Couples counselling and testing has been shown to increase behaviour change among couples in some settings, and is now seen as a high priority in many African countries with mature epidemics, where a high proportion of HIV transmissions are estimated to be taking place within stable partnerships, either due to infection acquired prior to the current partnership, or due to a concurrent sexual partnership. 35, 36
Couples counselling and testing involves counsellor-assisted mutual disclosure. The counselling provided is based on the results of both partners. Reduction in incidence in discordant couples has been reported.37 According to Elizabeth Marum of the CDC’s Global AIDS Program, it’s estimated that 35 to 75% of heterosexual transmissions could be prevented with couples counselling and testing. Expansion of couples testing to non-cohabiting couples has been proposed as the logical next step in promoting awareness of serostatus within couples.38
An initiative supported by the US President’s Emergency Plan for AIDS Relief (PEPFAR) HIV counselling and testing technical working group with the Zambia Emory HIV research group (ZEHR) and in collaboration with several African countries, to provide south-to-south technical assistance and training for expansion of couples HIV counselling and testing has begun.39
Door-to-door or home-based counselling and testing: examples from Uganda
Door-to-door or home-based testing has been piloted in Uganda and is being rolled out to other countries. It is proving to be a viable option supplementing traditional client-initiated testing and counselling in some settings, in particular in communities with high HIV prevalence and low knowledge of HIV status.
Two Ugandan studies reported on at the Sixteenth Conference on Retroviruses and Opportunistic Infections (CROI 2009) illustrate this.40, 41
The first, in south-eastern Uganda, compared the ability of home-based to clinic-based antiretroviral treatment programmes to encourage testing and counselling among household members of those receiving treatment.
Patients who received their antiretroviral therapy from the clinics were given vouchers to give to their household members for free testing and counselling. Household members of those who received their medications at home were offered home-based counselling and rapid testing.
Of the 7184 eligible household members recruited, 67% were in the home-based arm. 89% of household members who were available during home visits accepted the offer of counselling and testing. Household members in the home-based arm were more likely to take an HIV test than those in the clinic arm (p = 0.001). Moreover, home-based testing and counselling diagnosed 56% of all HIV-positive diagnoses compared to 27% in the clinic arm.
The authors noted that fewer young male household members had been recruited, possibly because they were away at work during home visits. They proposed increased outreach work to target this population and recommended expansion of home-based testing and counselling together with increased efforts to identify and address those issues that prevent people from accessing counselling and testing services.
The second study, from 2005-2007 in Bushenyi district, examined the outcomes of door-to-door testing and counselling using district-wide surveys one month prior to and one month after completion of the PITC intervention. Survey respondents were aged 18 to 49 and questions included HIV testing history, HIV risk behaviours and HIV-related stigma.
Testing uptake increased from 20% at baseline to 63% at completion (p < 0.01). An overall increase from 72 to 81% (p = 0.04) was reported in status disclosures. However for positive disclosures the increase was not significant. (p = 0.20)
The study revealed improvements in measures of stigma. For example, people were more (p = 0.01) willing to buy vegetables from an HIV-positive shopkeeper and felt that a person who discloses his/her HIV-positive status to their spouse is deserving of more respect.
While no real change in overall condom use (16% at base line compared to 14% at follow-up) was observed, there was a highly significant increase in condom use by HIV-positive men from 6% at baseline compared to 55% at follow-up (p = 0.02).
The authors note, door-to-door testing has increased uptake, eased disclosure, improved condom use among HIV-positive men and reduced HIV-related stigma.
Studies overall indicate acceptance of door-to-door or home-based testing is high, ranging from approximately 85% to 95%. It ensures privacy and minimises any inconveniences, for example, transportation issues and child care, as well as reducing perceived stigma. 42
High acceptance of repeat population-based PITC in rural Malawi
In settings or groups with high HIV incidence and prevalence, it is important to find ways to facilitate regular HIV testing, to ensure that individuals have up-to-date knowledge of their HIV status.
