Menzies N, Abang B, Nuwaha F, et al. The costs and effectiveness of four HIV counseling and testing strategies in Uganda. AIDS 2009;23(3):395-401.
To compare costs and outcomes of four different HIV counseling and testing (HCT) strategies in Uganda
This was a retrospective cohort of individuals who received HCT at one of four Ugandan HCT programs: stand-alone HCT, hospital-based HCT, household-member HCT, and door-to-door HCT.
Data were collected from four HCT projects in Uganda, each utilizing a different HCT strategy. Projects were selected from similar geographic areas to minimize differences in population characteristics and setting. Uganda has a mature generalized HIV epidemic predominantly driven by heterosexual sex, with an HIV prevalence of 7.5% and 5.0% in 15-49-year-old women and men, respectively. HCT coverage is low, and by 2007 only 25% of women and 21% of men reported ever having tested for HIV.
The study collected de-identified data from project data systems. Projects were evaluated between June 2003 and September 2005, with each project assessed for an evaluation period of 6-12 months coinciding with a period of uninterrupted project operations. Data were collected on a total of 84,323 HCT clients.
All four HCT strategies follow similar procedures, with HIV testing provided in a single session using a serial HIV rapid test algorithm. Pretest and post-test counseling was provided, covering basic HIV/AIDS information, the testing process, risk-reduction strategies, the interpretation of positive or negative test results, partner communication and disclosure, and voluntary consent. Referral for HIV care and treatment was provided for clients diagnosed as having HIV infection. Testing was free, voluntary, and private, and clients were encouraged to test with their partner (couples HCT).
Stand-alone HCT was the conventional HCT strategy, provided through free-standing centers, and was client initiated. Individuals attending the site were provided initial group counseling, with key messages reiterated and consent obtained in private sessions for couples or individuals. Clients found to be infected with HIV were referred to local health centers for follow-up.
Hospital-based HCT was a provider-initiated strategy, which was offered to all patients with unknown or undocumented HIV status who attended hospitals and major health centers regardless of illness presentation and using an opt-out approach. Pretest counseling was provided in a group setting, with key messages reiterated and consent obtained in private sessions. HCT was provided by health providers with HCT-specific training, and counselor-assisted disclosure to sexual partners and family members was provided if requested by the patient.
Door-to-door HCT was a home-based, provider-initiated strategy. Mobile teams offered HCT to clients at home, and community mobilizers ensured all households in a community were offered services. Door-to-door HCT was offered to all adults and to all children aged 0-14 years whose mother was HIV-infected, deceased, or of unknown HIV status. Initial group counseling was provided to family members and peers, followed by private pretest and posttest counseling for individuals and couples deciding to test.
Household-member HCT was similar to door-to-door HCT, with HCT offered to clients in their own homes. This strategy, however, specifically targeted the household members of individuals already identified as HIV-infected, reflecting research showing that household members were at greater HIV risk. Households were approached only after voluntary consent by the HIV-infected index client. This strategy was provided in conjunction with existing HIV treatment programs, and mobile teams traveled to households of willing program participants, offering HCT to all adults and to all children aged 0-14 years whose mother was HIV-infected, deceased, or of unknown HIV status. Individuals identified as HIV-infected were offered treatment through the same treatment program serving the index patient.
HCT strategies were compared in terms of outcomes that reflected three HIV control objectives: expanding knowledge of HIV status, especially to previously untested clients; reducing HIV transmission; and identifying HIV-infected individuals to receive care and treatment services. Cost-effectiveness ratios were estimated for the crude cost per client and the costs for reaching key target groups.
Both stand-alone HCT and hospital-based HCT reported high client HIV prevalence, at 19.1% and 27.2%, respectively. In contrast, the two home-based strategies reported relatively low client HIV prevalence. For household-member HCT, the low prevalence reflected a higher proportion of clients in the 5-14- year-old age group, who had a prevalence of 2.4%, compared with 17.0% in those older than 24 years old. For door-to-door HCT, the low average HIV prevalence was low across all age groups. Across all strategies, the peak HIV prevalence was found in the 35-to-44-year-old age group. Women and first-time clients also had higher HIV prevalence. A substantial percentage (>30%) of all HIV-infected clients had advanced immunosuppression (defined as CD4 cell count below 200 cells/mL) regardless of testing strategy, and almost one quarter of HIV-infected clients identified by hospital-based HCT had a CD4 cell count below 50 cells/mL. The door-to-door strategy identified the highest proportion (69.3%) of HIV-infected clients with a CD4 cell count above 200 cells/mL.
Although no strategy reported more than 25% of clients testing as part of a couple, many clients who tested as individuals were married or part of a cohabiting couple. There was wide variation in the percentage of clients who were married or part of a cohabiting couple who actually undertook couples HCT, ranging from 6.3% (hospital-based HCT) to 64.1% (household-member HCT). Married or cohabiting couples in hospital-based HCT and household-member HCT showed substantially higher risk of HIV discordance, related to the high HIV prevalence in these populations. The proportion of all clients who were part of a discordant couple ranged from 0.7% for hospital-based HCT to 3.1% for household-member HCT. It is notable that for all strategies, the infected partner was male in the majority of discordant couples.
Each of the three nontraditional strategies compared favorably with stand-alone HCT in terms of the crude cost per client, and door-to-door HCT was the least expensive strategy per client tested. Door-to-door HCT also appeared to be the most cost-effective in terms of reaching new clients, whereas hospital-based HCT appeared superior in terms of identifying HIV-infected clients.
The authors conclude all testing strategies had relatively low costs per client. Hospital-based HCT most readily identified HIV-infected individuals eligible for treatment, whereas home-based strategies more efficiently reached populations with low rates of prior testing and HIV-infected people with higher CD4 cell counts. The authors concluded that multiple HCT strategies with different costs and efficiencies will be needed to meet the UNAIDS/WHO call for universal HCT access by 2010.
There is no widely accepted quality-scoring tool for retrospective program evaluations such as this. Because this study was an individual-level analysis, it did not take into account any potential population benefits of bringing HCT to scale, such as reducing stigma, mobilizing communities to respond to the epidemic, or community-wide reductions in HIV transmission; and 2) although this study focused on the programmatic costs of HCT, it is likely that increasing HCT coverage would reduce future HIV treatment costs by averting new HIV infections. This may not have been true during the early years of the epidemic response, when treatment costs were determined by the limited availability of treatment slots, but it is becoming increasingly likely as HIV treatment services are scaled-up.
Although other studies have investigated the cost-effectiveness of stand-alone HCT in developing countries, this study directly compared four different HCT strategies that a national HIV program might consider. Results revealed clear differences between the four HCT strategies in terms of the populations served, the crude cost per client, and the relative cost-effectiveness in reaching key target groups.
This study highlights the need for ongoing empirical research as HCT services expand and diversify. In particular, research is needed to clarify the durability of HCT behavior change in resource-poor settings and to confirm the behavioral impact of HCT as implemented through provider-initiated and home-based strategies. Although there have been a number of studies investigating the effects of client-initiated HCT provided through stand-alone sites, it is not clear how these effects translate to provider-initiated HCT, in which services are provided in a variety of settings to clients who are not self selected in the same way as client-initiated HCT. Different types of HCT are appropriate and cost-effective in reaching different groups of people at risk for HIV infection.