Addressing the HIV care continuum through home-based HIV testing

Initiation of antiretroviral therapy and viral suppression after home HIV testing and counselling in KwaZulu-Natal, South Africa, and Mbarara district, Uganda: a prospective, observational intervention study.

Barnabas RV, van Rooyen H, Tumwesigye E, Murnane PM, Baeten JM, Humphries H, Turyamureeba B, Joseph P, Krows M, Hughes JP, Celum C. The Lancet HIV Volume 1, Issue 2, November 2014, Pages e68–e76

Antiretroviral therapy significantly decreases HIV-associated morbidity, mortality, and HIV transmission through HIV viral load suppression. In settings of high prevalence, outreach strategies are needed to find asymptomatic HIV-positive people, to link them to HIV care, to initiate antiretroviral therapy, and to achieve viral suppression. We aimed to assess the effect of a community-based strategy of HIV testing and counselling (HTC) and linkage to care in households. We did an uncontrolled prospective intervention study in 1600 households in two rural communities in KwaZulu-Natal, South Africa, and Mbabara district, Uganda, between Sept 27, 2011, and May 6, 2013. The intervention consisted of home HTC and, for HIV-positive people, point-of-care CD4 count testing, referral to care, and follow-up visits by lay counsellors, including the offer of couples HTC. Eligible participants were resident adults who were able to consent to HIV testing. The outcomes at 12 months were linkage to care, antiretroviral therapy initiation among HIV-positive people eligible for therapy (CD4 count ≤350 cells per µL), and viral suppression. We identified 3545 adults in 1549 households in the two communities. 3393 adults (96%) were enrolled and tested for HIV, of whom 635 (19%) were HIV positive. At baseline, 229 (36%) HIV-positive people were newly identified, 406 (64%) were previously known to be HIV positive, and 254 (40%) were taking antiretroviral therapy. By month 12, 619 (97%) HIV-positive people had visited an HIV clinic, and of 123 participants eligible for antiretroviral therapy, 94 (76%) had initiated antiretroviral therapy by 12 months. Of the 77 participants on antiretroviral therapy by month 9, 59 (77%) achieved viral suppression by month 12. Among all HIV-positive people, the number with viral suppression (<1000 copies per mL) increased from 287 (50%) to 370 (65%; p<0·0001) at 12 months. There were no reported cases of study-related social harm during the study. Community-based HTC in rural South Africa and Uganda achieved high coverage of testing and linkage to care. Among people eligible for antiretroviral therapy, a high proportion initiated antiretroviral therapy and achieved viral suppression, suggesting high adherence. Our results could be generalisable to other southern African countries with a high burden of HIV, but pilot studies would be useful in other settings before initiation of clinical trials to estimate the effectiveness and cost-effectiveness of the intervention.

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Editor’s notes: HIV testing is the gateway to accessing treatment and prevention services. But the proportion of people who know their status remains low in many high HIV prevalence settings. In addition, there are serious challenges in facilitating linkage to HIV care, antiretroviral therapy (ART) uptake and adherence. Only a quarter of people living with HIV in sub-Saharan Africa are estimated to be virally suppressed on ART. Routine facility-based HIV testing, termed provider-initiated HIV testing and counselling, is recommended by World Health Organization. However, this strategy identifies individuals at a later stage of HIV infection as it relies on presentation to health care facilities after symptoms have developed. Community-based approaches may therefore be more effective in enabling earlier identification of HIV infection.

This study investigates the effectiveness of home-based HIV testing and counselling (HTC), combined with point-of-care CD4 count testing, referral to care and follow-up visits by lay counsellors at one, three, six, nine and 12 months following an HIV diagnosis. The study not only measured uptake of testing but also investigated the effect of the activity on linkage to care, ART initiation and viral suppression after 12 months.

The results of the study are promising, with high rates of uptake of HIV testing, of linkage to HIV care (including of individuals who had tested previously but had not engaged with health care services) and of initiation of ART. In addition, some 77% of individuals who initiated ART achieved viral suppression at 12 months and the numbers of HIV-positive individuals with viral suppression also increased significantly. The main strengths of this study is that it moves beyond HTC and addresses the entire HIV care continuum. The programme used lay counsellors and community workers which would address the healthcare worker shortage as well as potentially enable ownership of the programme by communities.  However, the incremental contribution of each component of this programme (home HTC, point-of-care CD4 testing and follow-up visits) in achieving the various outcomes is not clear. This merits further study before such a programme can be implemented. Cost-effectiveness studies are also needed if this approach is to be scaled-up in resource-limited settings. 

South Africa, Uganda
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