Reaching Absent and Refusing Individuals During Home-Based HIV Testing Through Self-Testing—at What Cost?

Home-based oral self-testing for absent and declining individuals during a door-to-door HIV testing campaign in rural Lesotho (HOSENG): a cluster-randomised trial

Background: Despite the importance of HIV testing for controlling the HIV epidemic, testing rates remain low. Efforts to scale up testing coverage and frequency in hard-to-reach and at-risk populations commonly focus on home-based HIV testing. This study evaluates the effect of a gift (a US$5 food voucher for families) on consent rates for home-based HIV testing. Methods: We use data on 18 478 individuals (6 418 men and 12 060 women) who were successfully contacted to participate in the 2009 and 2010 population-based HIV surveillance carried out by the Wellcome Trust's Africa Health Research Institute in rural KwaZulu-Natal, South Africa. Of 18 478 potential participants contacted in both years, 35% (6 518) consented to test in 2009, and 41% (7 533) consented to test in 2010. Our quasi-experimental difference-in-differences approach controls for unobserved confounding in estimating the causal effect of the intervention on HIV-testing consent rates. Results: Allocation of the gift to a family in 2010 increased the probability of family members consenting to test in the same year by 25 percentage points [95% confidence interval (CI) 21–30 percentage points; P < 0.001]. The intervention effect persisted, slightly attenuated, in the year following the intervention (2011). Conclusions: In HIV hyperendemic settings, a gift can be highly effective at increasing consent rates for home-based HIV testing. Given the importance of HIV testing for treatment uptake and individual health, as well as for HIV treatment-as-prevention strategies and for monitoring the population impact of the HIV response, gifts should be considered as a supportive intervention for HIV-testing initiatives where consent rates have been low.

National Institute of Mental Health.

Home-based service delivery has been used to improve access to HIV testing and antiretroviral initiation across sub-Saharan Africa, but it has yet to be leveraged to improve pre-exposure prophylaxis (PrEP) uptake. We interviewed 37 adolescent girls and young women (AGYW) in Eastern Cape, South Africa to explore why they chose to initiate PrEP or not following home-based HIV testing and referral for PrEP, and what influenced time to PrEP initiation. Participants reported that home visits provided a source of trusted information and a way to involve family members in their PrEP initiation decisions, motivating some to start PrEP. AGYW who initiated PrEP were more likely to qualitatively perceive themselves to be at high risk for HIV compared with those who never initiated PrEP. Integrating home-based HIV testing with PrEP education and referral may be a valuable way to reduce familial barriers and boost PrEP uptake among AGYW in South Africa. Trial registration: NCT03977181. Retrospectively registered on June 6, 2019.

To explore the barriers and facilitators of linkage to and retention in care amongst persons who tested positive for HIV, qualitative research was conducted in a home-based HIV counselling and testing (HBCT) project with interventions to facilitate linkages to HIV care in rural KwaZulu-Natal, South Africa. The intervention tested 1272 adults for HIV in Vulindlela of whom 32% were HIV positive, received point-of-care (POC) CD4 testing and referral to local HIV clinics. Those testing positive also received follow-up visits from a counsellor to evaluate linkages to care. The study employed a qualitative methodology collecting data through in-depth semi-structured interviews. Respondents included 25 HIV-positive persons who had tested as part of HBCT project, 4 intervention research counsellors who delivered the HBCT intervention and 9 government clinic staff who received referrals for care. The results show that HBCT helped to facilitate linkage to care through providing education and support to help overcome fears of stigma and discrimination. The results show the perceived value of receiving a POC CD4 result during post-test counselling, both for those newly diagnosed and those previously diagnosed as HIV positive. The results also demonstrate that in-depth counselling creates an “educated consumer” facilitating engagement with clinical services. The study provides qualitative insights into the acceptability of confidential HBCT with same day POC CD4 testing and counselling as factors that influenced HIV-positive persons’ decisions to link to care. This model warrants further evaluation in non-research settings to determine impact and cost-effectiveness relative to other HIV testing and referral strategies.

