UK could look to Kenyan scheme as a way of increasing HIV testing in African communities

A voluntary counselling and testing (VCT) project developed in Africa has the potential to be successfully translated to the UK and could help reduce the high levels of undiagnosed HIV infection in the UK’s African community, according to research published in the December edition of Sexually Transmitted Infections.

But members of the African community drew attention to some potential barriers to service uptake, including concerns about stigma and confidentiality, and professionals raised concerns about onward referrals to HIV services and the appropriate training of testing staff.

Africans continue to be one of the groups most affected by HIV in the UK. In 2005, two-thirds of all new HIV diagnoses in the UK were among black and minority individuals, most of whom were from Africa. It is estimated that as many as a quarter of HIV-positive Africans in the UK are undiagnosed, and this contributes to the high burden of HIV-related illness and death observed in Africans in the UK.

Experts from around Europe recently met to discuss how rates of late HIV diagnosis could be reduced. Some of the strategies already being employed in the UK include opt-out HIV testing for all pregnant women, offering opt-out HIV tests to patients attending sexual health clinics, and offering an HIV test to patients with symptoms suggestive of HIV infection.

Efforts are also being made to make HIV testing more accessible, for example by offering tests in community-based organisations.

VCT projects in Africa could offer a model for community-based HIV testing in the UK. Investigators therefore undertook qualitative research to determine if such a scheme currently operating in Kenya would be acceptable to the community and viewed as feasible by NHS staff and other professionals.

The VCT scheme considered for translation was the Liverpool VCT Care and Treatment project in Kenya. It offers a one-stop, confidential service and is targeted at asymptomatic individuals who wish to know their HIV status. Trained counsellors offer pre- and post-test counselling, and administer a rapid HIV test, the result of which is available in one hour.

A total of 42 Africans from 14 different countries were recruited and participated in five different focus groups. In additional 28 ‘key informants’ participated in workshops to discuss how a community-based VCT model would translate to the UK.

There was a broad consensus that community-based VCT could be successfully offered in the UK. Community members identified several advantages of the project, including rapid testing and the bringing of HIV testing “into the community.” It was also suggested that community ownership of HIV testing could be increased through such a scheme.

But three significant barriers to the acceptance of community-based VCT became apparent. These were: fear of HIV-related stigma in the UK’s African community; anxieties about the confidentiality of a community-based service; and, concerns about the professionalism of the service.

Professionals also raised three key concerns in workshops surrounding:

• Onward-referral to NHS HIV treatment and care.
• Testing and quality control. Only NHS clinical staff are currently allowed to administer rapid HIV tests. A positive rapid test has to be confirmed by an ELISA blood test.
• Training of VCT counsellors. At the moment, community-based testing facilities must employ sexual health clinic staff. It was felt that it would be appropriate to use non-clinic staff as long as they received appropriate training and onward referrals were appropriately managed.

There was also a consensus that counsellors would need to be trained to answer questions about immigration status and entitlement to NHS HIV treatment and care and the prevention of mother-to-child HIV transmission. It was also agreed that VCT counsellors who were themselves living with HIV would need adequate support.

The investigators believe that their study has four implications for future research:

• There should be a pilot scheme to evaluate the acceptability and feasibility of community-based VCT in partnership with African communities in London.
• Regulatory organisations need to develop training guidelines for non-healthcare staff who wish to offer HIV VCT. Seconding staff from sexual health services may not be cost-effective and the service could be effectively delivered by other trained personnel.
• Over-coming the stigma that surrounds HIV in African communities is likely to be challenging, so sexual health services should be offered to Africans in culturally appropriate ways. Consideration should also be given to offering opt-out HIV testing as part of other health services in areas with a high HIV prevalence.
• The study shows the potential to learn from African service providers. The investigators comment, “learning from effective HIV service models in developing countries is an opportunity to build equitable partnerships through translational research.”