Home-based HIV testing improves health-seeking behaviour

The impact of home-based HIV counselling and testing on care-seeking and incidence of common infectious disease syndromes in rural western Kenya.

Bigogo G, Amolloh M, Laserson KF, Audi A, Aura B, Dalal W, Ackers M, Burton D, Breiman RF, Feikin DR. BMC Infect Dis. 2014 Jul 8;14(1):376. doi: 10.1186/1471-2334-14-376.

Background: In much of Africa, most individuals living with HIV do not know their status. Home-based counselling and testing (HBCT) leads to more HIV-infected people learning their HIV status. However, there is little data on whether knowing one's HIV-positive status necessarily leads to uptake of HIV care, which could in turn, lead to a reduction in the prevalence of common infectious disease syndromes.

Methods: In 2008, Kenya Medical Research Institute (KEMRI) in collaboration with the Centers for Disease Control and Prevention (CDC) offered HBCT to individuals (aged ≥13 years) under active surveillance for infectious disease syndromes in Lwak in rural western Kenya. HIV test results were linked to morbidity and healthcare-seeking data collected by field workers through bi-weekly home visits. We analyzed changes in healthcare seeking behaviors using proportions, and incidence (expressed as episodes per person-year) of acute respiratory illness (ARI), severe acute respiratory illness (SARI), acute febrile illness (AFI) and diarrhea among first-time HIV testers in the year before and after HBCT, stratified by their test result and if HIV-positive, whether they sought care at HIV Patient Support Centers (PSCs).

Results: Of 9 613 individuals offered HBCT, 6 366 (66%) were first-time testers, 698 (11%) of whom were HIV-infected. One year after HBCT, 50% of HIV-infected persons had enrolled at PSCs - 92% of whom had started cotrimoxazole and 37% of those eligible for antiretroviral treatment had initiated therapy. Among HIV-infected persons enrolled in PSCs, AFI and diarrhea incidence decreased in the year after HBCT (rate ratio [RR] 0.84; 95% confidence interval [CI] 0.77 - 0.91 and RR 0.84, 95% CI 0.73 - 0.98, respectively). Among HIV-infected persons not attending PSCs and among HIV-uninfected persons, decreases in incidence were significantly lower. While decreases also occurred in rates of respiratory illnesses among HIV-positive persons in care, there were similar decreases in the other two groups.

Conclusions: Large scale HBCT enabled a large number of newly diagnosed HIV-infected persons to know their HIV status, leading to a change in care seeking behavior and ultimately a decrease in incidence of common infectious disease syndromes through appropriate treatment and care.

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Editor’s notes: HIV testing is the entry point to HIV care and treatment. Despite increased availability of HIV treatment, many people in Africa still do not know their HIV status. Home-based counselling and testing (HBCT) has been used in some countries as a strategy to increase HIV testing rates.  However, the benefits of testing can only be fully realised if individuals who test HIV-positive are subsequently linked to care services.

In this study, 79% of individuals offered testing through a mass HBCT campaign accepted and 11% tested HIV-positive, showing that this is an effective strategy for improving HIV testing rates. By 24 months, only 58% of individuals who tested HIV-positive had enrolled into care. However, HBCT led to a change in health-seeking behaviour. This was demonstrated by an increase in proportion of clinic attendances for common infectious illnesses compared to the period before HBCT was implemented, among newly diagnosed HIV-positive persons who engaged in care. In addition, there was a significant decrease in incidence of common infectious disease among newly diagnosed HIV-positive persons; this is likely to be due to the use of cotrimoxazole prophylaxis and antiretroviral therapy following linkage to HIV care.

The main limitation of this study was that the differences in disease pre-and post-HBCT could be due to annual variations in disease burden, or due to other temporal factors. Notwithstanding this, the study does demonstrate that HBCT changed health-seeking behaviour, which in turn may reduce the incidence of common infectious disease.  As with all HIV testing strategies, in order to realise the full benefits of HBCT, it is crucial to ensure linkage to HIV care for individuals who test HIV-positive. 

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