Abstract
BackgroundOnly approximately one in five adults are offered HIV testing by providers when seeking care for symptoms of acute illness in Sub-Saharan Africa. Our aims were to estimate testing coverage and identify predictors of provider-initiated testing and counselling (PITC) and barriers to PITC implementation in this population.MethodsWe assessed HIV testing coverage among adult outpatients 18–39 years of age at four public and two private health facilities in coastal Kenya, during a 3- to 6-month surveillance period at each facility. A subset of patients who reported symptoms including fever, diarrhoea, fatigue, body aches, sore throat or genital ulcers were enrolled to complete a questionnaire independently of PITC offer. We assessed predictors of PITC in this population using generalised estimating equations and identified barriers to offering PITC through focus group discussion with healthcare workers (HCW) at each facility.ResultsOverall PITC coverage was 13.7% (1600 of 11,637 adults tested), with 1.9% (30) testing positive. Among 1,374 participants enrolled due to symptoms, 378 (27.5%) were offered PITC and 352 (25.6%) were tested, of whom 3.7% (13) tested positive. Among participants offered HIV testing, 93.1% accepted it; among participants not offered testing, 92.8% would have taken an HIV test if offered. The odds of completed PITC were increased among older participants (adjusted odds ratio [aOR] 1.7, 95% confidence interval [CI] 1.4–2.1 for 30–39 years, relative to 18–24 years), men (aOR 1.3, 95% CI 1.1–1.7); casual labourers (aOR 1.3, 95% CI 1.0–1.7); those paying by cash (aOR 1.2, 95% CI 1.0–1.4) or insurance (aOR 3.0, 95% CI 1.5–5.8); participants with fever (aOR 1.5, 95% CI 1.2–1.8) or genital ulcers (aOR 4.0, 95% CI 2.7–6.0); and who had tested for HIV >1 year ago (aOR 1.4, 95% CI 1.0–2.0) or had never tested (aOR 2.2, 95% CI 1.5–3.1). Provider barriers to PITC implementation included lack of HCW knowledge and confidence implementing guidelines, limited capacity and health systems constraints.ConclusionPITC coverage was low, though most patients would accept testing if offered. Missed opportunities to promote testing during care-seeking were common and innovative solutions are needed.
Highlights
HIV testing remains the gateway to HIV prevention, treatment, care and other support services
To achieve universal test coverage, the World Health Organization (WHO) in 2007, recommended an “opt-out” testing approach known as Provider-Initiated HIV Testing and Counselling (PITC), in which an HIV test is offered to all patients attending health facilities in countries with generalised epidemics as a standard part of medical care [1]
Using data from the observational phase of a stepped-wedge trial of an HIV-1 RNA testing intervention that enrolled patients aged 18–39 years who sought urgent care for symptoms of acute infectious illness, we aimed to describe provider-initiated testing and counselling (PITC) coverage and factors associated with completed HIV testing in this population
Summary
HIV testing remains the gateway to HIV prevention, treatment, care and other support services. A review looking at the operational implementation of PITC among non-pregnant adults in sub-Saharan (SSA) settings highlighted challenges in PITC implementation [2], with coverage estimated at only 20% [3]. PITC coverage has been lowest in general outpatient settings, despite a high yield of new HIV diagnosis [4,5,6]. Population survey data in 2012 indicated that only a third (34%) of adults 15–64 years, visiting a health facility were offered an HIV test, despite high acceptability (91.5%) among those offered testing [15]. Our aims were to estimate testing coverage and identify predictors of provider-initiated testing and counselling (PITC) and barriers to PITC implementation in this population
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