But establishing a culture of repeat testing is not easy, especially given the need for the over-stretched health system to reach those who have never tested at all.
The Malawi Longitudinal Study of Families and Health (MLSFH) was undertaken to examine the acceptability of repeat PITC in a rural area.
In 2004 91% (2983) of individuals offered an HIV test agreed to provide samples for HIV testing. The blood samples were collected by trained nurses using oral swabs and sent to the project’s laboratory where enzyme-linked immunosorbent assays (ELISA) and confirmatory Western blot tests were done.
Participants received test results (within two to four months) and post-test counselling through mobile testing and counselling clinics (tents) set up an average distance of about two kilometres from the participants’ homes.
A small random lottery was run to determine whether a monetary incentive would motivate participants to come back for their test results. Given that the majority of people within this region subsist on less than one US dollar a day, it was not surprising that most participants with lucky numbers for a financial reward of the equivalent of US$1 returned for their test results.
In 2006 repeat tests were offered using rapid tests (parallel DetermineTM and UniGold tests) in the participants’ homes, with no monetary incentive. The participants had a choice between receiving same-day test results at their homes or later at a mobile clinic. The majority chose to receive same-day test results at their homes. The participants and testing counsellors together disposed of the used testing kit in pit latrines at the participants’ homes to ensure confidentiality and to allay participants’ suspicions.
Approximately 75% of those who were tested and obtained results in 2004 were contacted for a repeat test. 92% (2758) of participants contacted agreed to take an HIV test in 2006. Nearly all those who received negative results in 2004 were likely to test again in 2006 (p = 0.01). Whereas, only about half of those who tested positive in 2004 were contacted for 2006 testing and about 80% of them accepted the repeat test and obtained their results. The authors attributed this difference to differential morbidity and mortality by HIV status. They noted that some people who tested positive for HIV in 2004 might have died or were hospitalised with HIV-related infections by 2006.
Overall, about 90% of those who were contacted accepted PITC over the two years, signifying high testing uptake. The authors found that distance to the testing centre negatively affected testing uptake and the greatest advantage of home testing is reduced cost of travelling to the clinics. In 2004, the nearest testing clinic to one of the study sites was about three hours bus journey at a cost of about US$4 equivalent.
The authors also felt that home testing might have reduced the psychosocial costs of coping with unfamiliar urban settings that the participants faced when they went for testing at urban clinics, and allayed the general perception that health professionals at the hospitals are unfriendly. The authors further attributed the success of the 2006 repeat test to rapid testing, noting that the time lag of about four months between test and results in 2004 may have reduced PITC uptake.
Availability of treatment in 2006 was another motivation for testing, the authors found. Public awareness created through the first Malawi national testing week campaigns that ran prior to the testing survey may also have played a role.
The authors noted that the majority of the participants received negative test results and because they might have over-estimated their chances of testing positive, the disclosure of negative test results may well have motivated others to test too (to find out if they also were negative).
The authors concluded that repeat door-to-door PITC was almost universally accepted in rural Malawi and is likely to be similarly acceptable in other rural settings if context-specific barriers are tackled and individuals who have already tested can later be located for repeat testing.
Testing and counselling as part of a 'combination prevention' approach: Project Accept
Project Accept is the first international multi-site community randomised controlled study to look at the potential success of multi-level structural HIV prevention interventions and measure the impact on HIV incidence and reduction in stigma. It aims at increasing HIV knowledge, changing community norms, increasing testing uptake and increasing social support for people living with HIV (PLHIV). It is an example of a prevention programme which integrates testing into a wide-ranging package of activities targeting the whole community, in order to develop a climate in which knowledge of HIV status is more likely to result in sustained behaviour change.
The trial is being carried out by a team of international researchers and is based in four different countries: at one site in Tanzania (Kisarawe), Zimbabwe (Mutoko), Thailand (Chiang Mai) and in two sites in South Africa (Soweto and Vulindlela).
