Home-based counselling and testing identifies people in need of treatment earlier

Home-based 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 Infectious Diseases.

In 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.

In 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.

The 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.

In 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.

Much 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.”

Home-based 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.

It 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.

Wachira 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.

AMPATH (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.

Since 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 offered,

All 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.

Of the 19,522 individuals tested 946 tested in HBCT, 10,261 in VCT, 8,073 in PITC and 272 in the tuberculosis clinic.

After 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).

Mills and Ford note the study provides “compelling evidence that widespread HBCT helps identify infected individuals earlier in their disease progression.”

HBCT 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.

HBCT also identified the highest proportion (24%) of discordant couples.

Mills 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.

They 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.

Broader implementation, they note, must be accompanied by operations research to effectively tailor approaches to different contexts.

Wachira and colleagues also stress the importance of documenting HBCT cost-effectiveness.

Mills 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.

Strengths 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 HBCT.

Limitations include missed CD4 cell counts at enrolment so data should be interpreted with some caution, note the authors.

Mills 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.”

Wachira J et al. What is the impact of home-based HIV counselling and testing on the clinical status of newly enrolled adults in a large HIV care program in Western Kenya?  Advance online edition CID December 8, doi: 10.1093/cid/cir789, 2011.

Mills EJ and Ford N. Home-based HIV counselling and testing as a gateway to earlier initiation of antiretroviral therapy. Advance online edition CID December 8, doi: 10.1093/cid/cir812, 2011.