Feasibility and effectiveness of two community‐based HIV testing models in rural Swaziland

Abstract

ObjectivesTo evaluate the feasibility (population reached, costs) and effectiveness (positivity rates, linkage to care) of two strategies of community-based HIV testing and counselling (HTC) in rural Swaziland.MethodsStrategies used were mobile HTC (MHTC) and home-based HTC (HBHTC). Information on age, sex, previous testing and HIV results was obtained from routine HTC records. A consecutive series of individuals testing HIV-positive were followed up for 6 months from the test date to assess linkage to care.ResultsA total of 9 060 people were tested: 2 034 through MHTC and 7 026 through HBHTC. A higher proportion of children and adolescents (<20 years) were tested through HBHTC than MHTC (57% vs. 17%; P < 0.001). MHTC reached a higher proportion of adult men than HBHTC (42% vs. 39%; P = 0.015). Of 398 HIV-positive individuals, only 135 (34%) were enrolled in HIV care within 6 months. Of 42 individuals eligible for antiretroviral therapy, 22 (52%) started treatment within 6 months. Linkage to care was lowest among people who had tested previously and those aged 20–40 years. HBHTC was 50% cheaper (US$11 per person tested; $797 per individual enrolled in HIV care) than MHTC ($24 and $1698, respectively).ConclusionIn this high HIV prevalence setting, a community-based testing programme achieved high uptake of testing and appears to be an effective and affordable way to encourage large numbers of people to learn their HIV status (particularly underserved populations such as men and young people). However, for community HTC to impact mortality and incidence, strategies need to be implemented to ensure people testing HIV-positive in the community are linked to HIV care.ObjectifsEvaluer la faisabilité (population atteinte, coûts) et l'efficacité (taux de positivité, liaison aux soins) de deux stratégies de dépistage et conseil (DC) communautaire du VIH en zone rurale au Swaziland.MéthodesLes stratégies utilisées étaient des DC mobiles (DC-M) et le DC à domicile (DC-D). Les informations sur l’âge, le sexe, les tests précédents et les résultats VIH ont été obtenues à partir des dossiers de routine du DC. Une série d'individus séropositifs consécutifs a été suivie pendant six mois à partir de la date du test afin d’évaluer les liaisons aux soins.Résultats9.060 personnes ont été testées: 2.034 par le biais du DC-M et 7026 par le biais du DC-D. Une plus grande proportion d'enfants et d'adolescents (<20 ans) ont été testés par le biais du DC-D que par celui du DC-M (57% vs 17%; p <0,001). Le DC-M a atteint une proportion plus élevée d'hommes adultes que le DC-D (42% vs 39%; p = 0,015). Des 398 personnes séropositives, seules 135 (34%) ont été inscrites à des soins VIH dans les 6 mois. De 42 personnes admissibles à la thérapie antirétrovirale, 22 (52%) ont commencé le traitement dans les 6 mois. Les liaisons avec les soins étaient plus faibles chez les personnes qui ont effectué un dépistage auparavant et celles âgées de 20 à 40 ans. Le DC-D était 50% moins cher (11 $ US par personne testée, 797 $ par personne inscrite dans les...

Brief counselling after home‐based HIV counselling and testing strongly increases linkage to care: a cluster‐randomized trial in Uganda

“…This was probably due to the already high (89%) level of linkage to care in the standard‐of‐care (referral only) arm of that trial. In contrast, linkage to care in our standard‐of‐care arm was 33%, a figure consistent with that observed after routine referral in previous studies 20, 30, 31, 38, 39, 40.…”

Systematic review and meta-analysis of community and facility-based HIV testing to address linkage to care gaps in sub-Saharan Africa

“…The percentage of men out of total persons tested was reported in 25 home HTC studies 5,14,18,29,31,32,37,38,41–45,63,64,66,68–72,88–90 , two home with self-testing 11,75 , 10 mobile 10,13,68,72,91–99 , 3 index partner 47,49,88 , 3 campaign 46,47,76 , 2 workplace 100,101 , 20 facility VCT 52,54,61,64,81,88,89,92,93,95,96,98,102–107 , and 13 facility PITC 58,60,82–84,86,99,108–113 (Fig. 2).…”

“…Percentage of participants reporting testing for the first time was included in 20 home HTC studies 5,14,18,29,31,32,38,41–44,63,65,66,68–72,88 , 11 mobile 10,12,68,93–95,97,103,114 , 3 campaign 46,47,77 , 3 key populations 25,115,116 , and 7 facility VCT 12,54,91,93,95,106 , and 5 facility PITC 58,86,88,111,112 . Pooled percentages of first-time testers were higher for community than facility modalities (Fig.…”

“…Yield of HIV positive individuals (HIV positivity) was reported in 29 home studies 14,15,18,27,29–32,34,36,38,41–45,63,65,66,68,70–73,88,89 , one home with self-testing 11 , 12 mobile 10,13,68,72,92–95,97,98,103,107,114 , five campaign 46,47,76,77,120 , three workplace 79,80,121 , four key population 12,115,116,122 , four index partner 48–50,88 , 27 facility VCT 54–56,64,81,84,88,91–93,95,98,102,104–107,114,118–120,123–127 , and 17 facility PITC 56,57,59,60,81,83–88,99,110–113,126 studies. Community-based strategies for the general population had lower HIV positivity (6–11%) than facility HTC (18–20%), whereas targeted community HTC for key populations and sexual partners of index patients had the highest HIV yield (Fig.…”

“…The proportion of individuals with CD4 count of less than 350 cells μL −1 at HIV diagnosis was reported in 7 home 14,38,42,43,65,72,73 , 3 mobile 91,94,114 , 3 campaign 46,47,76 , 8 facility VCT 60,81,107,126,127,129–131 and 5 facility PITC studies 61,81,99,126,130 . Community-based strategies identified HIV-positive individuals at higher CD4 counts than facility HTC, with campaign having the lowest proportion with CD4 count less than 350 cells μL −1 (26%, 95% CI = 22–30%) (Fig.…”