A hybrid mobile approach for population-wide HIV testing in rural east Africa: an observational study

Abstract

Background Despite large investments in HIV testing, only 45% of HIV-infected persons in sub-Saharan Africa are estimated to know their status. Optimal methods for maximizing population-level testing remain unknown. We sought to demonstrate the effectiveness at achieving population-wide testing coverage of a hybrid mobile HIV testing approach. Methods From 2013–2014, we enumerated 168,772 adult (≥15 years) residents of 32 communities in Uganda (N=20), and Kenya (N=12) using a door-to-door census. “Stable” residence was defined as living in community for ≥6 months over the past year. In each community we performed 2-week multi-disease community health campaigns (CHC) that included HIV testing, counseling, and referral to care if HIV-infected; CHC non-participants were approached for home-based testing (HBT) over 1–2 months. We determined population HIV testing coverage, and predictors of testing via HBT (vs. CHC) and non-testing. Findings HIV testing was achieved in 89% of stable adult residents (131,307/146,906). HIV prevalence was 9.6% (13,043/136,033 stable and non-stable adults); median CD4+ T-cell count was 514 cells/μL (IQR: 355–703). Among stable adults tested, 43% (56,106/131,307) reported no prior testing. Among HIV-infected adults, 38% (4,932/13,043) were unaware of their status. Among stable CHC attendees, 99.5% (104,635/105,170) accepted HIV testing. Of stable adults tested, 80% (104,635/131,307, range: 60–93%) tested via CHCs. In multivariable analyses of stable adults, predictors of non-testing included male gender (risk ratio [RR]: 1.52, 95% CI: 1.48–1.56), single marital status (RR: 1.70, 95% CI: 1.66–1.75), Kenyan residence (RR: 1.46, 95% CI: 1.41–1.50, vs. Ugandan), and out-of-community migration for ≥1 month in past year (RR: 1.60, 95% CI: 1.53–1.68). Testing was more common among farmers (RR: 0.73, 95% CI: 0.67–0.79) and adults with primary education (RR: 0.84, 95% CI: 0.80–0.89). Interpretation High HIV testing coverage was achieved in rural Ugandan and Kenyan communities using a hybrid, mobile approach of multi-disease CHCs followed by HBT. This approach allowed for flexibility at the community and individual level in reaching testing coverage goals. Men and mobile populations remain challenges for universal testing.

Men “missing” from population-based HIV testing: insights from qualitative research

“…Additionally, men were more likely than women to engage in HBT than testing at a visible CHC (Table 2) (Chamie et al, 2016). Analyses of IDI, FGD, and PO data for this study revealed a range of structural and cultural barriers to men’s participation in the study’s hybrid HIV testing approach that included mobile CHCs and home-based HIV testing (HBT) for campaign non-attendees (Table 3.)…”

“…SEARCH is a community cluster-randomized controlled trial in 32 communities of approximately 10,000 persons each in three regions in Kenya and Uganda, in which all communities received a community census and population-wide HIV testing at baseline. SEARCH uses a hybrid mobile HIV testing approach in which 2-week multi-disease community health campaigns (CHCs) are followed by home-based testing (HBT) of CHC non-participants (Chamie et al, 2016). …”

“How can I tell?” Consequences of HIV status disclosure among couples in eastern African communities in the context of an ongoing HIV “test-and-treat” trial

“…SEARCH aims to increase HIV testing and care uptake through community-led, multi-disease, and patient-centered approaches; study details are published elsewhere (Chamie et al, 2016). Study communities are predominantly rural, low socio-economic status areas typical of resource-poor settings in the region.…”

“…The provider cohort ( n = 50) was purposively selected from a list of government facility providers to include the range of cadre engaged in HIV care, including clinical officers, nurses, research assistants (engaged to track lost to follow up patients), HIV counselors, community health assistants, and peer educators. The community member cohort ( n = 112) was randomly selected from a household listing established by the SEARCH socioeconomic survey (Chamie et al, 2016, within strata defined by gender and HIV status: 5 HIV-negative and 9 HIV-positive individuals per community (3 with CD4 count above 500 cells/mm 3 , 3 on ART, and 3 eligible for ART but not linked to care at sampling).…”

Comparative assessment of five trials of universal HIV testing and treatment in sub‐Saharan Africa

“…unemployment, poverty) as well as the education level of their populations. The proportion of adults who had no secondary school education ranged from 13% in the South African communities of PopART (unpublished data) to 71% in the SEARCH communities 28. While all trials are conducted in areas which suffer from generalized HIV epidemics, the baseline prevalence of HIV also varied and was estimated to be 30% TasP trial sites 29, 29% in BCPP 30, 29% in Max ART 31, 22% in the South African sites of the PopART (unpublished data), 21% in the Zambian sites of PopART (unpublished data), 20% in SEARCH Kenyan communities 32, and is less than 10% in the SEARCH Ugandan communities 32.…”