Home‐based HIV voluntary counseling and testing in developing countries
Abstract
Background
The low uptake of HIV voluntary counseling and testing (VCT), an effective HIV prevention intervention, has hindered global attempts to prevent new HIV infections, as well as limiting the scale‐up of HIV care and treatment for the estimated 38 million infected persons. According to UNAIDS, only 10% of HIV‐infected individuals worldwide are aware of their HIV status. At this point in the HIV epidemic, a renewed focus has shifted to prevention, and with it, a focus on methods to increase the uptake of HIV VCT. This review discusses home‐based HIV VCT delivery models, which, given the low uptake of facility‐based testing models, may be an effective avenue to get more patients on treatment and prevent new infections.
Objectives
(1) To identify and critically appraise studies addressing the implementation of home‐based HIV voluntary counseling and testing in developing countries.
(2) To determine whether home‐based HIV voluntary counseling and testing (HBVCT) is associated with improvement in HIV testing outcomes compared to facility‐based models.
Search methods
We searched online for published and unpublished studies in MEDLINE (February 2007), EMBASE (February 2007), CENTRAL (February 2007). We also searched databases listing conference proceedings and abstracts; AIDSearch (February 2007), The Cochrane Library (Issue 2, 2007), LILACS, CINAHL and Sociofile. We also contacted authors who have published on the subject of review.
Selection criteria
We searched for randomized controlled trials (RCTs) and non‐randomized trials (e.g., cohort, pre/post‐intervention and other observational studies) comparing home‐based HIV VCT against other testing models.
Data collection and analysis
We independently selected studies, assessed study quality and extracted data. We expressed findings as odds ratios (OR), and relative Risk (RR) together with their 95% confidence intervals (CI).
Main results
We identified one cluster‐randomized trial and one pre/post‐intervention (cohort) study, which were included in the review. An additional two ongoing RCTs were identified. All identified studies were conducted in developing countries. The two included studies comprised one cluster‐randomized trial conducted in an urban area in Lusaka, Zambia and one pre/post‐intervention (cohort) study, part of a rural community cohort in Southwestern Uganda. The two studies, while differing in methodology, found very high acceptability and uptake of VCT when testing and or results were offered at home, compared to the standard (facility‐based testing and results). In the cluster‐randomized trial (n=849), subjects randomized to an optional testing location (including home‐based testing) were 4.6 times more likely to accept VCT than those in the facility arm (RR 4.6, 95% CI 3.6‐6.2). Similarly, in the pre/post study (n=1868) offering participants the option of home delivery of results increased VCT uptake. In the intervention year (home delivery) participants were 5.23 times more likely to receive their results than during the year when results were available only at the facility. (OR 5.23 95% CI 4.02‐6.8).
Authors' conclusions
Home‐based testing and/or delivery of HIV test results at home, rather than in clinics, appears to lead to higher uptake in testing. However, given the limited extant literature and the limitations in the included existing studies, there is not sufficient evidence to recommend large‐scale implementation of the home‐based testing model.
PICOs
Plain language summary
Home‐based HIV voluntary counseling and testing (VCT) in developing countries
The HIV AIDS epidemic remains a significant global problem, with the brunt of the epidemic borne by developing countries. Diagnosis and control of the infection depends on affected individuals seeking and knowing their HIV status and changing their behavior to remain uninfectedor, if already HIV‐infected, to seek to change their behavior in order to avoid infecting others. The uptake of VCT remains low, particularly in developing countries, and some of the challenges include ease of getting an HIV test. Researchers theorised that providing HIV testing and or results in homes would lead to wider acceptance of HIV testing.
Worldwide, it is estimated that 38 million people are infected with HIV, with over 90% in developing countries and 64% in sub‐Saharan Africa alone (24.5 million). In developing countries, only about 10% of those who need VCT have access to it. Challenges of HIV testing in those countries include the difficulty and cost of obtaining an HIV test. The objective of this review was to identify and critically appraise studies addressing the implementation of home‐based HIV voluntary counseling and testing in developing countries, and to determine whether home‐based HIV voluntary counseling and testing (HBVCT) is associated with improvement in HIV testing outcomes compared to facility‐based models.
The two trials found to meet our inclusion criteria were both done in developing countries and, together, involved 2,717 participants. The researchers compared acceptance of home‐delivered testing or receiving HIV test results to clinic‐based testing and receiving HIV test results. This review of two trials did not find sufficient evidence to recommend home‐based VCT, although our results suggested that it led to better acceptance of HIV testing.
