A pilot project which used a peer recruitment strategy,
financial incentives and the involvement of people living with HIV has
demonstrated that this approach can increase demand for HIV testing services
and efficiently identify people with HIV, report Sandra McCoy and colleagues in
the Journal of Acquired Immune Deficiency
But the project was not as successful as a Centers
for Disease Prevention and Control (CDC) study which demonstrated the
viability of this approach four years ago. In particular, a significant number
of those testing HIV positive had, in fact, been previously diagnosed – perhaps
suggesting that the $10 gift card exerted too powerful a pull in the low-income
community where the project was conducted.
Four different community organisations, offering HIV testing
at mobile or storefront locations, implemented the pilot in Oakland, California
in 2011. Just across the water from San Francisco, Oakland is a much poorer
city in which 46% of late HIV diagnoses are in African Americans. As older age
groups are more likely to have late diagnosis, the pilot focused on people aged
30 to 60 who identified as African American or Black.
The pilot began with the recruitment of 48 initial
participants. These individuals were provided with HIV testing and counselling
themselves (unless they already had diagnosed HIV) and were then asked to
recruit up to three other people to the study. These individuals were provided
with HIV testing and counselling, then asked to recruit three more people, and
so on. This peer recruitment approach is known as respondent
driven sampling (RDS).
Through successive waves of recruitment, a further 243 people
took part. Only 45% of the participants recruited someone else.
Financial incentives – described below –
were offered to all.
Participants were predominantly male, heterosexual and poor – three-quarters earned less than $10,000 a year and half had been homeless in
the last year. The average age was 47.
When recruiting, participants were encouraged to approach
people who might need to be connected to services. (The researchers deliberately
avoided targeting recruitment on the basis of sexual or drug-using behaviours,
which may be stigmatised and undisclosed.)
Participants were successful in recruiting from the priority
groups that had been specified – 23% of new recruits had never been tested for
HIV; 72% had not been tested in the last year; 81% had never used services
at the organisation providing testing; and 10% had been in prison in the last
A key outcome of interest was the number of participants
testing HIV positive. As a benchmark, at other HIV testing services provided by
the four community organisations, 16 of 2471 tests were positive (0.6%). This
corresponds to needing to test 154 people to find an individual with HIV.
Among those testing within the pilot (excluding the initial
participants, some of whom were known to have diagnosed HIV), 9 of 243
individuals were diagnosed with HIV (3.7%). This corresponds to needing to test
27 people to find an individual with HIV.
This would have seemed to be a particularly effective way of
identifying people with undiagnosed HIV had the researchers not checked the
public health department’s surveillance records. This revealed that seven of
the nine who’d tested positive were in fact previously diagnosed, including four
who had dropped out of medical care. Project staff ensured they reconnected
with care, “an unintended outcome of our study that nevertheless has public
health value”, say the authors.
However, with only two people testing positive for the first
time, prevalence comes down to 0.8%. The number needed to test in order to find
a person with HIV is 122, which is comparable to the figure for standard
The study had deliberately recruited some initial
participants who already had diagnosed HIV (10 of the 48). Other studies have shown
that people with HIV are more successful at recruiting people in need of
testing, and this appeared to be the case in this study, although the
difference was not statistically significant. In networks begun by a person
with HIV, 79% of recruits were considered to have high-risk behaviours or were
HIV positive, compared to 67% in networks begun by an HIV-negative person.