Universal HIV testing is now recommended in generalised HIV epidemic settings. Although home-based HIV counselling and testing (HB-HCT) has been shown to be effective in achieving high levels of HIV status awareness, little is still known about the cost implications of universal and repeated HB-HCT. We estimated the costs of repeated HB-HCT and the scale economies that can be obtained when increasing the population coverage of the intervention. We used primary data from the ANRS 12249 Treatment as Prevention (TasP) trial in rural South Africa (2012–2016), whose testing component included six-monthly repeated HB-HCT. We relied on the dynamic system generalised method of moments (GMM) approach to produce unbiased short- and long-run estimates of economies of scale, using the number of contacts made by HIV counsellors for HB-HCT as the scale variable. We also estimated the mediating effect of the contact quality – measured as the proportion of HIV tests performed among all contacts eligible for an HIV test – on scale economies. The mean cost (standard deviation) of universal and repeated HB-HCT was $24.2 (13.7) per contact, $1694.3 (1527.8) per new HIV diagnosis, and $269.2 (279.0) per appropriate referral to HIV care. The GMM estimations revealed the presence of economies of scale, with a 1% increase in the number of contacts for HB-HCT leading to a 0.27% decrease in the mean cost. Our results also suggested a significant long-run relationship between mean cost and scale, with a 1% increase in the scale leading to a 0.36% decrease in mean cost in the long run. Overall, we showed that significant cost savings can be made from increasing population coverage. Nevertheless, there is a risk that this gain is made at the expense of quality: the higher the quality of HB-HCT activities, the lower the economies of scale.

Introduction: The HPTN 071 (PopART) trial is a community randomised trial in Zambia and South Africa, examining the impact of combination prevention, including treatment as prevention using Universal Test and Treat (UTT), on community level HIV-incidence. This PhD evaluates the factors associated with uptake of the key interventions, during the first year of the trial. Methods: Two systematic reviews were conducted on home-based HIV testing and counselling (HB-HTC), and the cascade-of-care following community-based HTC, respectively. In addition, two case-control (CC) studies were nested within PopART, to examine factors associated with the uptake of the door-to-door home-based universal testing (CC study 1), and universal treatment (CC study 2) interventions. Results: Our results suggest that HB-HTC in sub-Saharan Africa is widely accepted – uptake among those offered HB-HTC was 83% in a systematic review and meta-analysis of studies (2000-2012). The second systematic review found considerable variability in measures used to report linkage-to-care and ART initiation and in outcomes reported, even for similar time periods following HIV-detection (studies between 2006-2016). CC1 found no differences between acceptors and non-acceptors of HB-HTC by demographic and behavioural characteristics. CC2 identified that the more lifetime sexual partners participants reported, the more likely they were to achieve timely linkage and ART initiation (TLA). Negative perceptions about clinic infra-structure were associated with failure to achieve TLA. Both CC studies found that favourable views about the Community HIV-care Providers was associated with uptake of interventions, while neither stigma nor unfavourable views about clinic staff were associated with uptake. Conclusion: This PhD contributes to knowledge on the cascade-of-care and UTT. It suggests that PopART interventions are acceptable across population sub-groups, providing optimism for achieving universal coverage using the PopART model to implement UTT. If individuals with high-risk sexual behaviour embrace interventions as we observed, there is great promise for treatment as prevention.

Among an estimated 33 million individuals who are infected with HIV worldwide, only 10% are aware of their status. HIV testing is the cornerstone to preventing further transmission and to caring for those infected, particularly as access to treatment improves in resource-limited settings. However, efforts to expand testing through facilities-based testing have not achieved adequate testing coverage, prompting efforts to reach more individuals through strategies such as home-based HIV testing. Home testing is showing promising early results in some high-prevalence, resource-limited settings. This article reviews the mechanisms and literature to date of this door-to-door approach.

