Findings from two Ugandan studies suggest that home-based HIV counselling and testing may augment traditional HIV counselling and testing services in important ways in some settings, both by increasing acceptance and uptake of HIV testing, but also by impacting attitudes toward HIV at a population level. The results of both studies were presented to the Sixteenth Conference on Retroviruses and Opportunistic Infections (CROI) on Wednesday by Sundeep Gupta of the Centres for Disease Control, Uganda, on behalf of the investigating teams.
Home- versus clinic-based counselling and testing
One of the studies was nested within a parent trial that compared home-based and clinic-based antiretroviral treatment (ART) provision in southeastern Uganda. Prevalence of HIV is high among family members of patients receiving ART, and these infections often go undiagnosed. The objective of this nested substudy was therefore to compare the ability of the clinic- and home-based ART programmes to encourage HIV counselling and testing in household members of ART recipients.
The recipients of antiretroviral therapy, either at clinics or at home, were regarded as 'index clients'. Index clients accessing ART at clinics were encouraged to give vouchers for free HIV testing (offered at the same clinic) to their household members. Index clients in the home-based arm received visits from study representatives who provided pre-test counselling to household members and offered them rapid home-based tests.
The study identified 7184 household members, 67% of whom were in the home-based arm. Of the household members actually at home at the time of the visits, counselling and testing acceptance was 89%. The household members in the home-based arm were significantly more likely to be subsequently tested for HIV than those in the clinic-based arm (56% vs 11%). When adjusted for age and sex, this fivefold difference doubled again (adjusted odds ratio [aOR], 10.4; 95% confidence interval [CI], 7.9% – 13.7%; p
Out of household members who were tested, nearly three times more tested HIV-positive in the clinic-based arm (17% clinic-based vs 7% home-based; AOR, 2.8; 95% CI, 2.0 – 3.9; p
The investigators then estimated the total number of HIV-positive household members, based on the 7% home-based prevalence rate found above, and further estimated that the home-based study arm succeeded in diagnosing 56% (189/339) of all such HIV-positive household members, and the clinic-based arm, 27% (45/168).
Previous studies have also shown a greater uptake of home-based compared to clinic-based counselling and testing. The researchers recommended that home-based counselling and testing (HCT) efforts be expanded, and that HCT should be further researched in other contexts such as households of HIV-positive persons not on ART.
Gupta noted that home-based testing is a "clear point of entry" for HIV services, and that "the next step is to get the people we identify as HIV-positive into clinical care". Since young male household members were underrepresented in the home visits (likely because visits occurred during the daytime when the men were likely to be at work), Gupta acknowledged the need to expand outreach to try to reach these men. Finally, given the high prevalence rates found by clinic-based testing, the team recommended that efforts be made to identify and address the barriers that prevent people from accessing such testing programmes
Effects of door-to-door voluntary counselling and testing
The second study examined the outcomes of a door-to-door voluntary HIV counselling and testing (VCT) programme in Uganda’s Bushenyi district. By using district-wide surveys before and after the VCT programme, the investigators found that testing rates improved greatly after the programme, and there were decreases in HIV stigma, although sexual risk behaviour was largely unaffected.
The first (baseline) survey was conducted in January 2005, shortly before the VCT programme began; the second (follow-up) survey was conducted in March 2007, the month following the programme’s completion. Surveys were administered to adults aged 18 to 49; different sample groups were interviewed in each phase. Survey respondents were asked about their HIV testing history and HIV risk behaviours, with additional survey questions that addressed HIV-related stigma.
The baseline and follow-up surveys were given to 1402 and 1562 people respectively. The proportion of people who reported ever having been tested for HIV increased from 20% at baseline to 63% at follow-up (p
The researchers also found improvements in measures of stigma, such as increased willingness to buy vegetables from an HIV-positive shopkeeper (74% vs 83%, p
Changes in risk behaviours, however, were much less significant. There was no change in overall reported condom use for the last sexual encounter (16% vs 14%, p = 0.53). When broken down by sex and HIV status, there was a significant increase in condom use by HIV-positive men (6% vs 55%, p = 0.02), but the increase in use by HIV-positive women was not significant (19% vs 28%, p = 0.36) and there was no change among HIV-negative persons (19% vs 13%, p = 0.17). (All percentages reported as before vs. after VCT.) Other studies have yielded conflicting results as to whether VCT affects risky sexual behaviour, and in this case Gupta said that "we need to find out why this behaviour was unaffected".
The investigators also acknowledged that before-and-after surveys could not establish the VCT programme as the sole cause of the changes (for instance, PMTCT scale-up may also have been a factor), and that the duration of any such changes is unknown. Nevertheless, they concluded that VCT appeared to lead to increases or improvements in testing, disclosure, stigma, and condom use among HIV-positive men. They called for door-to-door HIV counselling and testing programmes to be expanded in high-prevalence areas, and for studies to further explore the public health impact of this approach.
Lugada E et al. Comparison of home- and clinic-based HIV counseling and testing among household members of persons taking ART: Uganda. Sixteenth Conference on Retroviruses and Opportunistic Infections, Montreal, abstract 138, 2009.
Nuwaha F et al. Population-level changes in knowledge of HIV status, stigma, and HIV risk behavior after district-wide door-to-door voluntary counseling and testing: Bushenyi District, Uganda. Sixteenth Conference on Retroviruses and Opportunistic Infections, Montreal, abstract 139, 2009.