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Home-based HIV testing and counseling in rural and urban Kenyan communities
Global Health Sciences Literature Digest
Published March 27, 2013
Journal Article

Dalal W, Feikin DR, Amolloh M, Ransom R, Burke H, Lugalia F, Ouma A, Laserson KF, Mermin J, Breiman RF, Bunnell R. Home-based HIV testing and counseling in rural and urban Kenyan communities. J Acquir Immune Defic Syndr. 2013 Feb 1;62(2):e47-54.

Objective

To assess acceptance, HIV prevalence and treatment referral success rates of a large home-based HIV testing and counseling (HBTC) program.

Setting

Village clusters in Lwak, rural Nyanza province, Kenya, and in the densely-populated Kibera "slum" settlement of Nairobi, Kenya

Study Design

Prospective cohort sub-study of a population-based infectious disease surveillance (PBIDS) program.(1)

Population

Adults and children, primarily of the non-circumcising Luo ethnicity, participating in the PBIDS program.

Main Outcome Measures

Acceptance of HBTC and linkage to care. HIV prevalence among participants accepting HBTC was also measured.

Methods

All adults (age ≥18 years) enrolled in PBIDS and providing consent and approval were offered HBTC. Children (age <13 years) with HIV-infected mothers or whose mothers had died were offered HBTC with the consent and approval of a parent or guardian. Non-pregnant adolescents (age 13-17 years), living with parents, were eligible if they had parental consent and agreed to receive HBTC. Adolescents who were pregnant or were mothers, or lived with a consensual sexual partner, were also eligible and could give their own individual consent. It is not stated whether adolescents who were not pregnant, not mothers, and not living with parents or consensual sexual partners were eligible for HBTC.

HBTC counselors were trained in and had at least one year's experience in providing voluntary counseling and testing (VCT) services according to Kenya's VCT protocol.(2) Each counselor received an additional two weeks of training in HBTC. In each village cluster, community popular opinion leaders identified community mobilizers (CM) who were then given basic HIV information and were trained in a protocol for HBTC implementation in the community. CMs made appointments for the counselors and at the appointed times introduced them to participants receiving HBTC.

Counselors used a modified version of Kenya's national VCT data collection instrument, and offered testing to participants in as private a location as possible in the home. Participants who had previously tested were able to test again. Couples were able to receive testing results individually or together. Non-PBIDS participants within households were offered testing, but their data were excluded from all analyses. Rapid testing protocols followed Kenya's national guidelines. Each specimen was initially run in parallel in two approved rapid test kits. If results were discordant, a third approved test kit was used as a tie-breaker. Polymerase chain reaction (PCR) analysis was done with positive rapid test results from children ≤18 months old. In such cases, the PCR result was definitive. HBTC counselors delivered PCR results to the children's parent or guardian within four weeks.

Adults received rapid test results and risk reduction counseling immediately. Adults found to be HIV-infected were counseled about HIV care, treatment and prevention and were referred for free HIV care and treatment services at the nearest facility. It is not stated whether adolescents and older children also received their test results and counseling immediately, but it seems likely. Participants testing seropositive were offered CD4 testing, the results of which were available within 24 hours at the nearest PBIDS patient support center (PSC). Counselors returned to the homes of HIV-infected participants one month post-test to deliver CD4 results, answer questions, and administer a questionnaire about whether the participant had actually accessed HIV care, referring them again if they had not done so.

Results

Counselors offered HBTC to a total of 24,450 participants registered in PBIDS, of whom 19,966 (81.7%) accepted it. In urban Kibera, 8,836 (82.8%) of 10,673 participants accepted HBTC, and in rural Lwak, 11,130 (80.8%) of 13,777 participants accepted HBTC. In both settings, women were somewhat more likely than men to accept HBTC (Kibera 82.6% vs. 79.9%, p<0.0001; Lwak 80.3% vs. 75.4%, p<0.0001). Acceptance of HBTC was higher in adolescents (Kibera, 901/999, 90.2%; Lwak, 2335/2732, 85.5%) and highest in children age <13 years (Kibera, 376/383, 98.2%; Lwak, 814/851, 95.7%).

Among adults in Kibera who reported being in a married or cohabitating relationship, 38.0% chose to be counseled and tested together in HBTC. Of these couples, 7.9% were HIV-discordant, 7.8% were HIV-concordant positive, and 84.3% were HIV-concordant negative. Among Lwak adults who reported being in a married or cohabitating relationship, 51.7% chose to be counseled and tested together. Among these, 12.1% were HIV-discordant, 9.9% were HIV-concordant positive, and 77.9% were HIV-concordant negative. Among all HIV-infected persons in couples, 34.6% had an HIV-uninfected partner.

Linkage to care was poor in both settings. Overall, only around half of newly-diagnosed participants were available to receive their one-month follow-up visits (Kibera, n=362/773, 46.8%; Lwak, 596/1066, 55.9%). Of these, only 194 (53.6%) in Kibera and 260 (43.6%) in Lwak had attended a PSC. Of those who visited a PSC, 175 (88.8%) received cotrimoxazole prophylaxis in Kibera and 234 (90.0%) in Lwak. Among those with CD4 counts <250 cells/µL, 20 (34.5%) participants in Kibera and 23 (34.3%) in Lwak initiated antiretroviral therapy (ART).