Background: Home-based HIV counselling and testing (HBHCT) is highly acceptable&#13;\nand may be an effective strategy for HIV prevention and population-based test-and-treat&#13;\nprogrammes in sub-Saharan Africa (SSA). However, few data are available on linkage&#13;\nto care or on the effectiveness of strategies to increase linkage to care among HIVpositive&#13;\npersons identified through HBHCT in SSA. The aims of this PhD were to (i)&#13;\nsystematically review the literature on linkage to care among HIV-positive adults&#13;\ndiagnosed through HBHCT in SSA; and (ii) to conduct a cluster-randomised controlled&#13;\ntrial to measure the effectiveness of a counselling intervention after HIV diagnosis&#13;\nthrough HBHCT in increasing linkage to care in rural Masaka district, Uganda.&#13;\nMethods: (i) Five databases (Medline, Embase, Global Health, Web of Science, and&#13;\nAfrica-Wide information) were systematically searched for studies published between&#13;\n1st January 2000 and 19th August 2016. Authors of studies for which some required&#13;\ninformation was missing were requested to provide additional data. (ii) For the trial, 28&#13;\nrural communities were randomly allocated (1:1) to the intervention (HBHCT, referral,&#13;\nand brief home-based counselling sessions one and two months after HBHCT) or&#13;\ncontrol group (HBHCT and referral only). HIV-positive adults (≥18 years) not yet in&#13;\ncare were enrolled. Primary outcomes were linkage (registration with an HIV clinic) at&#13;\n6 months after HBHCT, and time to linkage. Analyses were by intention-to-treat using&#13;\nrandom effects logistic regression and Cox regression with shared frailty.&#13;\nResults: (i) 19 eligible studies were identified; one had all the required data. Additional&#13;\ndata were obtained for 13 studies; thus, 14 studies were included in the review. Linkage&#13;\nto care was generally lower (&lt;33%) if HBHCT was followed by referral only, and&#13;\nhigher (&gt;80%) if some strategy was used to facilitate uptake of referral. Only one study&#13;\nwas a randomised trial and most were susceptible to outcome ascertainment bias. (ii) In&#13;\nthe trial, 551 individuals tested HIV-positive; 205 (37.2%) were already in care and thus&#13;\nineligible. 302 (87.3% of those eligible) were enrolled (intervention, n=149). Retention&#13;\nwas similar across trial arms (92% overall). Overall linkage to care was 42.1%.&#13;\nCounselling was associated with a 2.18-fold [95% confidence interval (CI)=1.26-3.78]&#13;\nincrease in the odds of linkage. There was no evidence of a difference between arms in&#13;\nthe rate of linkage in the first two months, but subsequently the rate of linkage was&#13;\nhigher in the intervention arm (hazard ratio=4.87, 95% CI=1.79-13.27).&#13;\nConclusion: Counselling substantially increases linkage to care among HIV-positive&#13;\nadults identified through HBHCT and can increase antiretroviral therapy coverage in&#13;\nSSA.

Background:The aftermath of the conflict between Cameroon and Nigeria over the Bakassi peninsular seriously affected maternal and child health outcomes in this health district with high insecurity from kidnappings and pirate attacks, no communication network, limited means of transportation and very low literacy levels. Furthermore, HIV prevalence in Bakassi is yet to be ascertained but clinic reports show it could be ≥ 20% in pregnant women (PW). With the high levels of low-literacy rate coupled with strong negative cultural believes which discourages pregnant women from accessing clinics, it became practically impossible to change health seeking habits and prevent mother-to-child transmission of HIV without proper comprehension. With antenatal clinic uptake being only 7% in 2017, we sort to pilot a community based innovation to increase pregnant women and men tested for HIV and enrolment on antiretroviral treatment. Method:A community based technological innovation was used in this project which was located within 10 communities in Idabato – Bakassi. Project activities were; (1) development of animated video cartoons and incorporation in solar mobile devices, (2) training of 12 low-literate women, (3) community awareness, home-based HIV testing and treatment, (4) strengthening community leadership and advocacy. The project ran from October 2017 to June 2019. Result:Four animated video cartoon were developed with educative messages in local languages on ANC, male partner involvement, treatment adherence and stigma. A total of 6891 persons were educated in which 4441 women and 2450 men of child bearing age. ANC uptake increased from 7% in 2017 to 44% in December 2018. 356 pregnant women (PW) tested for HIV with 54 testing HIV positive. Of the 54 PW tested HIV positive, 49 PW placed on treatment at community level. Also, 412 Non-PW were tested for HIV, with 50 testing HIV positive. Of the 50 non-PW who tested HIV positive, a total of 44 were placed on treatment. For male partners, 131 were tested for HIV and 59 tested positive for HIV with 13 male partners being placed on treatment. Next Steps: increasing ANC and HIV testing rate amongst pregnant women in culturally sensitive and low literate communities is possible with innovative strategies to behaviour change communication. It will be important to strengthen sample collection for viral load testing to ascertain the number of persons who attained viral load suppression through this strategy.

