Offering people the opportunity to self-test at home and
then start antiretroviral therapy after counselling at home, together with home
delivery of antiretroviral drugs, increased the number of people linked to care
after testing and started on treatment almost threefold, a randomised study in
Malawi has shown.
The findings, presented this month at the 20th
Conference on Retroviruses and Opportunistic Infections (CROI 2013) in Atlanta, are the
latest from a series of studies that have looked at task-shifting and improving
the ways in which people in need of antiretroviral treatment are linked to care
in sub-Saharan Africa.
Self-testing for HIV, using the OraQuick oral HIV antibody
test, is a progression from door-to-door counselling and testing, which has
been found highly acceptable in a number of countries in sub-Saharan Africa.
Self-testing, in which people carry out the test themselves without a third
party present, may overcome barriers such as the need to attend a health
facility for testing, or the need to disclose immediately to other family
carried out by the ZAMBART research programme in Lusaka, Zambia, found that
self-testing was highly acceptable, and around 92% of those who carried out a
self-test were able to read the result correctly.
"Less than a quarter of African adults test for HIV
each year, making better access to HIV-testing in the community a critical area
for improvement. Self-testing has a lot of promise, but there is little
to be gained if people who test positive do not access treatment,” said Dr
Peter Macpherson of Liverpool School of Tropical Medicine and the Malawi-Liverpool-Wellcome
Clinical Research Programme, the study’s prinicipal investigator.
“Loss to follow-up before accessing HIV care is a real
danger following any positive HIV test, especially in poor communities like our
study site in Malawi,” he added. “Self-testing is only just now coming to
Africa, with understandable concerns around linkage into HIV care that are
still very much unknown.”
Offering people the opportunity to be linked to care in
their own home, by receiving home visits for counselling and treatment
preparation, and then beginning treatment with medication delivered to their
home, might reduce loss to follow-up.
The study of self-testing and linkage to care took place in
Blantyre, Malawi, in an urban neighbourhood with an HIV prevalence estimated at
18%. The study compared 14 neighbourhood clusters, each comprising
approximately 1200 adult residents (16,600 in total), that were randomised
equally to receive one of two interventions:
Self-testing available on request in the
community, with antiretroviral initiation at home and delivery of medication
and monitoring by community health workers at home, for the first two weeks of
Self-testing available on request in the
community, and referral to a local primary health clinic for care.
The primary endpoint of the study was the proportion of all
adult cluster residents who initiated antiretroviral therapy, whether at home
or in the clinic (people in clusters randomised to home initiation had the
option of starting treatment at the clinic, rather than at home, if they
The proportion of all residents who self-tested, and the
proportion who disclosed a positive result to a community counsellor, were
Overall, 58% of adult residents in the study clusters
availed themselves of the opportunity to test for HIV at home. Uptake was
highest during the first month of the six-month study, but remained
consistently higher in the clusters where treatment initiation at home was
Self-testing was somewhat higher in the home treatment
initiation group – 64.9 vs 52.7%, a non-significant difference, but people who
self-tested in the home treatment clusters were significantly more likely to
disclose a positive result to a community counsellor (6 vs 3.3%, risk ratio
1.86, 95% confidence interval, 1.16-2.97), due to the fact that home treatment initiation could only be
accessed through a community counsellor.
People in the home treatment clusters were also
significantly more likely to initiate antiretroviral therapy. Indeed, home
treatment initiation almost tripled the rate of treatment initiation, compared
with either the standard of care clusters or the background rate of treatment
initiation at local health facilities in an equivalent prior to the study.
Overall, 2.2% of the population in the home treatment
initiation clusters started treatment during the study period, compared with
0.7% of the population in the standard of care clusters, a risk ratio of 2.94
(95% CI 2.1-4.12). The researchers estimated that 46% of eligible treatment-naive adults (CD4 counts
<350 cells/mm3) started ART in the home treatment initiation
clusters, compared with 15% in the control arm.
Peter Macpherson told aidsmap:
“We have no formal
qualitative data yet on why home initiation of care was so much more
acceptable. Anecdotally and from previous work with patients accessing services
through the routine clinic system, we know that they find the pre-ART care
pathway to be challenging, requiring multiple expensive facility visits.
Facilities are also reported to be busy and clinicians perceived to be rushed.
Patients who received home initiation reported that they appreciated the
confidential and convenient nature of the services.”
“We are excited
by these results, showing that high uptake of ART can be achieved through
self-testing, provided that the right kind of support is available,” said Peter Macpherson. “This is
an approach that could be rapidly scaled-up as part of community HIV testing
programmes to improve access to ART. Importantly, our results suggest
that most people who have self-tested
positive do need extra help to get them into HIV care in a timely fashion – so
that this type of additional intervention may need to be factored in from the