Home-based counselling and testing with point-of-care CD4 counts maximises linkage to care in rural South Africa

Carole Leach-Lemens
Published: 26 June 2013

Home-based testing and counselling (HBCT), combined with same day point-of-care CD4 testing and lay counsellor follow-up visits (HBCT-Plus), resulted in almost universal uptake of HIV testing, linkage to care and antiretroviral treatment (ART) initiation in rural KwaZulu-Natal, South Africa, where HIV prevalence is 30%, researchers report in the advance online edition of the Journal of Acquired Immune Deficiency Syndromes.

Findings from this pilot study of 671 adults show the significant effect HBCT-Plus can have on knowledge of HIV status, linkage to care, starting ART, adherence and reduced HIV infectiousness, so providing important clinical and public health benefits.

In total, 86% of those eligible for ART (according to South African guidelines at the time – a CD4 cell count at or under 200 cells/mm3) started ART within the first three months.

By the six-month stage of the study, there was a significant decrease in mean viral load (0.31 log10 copies/ml, p=0.009) in the 30% (196) identified as HIV positive, of whom 73 (36%) were newly identified, and an increase in the proportion with viral load under 1000 copies/ml among those eligible for ART.

South Africa has the greatest number of people living with HIV worldwide, yet only one-in-two people knows their HIV status.

HBCT (delivering HIV counselling and testing by lay counsellors to adults in their homes in resource-limited settings) has high acceptability and uptake in diverse settings in sub-Saharan Africa, identifying HIV-infected people previously unaware of their status, and doing so at higher CD4 cell counts.

HBCT’s success in achieving high testing rates, knowledge and self-disclosure is not matched, however, by corresponding rates of engaging with and remaining in care. The authors cite a district-wide HBCT study in Uganda comprising over 250,000 participants, with more than 11,000 people (4.3%) identified as HIV positive – of whom only 11% started ART.

The later someone presents for care, the poorer the response to ART, the higher the potential for death, disease and increased treatment costs; the less time on treatment, the greater the likelihood of contributing to increased transmission rates.

Strategies to effectively link newly identified HIV-positive people into care and determine their eligibility for ART are clearly needed, write the authors.

They evaluated this new model – HBCT-Plus – to see if it:

  1. achieved high HIV testing coverage

  2. identified HIV-positive people unaware of their HIV status

  3. reduced potential barriers to engagement in HIV care, and

  4. reduced infectiousness through high uptake of, and adherence to, ART.

Conducted from March 2011 to March 2012 in the Vulindlela subdistrict of Umgungundlovu District, Kwa-Zulu-Natal, where unemployment is high and per capita income low (under US$2 a day), the study comprised a geographically distinct area of adjoining households within walking distance of a primary health centre and an ART care centre.

Individuals found to be HIV positive received point-of-care CD4 testing in their home when they received a positive rapid HIV test result. Results of the CD4 test determined eligibility for ART. Same-day counselling topics included the importance of HIV care and adherence, information about HIV care options and a referral letter so individuals would be prepared on arrival at the clinic.

While participants were compensated with a food parcel for their time, no financial incentives or transport compensation were given to attend the clinic.

Follow-up visits at one, three and six month(s) evaluated linkage to care and ART uptake. Plasma viral load was measured at baseline and at six months.

This model successfully provided a critical step linking HIV testing and treatment. Point-of-care CD4 testing and results with same-day counselling eliminated the need for additional clinic visits for blood work, results and ART assessment.

“We demonstrated that point-of-care CD4 testing was highly acceptable at the time of learning one was HIV-infected, feasible to be conducted in homes in a rural South African setting, facilitated specific counselling on HIV care and faster determination of ART and had excellent agreement with a paired venous sample tested by flow cytometry [with a mean difference of 16 cells/mm3 (95%CI: -1 to 32 cells/mm3)].”

Median CD4 count was 435 cells/mm3 (IQR: 297-591 cells/mm3) by point-of-care testing and 423 cells/mm3 by flow cytometry (IQR 282-5910 cells/mm3).

Median age of HIV-positive participants was 34 years; 82% (164) were female, over half of whom did not know their partner’s status.

Among those (128) who reported knowing their HIV status, the median time since diagnosis was 33 months (IQR 7-60). While 92% reported having a CD4 blood specimen taken, only 52% (61) received the result.

At the time of the HBCT-Plus visit, 83% (15) of those with CD4 counts at or under 200 cells/mm3 were not on ART, although eligible for treatment.

The numbers of HIV-positive participants who reported ever visiting an HIV clinic increased from 116 (57%) at baseline to 196 (96%) at six months (p<0.0001).

While the mean number of sex partners among HIV-positive participants did not change, reported consistent condom use increased significantly, from 44% at baseline to 68% at six months (p<0.0001).

Of the 58 couples where both partners tested, 95% mutually disclosed their status.

Comparison of plasma viral load at baseline and six months provided an objective measure of the prevention impact of HBCT-Plus, as well as its impact on HIV care linkages and starting ART.

Among those with CD4 counts of 200 or less at baseline, the percentage of those with viral load suppression (under 1000 copies/ml) increased from 20 to 80% (p=0.01) and, for those with CD4 counts of 350 or less, from 44 to 63% (p=0.02).

Implementation of South Africa’s new treatment guidelines – starting ART at 350 cells/mm3 or less – began three months into the pilot so it was encouraging, write the authors, to see a high proportion of viral suppression among those with CD4 counts of 350 or less.

With only 46% (22) of those with CD4 counts of 350 or less at baseline starting ART between the three-month visit and the six-month follow-up visit, when viral load was measured, incomplete viral load suppression is probable: “…thus the reduction in viral load and infectiousness we observed is a conservative measure of the program’s impact, given the expanding ART guidelines in South Africa and relatively short...follow-up interval.”

A recent modelling paper has estimated that, with 90% annual HIV testing of adults and treatment according to current South African guidelines, the programme would break even within two years, due to savings made through averting new HIV cases.

The authors conclude: “Further evaluation of this model in diverse African settings should be undertaken to evaluate the impact and cost-effectiveness of HBCT and to inform national HIV treatment and prevention programs.”

Reference

van Rooyen H et al. High HIV testing uptake and linkage to care in a novel program of home-based HIV counselling and testing with facilitated referral in KwaZulu-Natal, South Africa. J Acquir Immun Defic Syndr, advance online edition, doi: 10.1097/QAI.0b013e31829b567d, 2013.

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