BackgroundCamellia is a single-arm longitudinal cohort study. We engaged a Community Advisory Board to support refinement of an existing mHealth app platform for use among cis- and transwomen in Alabama, one of seven states prioritized in the federal Ending the HIV Epidemic (EHE) strategy. We partnered with the Alabama Department of Public Health to recruit from a database of women recently diagnosed with gonorrhea or syphilis, aged 18–50, across Alabama. Potential participants are recruited by telephone. A home-based HIV and sexually transmitted infection (STI) testing program allows the study to offer tailored sexual health information, testing, linkage to care and support while assessing STI and HIV incidence and associated predictors.MethodsStudy participants are enrolled into the digital Camellia Cohort in which they complete home-based HIV and STI testing and online surveys every 6 months. Participants are followed for at least 24 months or until study completion (up to 42 months). Primary outcomes include predictors, mediators and moderators for HIV and STI incidence and pre-exposure prophylaxis (PrEP) use via self-report, medical record review, and dried blood spots.ConclusionThe Camellia Cohort integrates epidemiologic methods, mHealth technology, and data science to better characterize HIV transmission dynamics and engagement in the prevention care cascade among women in an EHE focus state. This study will provide critical insights into the feasibility and acceptability of a remote, light-touch cohort design, while also providing data on STI and HIV incidence, PrEP use, and key mediators and moderators influencing prevention behaviors among women with indications for PrEP in this high-priority region.

Linkage to HIV care remains suboptimal among men. We investigated the effectiveness of a male-targeted HIV-specific decision support app, Empowering People through Informed Choices for HIV (EPIC-HIV), on increasing linkage to HIV care among men in rural South Africa. Home-Based Intervention to Test and Start (HITS) was a multi-component cluster-randomized controlled trial conducted among 45 communities in uMkhanyakude, KwaZulu-Natal. The development of EPIC-HIV was guided by self-determination theory and human-computer interaction design to increase intrinsic motivation to seek HIV testing and care among men. EPIC-HIV was offered in two stages: EPIC-HIV 1 at the time of home-based HIV counseling and testing (HBHCT), and EPIC-HIV 2 at 1 month after a positive HIV diagnosis if not linked to care. Sixteen communities were randomly assigned to the arms to receive EPIC-HIV, and 29 communities to the arms without EPIC-HIV. Among all eligible men, we compared linkage to care (initiation or resumption of antiretroviral therapy after > 3 months of care interruption) at local clinics within 1 year of a home visit, ascertained from individual clinical records. Intention-to-treat analysis was performed using modified Poisson regression with adjustment for receiving another intervention (i.e., financial incentives) and clustering at the community level. We also conducted a satisfaction survey for EPIC-HIV 2. A total of 13,894 men were eligible (i.e., aged ≥ 15 years and resident in the 45 communities). The mean age was 34.6 (±16.8) years, and 65% were married or in an informal union. Overall, 20.7% received HBHCT, resulting in 122 HIV-positive and 6 discordant tests. Among these, 54 men linked to care within 1 year after HBHCT. Additionally, of the 13,765 eligible participants who did not receive HBHCT or received HIV-negative results, 301 men linked to care within 1 year. Overall, only 13 men received EPIC-HIV 2. The proportion of linkage to care did not differ between the arms randomized to EPIC-HIV and those without EPIC-HIV (adjusted risk ratio = 1.05; 95% CI:0.86-1.29). All 13 men who used EPIC-HIV 2 reported the app was acceptable, user-friendly, and useful for getting information on HIV testing and treatment. The reach was low, although the acceptability and usability of the app were very high among those who engaged with it. Enhanced digital support applications could form part of interventions to increase knowledge of HIV treatment among men. Clinical Trial Number: ClinicalTrials.gov # NCT03757104.

