HIV counselling and testing (HBCT) was shown to be the most effective gateway for
getting those who tested HIV-positive into care at an early stage of HIV
disease, before they became ill, compared to voluntary counselling and testing
(VCT), provider-initiated testing and counselling (PITC) or HIV testing in a
tuberculosis (TB) clinic, researchers report from a study of western Kenya
published in the advance online edition of Clinical
this retrospective observational study Wachira and colleagues, on behalf of the
US Agency for International Development-Academic Model Providing Access to
Healthcare (USAID-AMPATH), found median CD4 cell counts at enrolment into care
were 323 cells/mm3 (194-491), 217 cells/mm3 (87-404), 190
cells/mm3 (70-371) and 136 cells/mm3 (59-266) for HBCT,
VCT, PICT and the tuberculosis clinic, respectively.
an accompanying editorial commentary Mills and Ford state that timely access to
ART is the single most effective intervention in reducing death and disease
among people with HIV or AIDS.
World Health Organization (WHO) now recommends that people living with HIV
should start treatment at a CD4 count around 350 in order to reduce the risk of
illness, particularly tuberculosis. However many people are diagnosed only when
they become sick because they did not undergo HIV testing earlier.
spite of the increased availability of a wide variety of testing and
counselling services HIV testing uptake remains low in Kenya as throughout sub-Saharan Africa.
attention, Mills and Ford note, has been focused on the importance of an
earlier start of ART but little on how to encourage people to get treatment
earlier. The importance of linking testing to getting people into care is now
recognised. An essential part of this is “ identifying people as early as
possible to decrease the likelihood of transmission between partners and provide
an early opportunity to engage patients into care.”
counselling and testing, Mills and Ford and Wachira and colleagues note,
provides a potential important strategy to identify people before their disease
progresses. Unlike other testing and counselling strategies HBCT is provided in
the home by specially trained HIV counsellors.
may also present an opportunity to engage populations such as the elderly, men
and adolescents; often not part of testing campaigns they are underrepresented
in ART programmes so resulting in higher mortality rates, note Mills and Ford.
and colleagues note while limited studies have looked at the role of HBCT in
increasing testing uptake, none have looked at it in promoting timely access to
care when compared to other testing points.
(a joint partnership between Moi University School of Medicine, the Indiana
University School of Medicine and Moi Teaching and Referral Hospital)
began in 2001. In 2004 USAID became a major partner.
2001 over 130,000 adults and children have enrolled in 25 ministry of health
facilities and numerous satellite clinics in western Kenya. HIV and TB-related care is
provided free at the point of care. Comprehensive HV care services including
HIV testing and counselling through VCT, PITC (inpatient and outpatient
clinical departments, antenatal clinics and tuberculosis clinics) and HBCT are
patients aged 14 years of age or older who enrolled in any of the AMPATH
clinics from August 2008 until April 2010 with a documented point of entry on
their initial clinical encounter form were included.
the 19,522 individuals tested 946 tested in HBCT, 10,261 in VCT, 8,073 in PITC
and 272 in the tuberculosis clinic.
controlling for age and sex those who tested in HBCT compared to those who got
a diagnosis in a TB clinic were less likely to have WHO stage 3 or 4 disease at
enrolment (AOR: 0.04; 95% CI:.03-.06); less likely to enrol with a CD4 cell
count under 200 cells/mm3 (AOR:0.20; 95% CI: .14-28); and less
likely to enrol in care with a serious complaint (AOR:0.08; 95% CI: .05-12).
and Ford note the study provides “compelling evidence that widespread HBCT
helps identify infected individuals earlier in their disease progression.”
enrolled twice the proportion of HIV-infected pregnant women compared to VCT,
PITC or tuberculosis entry points. The authors note that HBCT could complement
PMTCT by identifying and referring those women who are not accessing antenatal
care or PMTCT services.
also identified the highest proportion (24%) of discordant couples.
and Ford suggest that home-based counselling and testing could also become an
important means of implementing long-standing recommendations to test household
members of HIV-infected persons and support forthcoming WHO recommendations for
an earlier ART start in discordant couples.
suggest HBCT could be integrated with broadly trained health workers providing
a gateway to other conditions including active case finding for tuberculosis,
screening for heart conditions and diabetes.
implementation, they note, must be accompanied by operations research to
effectively tailor approaches to different contexts.
and colleagues also stress the importance of documenting HBCT
and Ford note recent studies have shown that providing CD4 cell counts at the
time of testing improves ART start rates suggesting the potential for
innovative approaches to integrate point-of-care CD4 cell counts into HBCT.
include the unique setting offering a number of testing and counselling
strategies including HBCT as well as free provision of care and treatment
supported a robust analysis. Patients may have tested at one site and enrolled
in care at another and were included in the analysis reflecting routine
circumstances (effectiveness) rather than an ideal situation (efficacy) of
include missed CD4 cell counts at enrolment so data should be interpreted with
some caution, note the authors.
and Ford conclude “ HBCT appears to be a feasible and acceptable approach that
can further both HIV treatment and prevention objectives and potentially
support broader health objectives.”