Among the 504 (52.6%) newly-diagnosed participants in both settings who did not attend a PSC between the time of HBTC and the follow-up visit, half (n=255, 50.6%) reported that they were planning to go later, 135 (26.8%) said they had not had time, and 86 (17.1%) said they had been waiting for the counselor's follow-up visit.

Overall, 658 (59%) of 1,114 newly diagnosed adults who received CD4 testing had CD4 cell counts of ≥350 cells/µL; 278/1,114 (25%) had CD4 counts ≥250 cells/µL, which was the ART-eligibility threshold at the time.

Across settings, HIV prevalence among participants accepting HBTC was significantly higher in women than men (18.9% vs. 12.8%, p<0.0001). The overall adult HIV prevalence was 16.3%, with 14.9% infected in Kibera and 17.6% infected in Lwak. In Kibera, prevalence was highest in adults ages 35-44. Among women of that age range, prevalence was 27.1%, while it was 19.3% in their male counterparts. In Lwak, HIV prevalence was 31.6% in men ages 35-44 and the same proportion in women ages 25-34.

Among adults testing for the first time, HIV prevalence was 12.6% in Kibera and 14.2% in Lwak. Among children testing for the first time, prevalence was 10.3% in both settings. Considering the high prevalence in the other age groups, HIV prevalence in adolescents testing for the first time was relatively low in both settings (Kibera, 0.8%; Lwak, 3.0%). In both Kibera and Lwak, however, prevalence was much higher in first-time-testing adolescent females than in first-time-testing adolescent males (Kibera, 1.4% vs. 0.0%; Lwak, 4.4% vs. 1.7%).

More than one third (n=5400, 34.8%) of adults reported previously having tested negative for HIV. Of these, 225 (7.2%) in Kibera and 172 (7.6%) in Lwak tested seropositive in HBTC. Among adolescent females who had previously tested, HIV prevalence was again quite high when compared to previously-testing males (Kibera, 3.3% vs. 0.0%; Lwak, 9.1% vs. 1.0%).

Conclusions

The authors conclude that HBTC was widely accepted and reached many previously undiagnosed individuals, couples, and children. They suggest that HBTC is a promising strategy for greatly increasing population level coverage of HIV prevention, care, and treatment.

Risk of Bias

The risk of bias in this study is moderate to high. The underlying PBIDS program is not described, and the reference provided in the paper addresses only the Kibera study site.(3) While results from the two settings were compared with each other, there was no external comparator. The authors point out that as the study population was already participating in a public health research project, acceptance rates may not have been representative of the general population. They suggest that participants may have been more likely to participate because of their familiarity with public health research, or, conversely, they may have been less likely to participate because of "study fatigue" or concerns about confidentiality.

In Context

Most people in low- and middle-income countries who have been exposed to HIV have not accessed HIV testing and counseling services and don't know whether they have the infection.(4) An even larger proportion don't know their sexual partner's HIV status.(5, 6) Knowledge of status among people living with HIV can lead to greatly reduced HIV transmission risk behavior.(7, 8) Once diagnosed, many HIV-infected persons access ART, which can reduce HIV transmission by more than 90%.(9)

Programmatic Implications

Randomized controlled trials of this intervention are needed. Although existing evidence is limited and of low quality, HBTC could be an important tool for helping people to know if they are infected and getting them into care if they are. Clinics may wish to implement pilot HBTC programs.

References

  1. Breiman RF, Olack B, Shultz A, et al. Healthcare-use for major infectious disease syndromes in an informal settlement in Nairobi, Kenya. J Health Popul Nutr. 2011;29:123-133.
  2. National AIDS and STI Control Programme (NASCOP). National Guidelines for HIV Testing and Counselling in Kenya. [accessed 7 March 2013]
  3. Breiman RF, Olack B, Shultz A, et al. Healthcare-use for major infectious disease syndromes in an informal settlement in Nairobi, Kenya. J Health Popul Nutr. 2011;29:123-133.
  4. Joint United Nations Programme on HIV/AIDS (UNAIDS). Report on the Global AIDS Epidemic, 2010. [accessed 11 March 2013]
  5. Njozing BN, Edin KE, Sebastian MS, et al. "If the patients decide not to tell what can we do?"-TB/HIV counsellors' dilemma on partner notification for HIV. BMC Int Health Hum Right. 2011;11:6.
  6. Niccolai LM, Farley TA, Ayoub MA, et al. HIV-infected persons' knowledge of their sexual partners' HIV status. AIDS Educ Prev. 2002;14:183-189.
  7. Marks G, Crepaz N, Janssen RS. Estimating sexual transmission of HIV from persons aware and unaware that they are infected with the virus in the USA. AIDS. 2006;20:1447-1450.
  8. Bunnell R, Opio A, Musinguzi J, et al. HIV transmission risk behavior among HIV-infected adults in Uganda: results of a nationally representative survey. AIDS. 2008;22:617-624.
  9. Anglemyer A, Rutherford GW, Baggaley RC, Egger M, Siegfried N. Antiretroviral therapy for prevention of HIV transmission in HIV-discordant couples. Cochrane Database Syst Rev. 2011 Aug 10;(8):CD009153.