Home initiation of ART may be valuable addition to services to achieve universal access to treatment

Effect of optional home initiation of HIV care following HIV self-testing on antiretroviral therapy initiation among adults in Malawi: a randomized clinical trial

MacPherson P, Lalloo DG, Webb EL, Maheswaran H, Choko AT, Makombe SD, Butterworth AE, van Oosterhout JJ, Desmond N, Thindwa D, Squire SB, Hayes RJ, Corbett EL Journal of the American Medical Association. 2014 Jul 23-30;312(4):372-9. doi: 10.1001/jama.2014.6493.

Importance: Self-testing for HIV infection may contribute to early diagnosis of HIV, but without necessarily increasing antiretroviral therapy (ART) initiation.

Objective: To investigate whether offering optional home initiation of HIV care after HIV self-testing might increase demand for ART initiation, compared with HIV self-testing accompanied by facility-based services only.

Design, setting, and participants: Cluster randomized trial conducted in Blantyre, Malawi, between January 30 and November 5, 2012, using restricted 1:1 randomization of 14 community health worker catchment areas. Participants were all adult (≥16 years) residents (n = 16 660) who received access to home HIV self-testing through resident volunteers. This was a second-stage randomization of clusters allocated to the HIV self-testing group of a parent trial.

Interventions: Clusters were randomly allocated to facility-based care or optional home initiation of HIV care (including 2 weeks of ART if eligible) for participants reporting positive HIV self-test results.

Main outcomes and measures: The pre-planned primary outcome compared between groups the proportion of all adult residents who initiated ART within the first 6 months of HIV self-testing availability. Secondary outcomes were uptake of HIV self-testing, reporting of positive HIV self-test results, and rates of loss from ART at 6 months.

Results: A significantly greater proportion of adults in the home group initiated ART (181/8 194, 2.2%) compared with the facility group (63/8 466, 0.7%; risk ratio [RR], 2.94, 95% CI, 2.10-4.12; P < .001). Uptake of HIV self-testing was high in both the home (5 287/8 194, 64.9%) and facility groups (4 433/8 466, 52.7%; RR, 1.23; 95% CI, 0.96-1.58; P = .10). Significantly more adults reported positive HIV self-test results in the home group (490/8 194 [6.0%] vs the facility group,   278/8 466 [3.3%]; RR, 1.86; 95% CI, 1.16-2.97; P = .006). After 6 months, 52 of 181 ART initiators (28.7%) and 15 of 63 ART initiators (23.8%) in the home and facility groups, respectively, were lost from ART (adjusted incidence rate ratio, 1.18; 95% CI, 0.62-2.25, P = .57).

Conclusions and relevance: Among Malawian adults offered HIV self-testing, optional home initiation of care compared with standard HIV care resulted in a significant increase in the proportion of adults initiating ART.

Abstract [1]  Full-text [free] access  [2]

Editor’s notes: This study extends the recent drive to bring HIV testing closer to individuals and away from facilities by offering the option of initiating ART at the door-step. There are many benefits of such a strategy for asymptomatic individuals, and the popularity is clear from the high uptake of self-testing in this and other studies. The higher self-report of HIV positivity in the home initiating group probably reflects favourable disclosure and low stigma related conditions for this subset of community members. It is noteworthy that a greater number of home initiators were lost-to-follow-up 6 months after initiating ART. The authors highlight that the difference was not statistically significant. Although the pooled retention across initiation groups was lower than national retention data i.e., ART retention at 6 months was 72% vs 80% in the Malawi national programme, it was still within the range seen in other programmes. Home initiation of ART may be a valuable addition to services in the drive towards universal access to treatment. 

Health care delivery [5]
Africa [6]
Malawi [7]
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