Loss of lay counsellors leads to fall in HIV testing in KwaZulu-Natal

The withdrawal of lay counsellors from primary health clinics in KwaZulu-Natal led to a sharp fall in the number of people taking an HIV test in 2015, a study published in advance online in the journal AIDS has shown. The findings highlight the important role that lay counsellors play in increasing the number of people diagnosed with HIV in a sub-Saharan African setting, the researchers say.

Lay counsellors may provide HIV counselling and testing at health facilities, as well as adherence support and HIV treatment education to people preparing for treatment. Lay counsellors take on tasks that do not require extensive medical training, freeing healthcare workers to do other work. This process, known as task shifting, has been adopted in many African countries in order to increase the capacity of the health system to provide HIV treatment.

Lay counsellors are used in different ways in sub-Saharan Africa. Even in South Africa, employment practices vary – including rates of pay and the types of work that lay counsellors may be called on to do. Not every facility uses lay counsellors, and in 2014 lay counsellors in KwaZulu-Natal began to be redeployed, leaving some clinics without their help.



In discussions of consent for medical treatment, the ability of a person to make a decision for themselves and understand its implications. Young children, people who are unconscious and some people with mental health problems may lack capacity. In the context of health services, the staff and resources that are available for patient care.

task shifting

The delegation of healthcare tasks usually performed by more highly trained health personnel to those with less training, such as nurses and community health workers. Task shifting has allowed HIV services to be scaled up, especially in resource-limited settings.

test and treat

A public health strategy in which widespread HIV testing is facilitated and immediate treatment for those diagnosed with HIV is encouraged.


In the context of drugs or alcohol, withdrawal is when a person cuts out, or cuts back, on using the substance, also known as detoxification or detox. In a context of sexual risk reduction, it refers to the insertive partner in penetrative sex withdrawing before ejaculation. It is not a particularly effective way to lower the risk of HIV transmission or pregnancy.


The Joint United Nations Programme on HIV/AIDS (UNAIDS) brings together the resources of ten United Nations organisations in response to HIV and AIDS.

The redeployment was designed to address the lack of career development opportunities for lay counsellors. Lay counsellors complain of a lack of training and support and lack of payment. Lay counsellors were offered training in nursing and social work from the beginning of 2015 but were not replaced with a new cadre of lay counsellors. Instead, nurses or remaining lay counsellors were expected to take up their work.

MSF video on lay counsellors in KwaZulu-Natal, 2016

Researchers from Duke University, Heidelberg University and Harvard University’s T.H. Chan School of Public Health looked at the impact of lay counsellors on the uptake of HIV testing by comparing HIV testing rates before and after the removal of lay counsellors from nine clinics in the uMlalazi district of KwaZulu-Natal. Redeployment began in January 2015 and was completed in a second wave in June 2015.

The study compared testing rates in 2014 and after each wave of redeployment. In 2014 the clinics employed 27 lay counsellors, 15 between January and May 2015 and six in the period June-December 2015.

A total of 24,526 HIV tests took place at the nine clinics, two-thirds in the period prior to redeployment. A further 21% of tests took place between January and May 2015, and 13% between June and December 2015. The average number of tests fell from 93 women and 37 men tested per month in 2014 to 35 women and 15 men tested per month by the second half of 2015.

Analysis of individual clinics showed that HIV tests per month declined markedly in five out of nine clinics as lay counsellor numbers fell and remained stable only in two clinics, one of which was able to retain two lay counsellors until the end of the study period. Overall, HIV testing numbers fell by 4.9% for every 10% loss of lay counsellor capacity. Losing one lay counsellor was associated with 30 fewer HIV tests at a clinic each month (P < 0.001).

The researchers say that their findings “support the recent announcement by UNAIDS that it will lead a major international effort to train and deploy two million additional community health workers in sub-Saharan Africa (with a primary focus on HIV)” by 2020.

They point out that 'test and treat' policies will require widespread and regular HIV testing to achieve the goals of 90% of people with HIV diagnosed by 2020. Increasing testing capacity will be essential and lay counsellors will be one essential element in increasing capacity, the authors conclude.


Hu J et al. The impact of lay counsellors on HIV testing rates: quasi-experimental evidence from lay counsellor redeployment in KwaZulu-Natal, South Africa. AIDS, advance online publication, 14 June 2018.