The community participants are randomised into either control or intervention communities. Control communities belong to the “standard-of-care” arm and receive clinic-based testing and counselling within existing hospitals and health centres. The project has set up clinics reflective of local services for the Tanzanian and Zimbabwean sites because there were no existing counselling and testing services. There has been no active recruitment beyond the standard procedures used by local clinics to promote testing for the control group.
The intervention arm provides participants with community mobilisation, community-based mobile testing and counselling and post-test support services (PTSS). The intervention uses three key strategies based on different theories.
Community mobilisation (CM) is aimed at increasing HIV testing and free discussion about HIV through community outreach work. This is based on “diffusion theory’’ which asserts that in every community there are a small number of people who adopt changes ahead of everyone else (early adopters) and then influence others in their social networks.
Each site has a co-ordinator who supervises a community working group made up of community leaders, gatekeepers and community health workers most of whom are early adopters of testing and counselling. There are outreach workers who disseminate all relevant information through print-outs, one-to-one and group discussions. They do this around mobile testing sites, door-to-door campaigns, at community meetings or social events. Lastly, community-based outreach volunteers ‘diffuse’ (relay) the intervention throughout their networks of friends and colleagues after being trained.
Community-based HIV mobile voluntary counselling and testing (CBVCT) is aimed at increasing access to testing and counselling and normalising HIV status within the communities. This component uses “tipping point theory” which asserts that a turning point (tipping point) occurs when a certain level of adoption takes place in a social network. This implies that when more people accept testing and counselling, a point would be reached when testing and talking about HIV would become a routine activity for the community thus reducing stigma.
This component is also meant to remove structural barriers to testing and counselling for example, testing fees, transport costs and waiting times for the results by providing testing and counselling services at the village level. Easy access to testing and counselling would increase testing rates, change social norms about testing and increase HIV awareness and discussions in the community so decreasing HIV transmission risks.
The community testing locations are primarily social places, for example, like markets and transport centres, identified in consultation with the community. The four African sites offer testing and counselling services in tents and caravans while the Thailand site uses community centres and temples. Each site has a schedule for the mobile unit’s visits which include weekdays and weekends as well as evenings to allow access for those community members in full-time employment.
Counsellors obtain informed consent. Counselling sessions include a condom demonstration with participants being given condoms to take home. Rapid tests with same-day results are offered to all testing and counselling participants but those who wish to receive their results later are given identification cards with details of the next mobile team’s visit. To reduce stigma, the mobile team also serves people only seeking information without testing. Regardless of test results, all participants are referred to post-test support services.
Comprehensive post-test support services (PTSS) are aimed at improving the psycho-social health of PLHIV and helping those who test negative to maintain their negative status, by providing a culturally relevant support system. It is based on “social action theory” which argues that health protective behaviours are the result of 1) an individual’s ability to exercise self-control 2) the influence of external factors, for example, whether an individual is in a relationship or not and 3) the individual’s response to internal emotional states.
The investigators anticipated that PTSS would improve the individual’s technical skills, for example consistent condom use, social skills including safer sex negotiations as well as interpersonal skills which might include problem-solving skills, all of which could help reduce HIV transmission. Support groups in conjunction with coping effectiveness training and stigma reduction workshops help PLHIV to manage depression and stress.
From the preliminary results, the researchers found that community-based testing and counselling resulted in a fourfold increase in uptake. These findings are similar to other studies showing that home-based testing and counselling increases testing uptake.43, 44
Results also show that most ‘intervention communities’ used mobile testing services provided by Project Accept rather than standard testing clinics. However, in Thailand about a third of individuals from intervention groups took their tests at standard community testing centres compared to two-thirds taking a test at the mobile testing centres.
The investigators attributed this to the fact that unlike in the African sites, standard testing clinics in Thailand are easily accessible to the community. Overall, very few control communities sought testing from neighbouring intervention communities (17 individuals in Zimbabwe, 7 in Tanzania and 23 in Thailand).
