Abstract
Improving access to HIV testing is a key priority in scaling up HIV treatment and prevention services. Home-based voluntary counselling and testing (HBT) as an approach to delivering wide-scale HIV testing is explored here. We conducted a systematic review and random-effects meta-analysis of studies published between 1 January 2000 and 24 September 2012 that reported on uptake of HBT in sub-Saharan Africa, to assess the proportion of individuals accepting HBT and receiving their test result. Our initial search yielded 1,199 articles; 114 were reviewed as full-text articles, and 19 publications involving 21 studies (n = 524,867 individuals offered HBT) were included for final review and meta-analysis. The studies came from five countries: Uganda, Malawi, Kenya, South Africa, and Zambia. The proportion of people who accepted HBT (n = 474,377) ranged from 58.1% to 99.8%, with a pooled proportion of 83.3% (95% CI: 80.4%-86.1%). Heterogeneity was high (τ(2) = 0.11). Sixteen studies reported on the number of people who received the result of HBT (n = 432,835). The proportion of individuals receiving their results out of all those offered testing ranged from 24.9% to 99.7%, with a pooled proportion of 76.7% (95% CI: 73.4%-80.0%) (τ(2) = 0.12). HIV prevalence ranged from 2.9% to 36.5%. New diagnosis of HIV following HBT ranged from 40% to 79% of those testing positive. Forty-eight percent of the individuals offered testing were men, and they were just as likely to accept HBT as women (pooled odds ratio = 0.84; 95% CI: 0.56-1.26) (τ(2) = 0.33). The proportion of individuals previously tested for HIV among those offered a test ranged from 5% to 66%. Studies in which <30% of individuals had been previously tested, local HIV prevalence was <10%, incentives were provided, or HBT was offered to household members of HIV-positive individuals showed higher uptake of testing. No evidence was reported of negative consequences of HBT. HBT could substantially increase awareness of HIV status in previously undiagnosed individuals in sub-Saharan Africa, with over three-quarters of the studies in this review reporting >70% uptake. It could be a valuable tool for treatment and prevention efforts.
Highlights
Improving access to HIV testing is a key priority in scaling up HIV treatment and prevention services
National population surveys in six sub-Saharan African countries found that amongst participants living with HIV there was a wide range in the proportion of respondents aware of their status [5]
We conducted this systematic review and meta-analysis based on a pre-defined search protocol (Text S2) that conformed to the criteria set out by the Meta-Analysis of Observational Studies in Epidemiology (MOOSE) group [18] and was in accordance with the PRISMA statement (Text S1)
Summary
Improving access to HIV testing is a key priority in scaling up HIV treatment and prevention services. Home-based voluntary counselling and testing (HBT) has been suggested as an effective out-of-facility approach for identifying HIV-infected people at an earlier stage of their disease and for enrolling them into care and treatment in a timely manner [12,13,14]. Even in health care settings in which voluntary counseling and HIV testing is routinely offered, such as to pregnant women, the number of people who use these services is low. This situation is partly because of the stigma and discrimination associated with HIV, which makes people reluctant to volunteer to come forward to be tested for HIV. HBT has obvious advantages and upholds the ‘‘3 Cs’’ principles of HIV testing: that testing is confidential, accompanied by counseling, and conducted only with informed consent
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