Were WA, Mermin JH, Wamai N, Awor AC, Bechange S, Moss S, Solberg P, Downing RG, Coutinho A, Bunnell RE. Undiagnosed HIV Infection and Couple HIV Discordance Among Household Members of HIV-Infected People Receiving Antiretroviral Therapy in Uganda. J Acquir Immune Defic Syndr. 2006 Sep;43(1):91-5.
To identify HIV-infected members and HIV-discordant couples in households of individuals on antiretroviral therapy (ART) in an effort to reduce HIV transmission and improve ART adherence.
This was a cross-sectional study of voluntary counseling and testing (VCT) uptake, HIV prevalence and HIV discordance among couples, set within a larger randomized controlled trial evaluating different ART monitoring regimens through home-based ART care and follow up.
The study took place in rural eastern Uganda between May 2003 and December 2004.
All HIV-infected adults aged 18 and older, eligible for ART, and attending an AIDS care support organization were eligible for enrollment in the study. These index participants then consented to have study staff visit their homes and offer VCT to all of their household members.
There was no intervention in this study.
Uptake of VCT, HIV prevalence among household members, ART eligibility among HIV-positive household members, and discordance among couples were assessed.
VCT was offered to 2373 household members of 730 index clients. Overall, 2348 (99%) accepted VCT, and HIV prevalence among household members was 7.5%. Prevalence was highest in the 25-44 year age group (37.1%) and lowest among those age 6 to 24 years (2.9%). Of the 176 household members who tested HIV-positive, 74% had not been previously tested. The most common barrier to testing cited by household members was having no perceived risk of infection. Thirty percent of the household members who tested HIV-positive were eligible for ART. Of the 120 spouses of HIV-positive index participants starting ART and living in the households, 99% had never been tested for HIV and 52 (43%) were HIV-positive.
The authors conclude that provision of VCT to family members of people in HIV care and treatment programs is an important intervention for case finding and prevention of HIV transmission, especially among discordant couples.
There is no standardized quality rating for this type of study. The authors note that high acceptance rates of VCT were in the context of provision of ART, and therefore may not be applicable in other settings where ART is not being offered.
Generally, uptake of VCT seems to be higher during home visits than in clinics. Facility-based PMTCT programs have shown that only between 3 and 15% of partners of pregnant women received testing,(1) and two general population studies in Uganda showed two-to-four-fold increases in receipt of HIV test results when provided to participants at home as opposed to through a clinic.(2,3,4,5) In addition, providing couples with VCT may decrease risky sexual behavior and HIV transmission among HIV-discordant couples.(6,7,8)
The authors note that implementation of home-based VCT is feasible in Uganda, especially now that the Ugandan Ministry of Health has changed its counseling and testing guidelines to include testing using a rapid finger-stick test. However, cost-effectiveness analyses are needed. In addition, the authors state that evaluation of home-based testing in more urban settings where acceptance rates of VCT may differ is necessary, as are studies of the potential negative social consequences of in-home partner VCT.
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