MC-HTC arm, respectively. In both arms, only a quarter of individuals who tested positive accessed HIV care within a month of their positive test result. Finally, HB-HTC reached more first-time testers (particularly among adolescents) and tended to reach more men than MC-HTC.
What Do These Findings Mean?
These findings suggest that, in rural Lesotho, both HB-HTC and MC-HTC delivered as part of a multi-disease campaign can achieve a high uptake of HTC. Various aspects of the trial design (for example, the small number of clusters) may limit the accuracy of the findings reported here. Notably, however, these findings suggest that the choice between HB-HTC and MC-HTC should be guided by the objective of the HTC intervention in specific settings. Where equity of access is of concern and where increased HTC coverage, particularly among groups in which HTC coverage is generally poor (including men, first-time testers, and children), is paramount, HB-HTC may be the preferred option. By contrast, the MC-HTC approach may be more appropriate in settings where the detection of new HIV infections is the major goal. Finally, and importantly, the findings of this trial highlight the need for further research into strategies designed to improve the linkage between HIV testing and enrollment into care.
Please access these websites via the online version of this summary at http://dx.doi.org/10.1371/journal.pmed.1001768.
The World Health Organization provides information on all aspects of HIV/AIDS, including information on HIV counseling and testing (in several languages)
Information is available from the US National Institute of Allergy and Infectious Diseases on HIV infection and AIDS
NAM/aidsmap provides basic information about HIV/AIDS and summaries of recent research findings on HIV care and treatment
Information is available from Avert, an international AIDS charity, on many aspects of HIV/AIDS, including information on the global HIV/AIDS epidemic, on HIV testing, and on HIV/AIDS in Lesotho
The UK National Health Service Choices website provides information (including personal stories) about HIV/AIDS
The “UNAIDS Report on the Global AIDS Epidemic 2013” provides up-to-date information about the AIDS epidemic and efforts to halt it
Stories about living with HIV/AIDS are available through Avert and through healthtalk.org
More information about this trial is available