Background: The universal test-and-treat strategy (UTT) aims to maximize population viral suppression (PVS), i.e. the proportion of all people living with HIV (PLHIV) on antiretroviral treatment (ART) and virally suppressed in a community. We investigated whether PVS improved during the course of the ANRS 12249 TasP trial conducted in rural South Africa and investigating UTT impact on HIV incidence. Methods: The TasP cluster-randomized trial (2012-2016) implemented six-monthly repeat home-based HIV counselling and testing (RHBCT) and referral of PLHIV to local HIV clinics in 2×11 clusters opened sequentially. ART was initiated according to national guidelines in control clusters and regardless of CD 4 count in intervention clusters. We measured residency status, HIV status and HIV care status for each participant. PVS was computed per cluster among all resident PLHIV (≥16, including those not in care) at cluster opening and daily thereafter. We used a mixed linear model to explore time patterns in PVS, adjusting for sociodemographic changes at cluster level. Findings: 8 563 PLHIV were followed. Between cluster opening and January 1, 2016, PVS increased significantly in both arms (intervention: 23·5% to 46·2%, +22·8, p<0·001; control: 26·0% to 44·6%, +18·6, p < 0·001), but not differently by arm (p=0·514). In the final adjusted model, PVS increase was most associated with increased RHBCT (measured by time since cluster opening). Contextual changes (measured by calendar time) also contributed slightly. The effect of universal ART was positive but not significant. Conclusions: Changes in ART initiation guidelines alone are not enough to significantly increase PVS. Trial Registration Number: The trial was also registered on ClinicalTrials.gov: NCT01509508 and South African National Clinical Trials Register: DOH-27-0512-3974. Funding Statement: This trial was sponsored by the French National Agency for AIDS and Viral Hepatitis Research (ANRS; grant number, 2011-375), and funded by the AN S, the Deutsche esellschaft f r Internationale Zusammenarbeit (GIZ; grant number, 81151938), and the International Initiative for Impact Evaluation, Inc. (3ie) with support from the Bill & Melinda Gates Foundation. The content is solely the responsibility of the authors and does not represent the official views of 3ie or the Bill & Melinda Gates Foundation. This trial was done with the support of Merck and Gilead Sciences, which provided the Atripla drug supply. The Africa Health Research Institute, (previously Africa Centre for Population Health, University of KwaZulu-Natal, South Africa) receives core funding from the Wellcome Trust, which provides the platform for the population-based and clinic-based research at the centre. Declaration of Interests: CI received honoraria for consulting services rendered to Gilead Sciences. All other authors declare that they have no conflicts of interest. Ethics Approval Statement: The Biomedical Research Ethics Committee (BREC), University of KwaZulu-Natal, South Africa (BFC 104/11) and the Medicines Control Council of South Africa approved the trial.

Objective:To determine the uptake of home-based HIV counselling and testing (HCT) in four HPTN 071 (PopART) trial communities (implementing a ‘full’ combination HIV prevention package that includes universal HIV testing and treatment) in Zambia. We also explore factors associated with uptake of HCT in these communities.Design:HPTN 071 (PopART) is a three-arm community-randomized trial in 12 communities in Zambia and nine communities in South Africa evaluating the impact of a combination HIV prevention package, including universal HIV testing and treatment, on HIV incidence.Methods:Using a door-to-door approach that includes systematically revisiting households, individuals were offered participation in the intervention, and verbal consent was obtained. Data were analysed for the first 18 months of the intervention, December 2013 to June 2015 for individuals 18 years and older.Results:Among 121 130 enumerated household members, 101 102 (83.5%) accepted the intervention. HCT uptake was 72.2% (66 894/92 612), similar by sex but varied across communities. HCT uptake was associated with younger age, sex, community, being symptomatic for TB and sexually transmitted infections and longer time since previous HIV test. Knowledge of HIV status due to the intervention increased by 36% overall and by 66% among HIV positive participants; the highest impact was among 18–24 years old.Conclusion:Overall acceptance of HIV-testing through offering a door-to-door-based combination HIV prevention package was 72.2%. The intervention increased knowledge of HIV status from ∼50 to ∼90%. However, challenges still remain and a one-off intervention is unlikely to be successful but will require repeated visits and multiple strategies.

The study aimed to determine factors contributing to the acceptability of home-based HIV counselling and testing (HBHCT) among commuters in Johannesburg inner city. Simple random sampling was used to select participants in a venue based intercept survey at Noord Street taxi rank in Johannesburg central business district. A total of 1146 individuals were interviewed and logistic regression analysis assessed factors associated with HBHCT acceptability. HBHCT acceptability was 64%. Home testing was preferred as an alternative to testing at a health facility. High school education (adjusted odds ratio [aOR] 0.61, CI: 0.46-0.85), inner city residence aOR 0.70, CI: 0.52-0.94), previous HIV testing in the hospital (aOR 0.22, CI: 0.15-0.32) and at home (aOR 0.18, CI: 0.11-0.27) were significantly less likely associated with HBHCT acceptability. Being married (aOR 1.64, CI: 1.15-2.32), recent HIV testing (aOR 1.85, CI: 1.15-2.99) and having experienced negative health worker attitude (aOR 2.41, CI: 1.66-3.48) were significantly more likely associated with HBHCT acceptability. High acceptability of HBHCT among urban-based commuters plus factors that would deter HBHCT acceptability were identified. Further research to identify strategies to improve HBHCT acceptability among commuter populations is needed.