The researchers concluded that increased uptake of testing and counselling in the intervention communities in all three African sites and the utilisation of clinic-based standard testing by intervention communities in Thailand validated the theoretical background of the study. They noted that this intervention was designed for use in resource-limited settings and its implementation is relatively cheap because it relies heavily on volunteers and peer support. While this is in line with WHO’s recommendation that interventions should be simple and inexpensive, it assumes a ready supply of volunteers.
The cost and effectiveness of four HIV testing and counselling strategies in Uganda 45, 46
Although new methods of providing testing are emerging, there is still little in the way of cost-effectiveness data to guide decision-making about which interventions are the best use of resources. Previous studies have shown that cost per test and counselling-service user at a stand-alone centre is about US$13-36.
Uganda was the first sub-Saharan African country to offer HIV client-initiated testing and counselling by 1990. However, population testing is still low with indications of increasing sexual risk-taking that could lead to increased HIV prevalence in the country.47
The conventional testing and counselling method used in Uganda is client-initiated. People who want an HIV test can go to free stand-alone clinics. Recent technologies have revolutionised testing leading to more PITC strategies that involve taking testing and counselling to the communities.
A recent study compared costs and effectiveness of four different testing and counselling strategies used in Uganda:
- The first is stand-alone testing and counselling. A conventional client-initiated set-up where attendance is promoted through campaigns such as posters placed at clinics and other strategic locations. It involves group counselling with key messages repeated to an individual in private pre-test and post-test sessions. Those with a positive diagnosis are referred to local health services for follow-up.
- The second is hospital-based testing and counselling. A PITC intervention offered to all patients with unknown HIV status seeking health services regardless of their illness, with an opt-out option. Those who test positive are referred to further care. However, it identifies many people with HIV at very low CD4 cell counts, often too late to benefit from effective treatment.
- The third strategy is door-to-door testing and counselling using mobile teams to offer testing and counselling to individuals in their homes. It is offered to all adults and children under 14 years of age whose mothers are infected, deceased or of unknown HIV status. It involves initial group counselling for family members followed by pre- and post-test counselling for those accepting the test. It has the potential to reduce testing barriers, reach underserved populations and increase couples testing.
- Lastly, household-member testing and counselling is where testing and counselling is offered to individuals in their homes targeting household members of those who have had a positive HIV diagnosis. Voluntary consent of the household member who has already tested positive is sought. All adults and children under 14 years of age whose mothers are infected, deceased or of unknown HIV status are offered a test.
The authors collected data from the project accounts and inventories as well as from interviews with the projects’ personnel. Cost-effectiveness analyses were performed to compare the average crude cost per person tested, the cost per new testing and counselling client (those who never tested before) and the cost per new HIV-positive diagnosis.
Results showed that household-member testing and counselling reached more people under 15 years of age, compared to the other three strategies while hospital-based testing and counselling received more (68%) female service users, possibly through antenatal care. The three provider-initiated interventions attracted more first-time testers and recorded testing and counselling acceptance of around 99% with the door-to-door service recording the highest number of couples tested.
The authors also found that stand-alone and hospital-based testing and counselling recorded the highest service-user HIV prevalence suggesting that many people who sought hospital care were already infected and ill. Hospital-based testing and counselling identified more people with lower CD4 cell counts (< 200 copies/mm3) whereas door-to-door testing and counselling identified more individuals with higher CD4 cell counts.
Lastly, the researchers found that the PITC cost less (range, US$8-15) per new client and client tested than conventional stand-alone client-initiated testing and counselling (US$20-30). Door-to-door testing and counselling was found to be the least expensive per client tested (US$8.30) and cost effective in reaching new service users (US$9.30). On the other hand, hospital-based testing and counselling was the most cost effective in identifying HIV-infected individuals at an average cost of about US$43 per patient tested positive.
This evidence suggests that door-to-door testing is cost effective in screening for population level HIV incidence whereas hospital-based testing is best for diagnostic purposes to confirm whether reported or observed illnesses are as a result of seroconversion.