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Increasing uptake of HIV testing and counseling among the poorest in sub-Saharan countries through home-based service provision
Global Health Sciences Literature Digest
Published November 30, 2009
Journal Article

Helleringer S, Kohler HP, Frimpong JA, Mkandawire J. Increasing uptake of HIV testing and counseling among the poorest in sub-Saharan countries through home-based service provision. J Acquir Immune Defic Syndr 2009 Apr 6.

In Context

The rapid expansion of HIV treatment is an important response to the HIV/AIDS epidemic in sub-Saharan countries. Enrollment of infected individuals in treatment programs, however, is hampered by low uptake of HIV testing and counseling (HTC). A strong socioeconomic gradient has been identified in the uptake of HTC with uptake lowest among members of the poorest households in sub-Saharan countries. The resultant inequalities in access to HTC also likely create inequalities in access to antiretroviral treatment.(1,2,3,4)

Objective

To measure uptake of home-based HTC and estimate HIV prevalence among members of the poorest households in a sub-Saharan population

Setting

Six villages on Likoma Island, Malawi

Study Design

This study is a pre- and post-intervention evaluation of a convenience sample of individuals living in the study area, at home, and willing to participate in the study.

Participants

Residents of six villages on Likoma Island aged 18-35 years and their spouses

Outcome

Uptake of home-based HTC services and HIV prevalence among the poorest households

Methods

Participants were offered home-based HTC services. Socioeconomic status, HIV testing history, and HIV risk factors were assessed. Differences in HTC uptake and HIV infection rates between members of households in the lowest income quartile and the rest of the population were estimated using logistic regression.

Results

Overall, 23.5% of men and 22.4% of women had been tested previously for HIV. Members of households in the lowest income quartile were significantly less likely to have ever used facility-based HTC services than were the rest of the population (odds ratio [OR] 0.60, 95% confidence interval (CI): 0.36-0.97). In contrast, the participants were significantly more likely to accept home-based HTC provided during the study (81.7% compared to 73.6% in the highest income quartile, adjusted OR 1.70, 95% CI: 1.04-2.79). Socioeconomic differences in uptake of home-based HTC were not due to underlying differences in socioeconomic characteristics or HIV risk factors. The prevalence of HIV infection (5.4%) was significantly lower among members of the poorest households tested during home-based HTC than among members of households with the highest income quartile (9.4%, adjusted OR 0.37, 95% CI: 0.14-0.96).

Conclusions

Uptake of HTC was greater during a home-based HTC campaign on Likoma Island, particularly among the poorest people. Home-based HTC has the potential to significantly reduce existing socioeconomic gradients in HTC uptake and help mitigate the impact of AIDS on the most vulnerable households.

Quality Rating

There is no standard quality rating for pre- and post-intervention evaluation studies of this type; however, the limitations cited by the authors were their assessment of prior use of facility-based HTC services, their measure of household poverty, their measures of sexual activity, and the age of their population (results not applicable to younger populations).

Programmatic Implications

Home-based HTC services have the potential to reach large numbers of people who previously have not been tested and, even more so, the very poor, a demographic group that typically does not access HTC services. Making HTC services available to the very poor will likely lead to improved access to antiretroviral treatment and possibly will decrease disparities.

References

  1. Malawi National Statistical Office. Malawi Demographic and Health Survey 2004-Preliminary Report. Claverton, MD: Malawi National Statistical Office, Zomba, Malawi and Measure DHS; 2004. Accessed July 18, 2008.
  2. Uganda Bureau of Statistics (UBOS) and Macro International Inc. Uganda Demographic and Health Survey 2006. Calverton, MD: UBOS and Macro International Inc; 2007. Abstract not available.
  3. Central Statistical Office (Zimbabwe) and Macro International Inc. Zimbabwe Demographic and Health Survey 2005-06. Calverton, MD: UBOS and Macro International Inc; 2007. Abstract not available.
  4. Central Bureau of Statistics (Kenya) and Macro International Inc. Kenya Demographic and Health Survey 2003. Calverton, MD: UBOS and Macro International Inc; 2004. Abstract not available.