Expanding HIV testing and linkage to care in southwestern Uganda with community health extension workers

Abstract

Introduction: Achieving the UNAIDS goals of 90–90-90 will require more than doubling the number of people accessing HIV care in Uganda. Community-based programmes for entry into HIV care are effective strategies to expand access to HIV care, but few programmes have been evaluated with a particular focus on scale-up.Methods: Integrated Community Based Initiatives, a Uganda-based non-governmental organization, designed and implemented a programme of community-based HIV counselling and testing and facilitated linkage to care utilizing community health extension workers (CHEWs) in rural Sheema District, Uganda. CHEWs performed programme activities during 1 October 2015 through 31 March 2016. Outcomes for this evaluation were (1) the number of people tested for HIV, and (2) the proportion of those testing positive who were seen at an ART clinic within three months of their positive test, and (3) the cost of the programme per person newly diagnosed with HIV. Microcosting methods were used to calculate the programme costs. Program scalability factors were evaluated using a published framework.Results: Sixty-two CHEWs attended a five-day training that introduced the biology of HIV, the conduct of confidential HIV testing, HIV prevention messages, and linkage, referral, and reporting requirements. CHEWs received a $30 monthly stipend and a field testing kit that included a bicycle, field bag, umbrella, gumboots, reporting booklet, pens, and HIV testing materials. Trained CHEWs tested 43,696 persons for HIV infection during the six-month programme period. Nine-hundred seventy-four participants (2.2%) were identified as HIV positive, and 623 participants (64%) were linked to HIV care. An estimated 69% of adult residents received testing as part of this campaign. The programme cost $3.02 per person test, $135.70 per positive person identified, and $212.15 per HIV-positive person linked to care.Conclusions: Lay community health extension workers (CHEWs) can be rapidly trained to scale-up home-based HIV testing and counselling (HTC) and linkage to care in a high-quality and low-cost manner to large numbers of people in a rural, high burden setting. A combination HIV testing approach, such as adding partner testing to community-based testing, could increase the proportion of HIV-positive persons identified.

Research priorities to inform “Treat All” policy implementation for people living with HIV in sub‐Saharan Africa: a consensus statement from the International epidemiology Databases to Evaluate AIDS (IeDEA)

“…For example, men are a particularly important group for tailored testing strategies, as they are less likely to be tested for HIV until they become ill . A number of models show promise for optimizing uptake of HIV testing and screening, including home‐ and community‐based testing, index partner testing, the integration of HIV testing into multi‐disease community‐level health campaigns, the use of lay cadres to expand testing and linkage to care, and self‐testing . Research approaches: Cluster randomized controlled trials (RCTs), rigorous programme evaluations, mixed methods studies on optimal timing of and barriers to repeat testing, and discrete choice experiments on preferences related to testing location (home or community based) and modalities (e.g. integration of HIV testing into other health services) will aid in identifying effective strategies that improve early diagnosis and linkage to care, particularly for underserved groups.…”

A Systematic Review of the Current Status of Safer Conception Strategies for HIV Affected Heterosexual Couples in Sub-Saharan Africa

“…Like our review, a recent consensus statement supporting safer conception and pregnancy for couples living with HIV found that access to SCS is limited by stigma toward HIV affected couples having children and that this stigma limits provision of safer conception services [75]. Increasing community education about SCSs via community health worker networks may help increase acceptability for previously unfamiliar conception strategies and reduce community-, provider-, or family-level stigma around pregnancy in HIV affected couples, as was accomplished with increasing community knowledge and acceptance of HIV testing [76, 77] and couples’ HIV counseling and testing [78–80]. …”

Evidence for scale up: the differentiated care research agenda

“…The concept of differentiated care is applicable across the care cascade from prevention to testing to viral suppression. While the majority of studies in this issue are limited to the provision of ART, an article from Uganda by Asiimwe et al provides evidence that lay cadres can be leveraged to expand testing services and supporting linkage of PLHIV to care [ 50 ].…”