Home-based Human Immunodeficiency Virus Research Articles

HIV Testing Uptake Among Ethiopian Rural Men: Evidence from 2016 Ethiopian Demography and Health Survey Data.

Human immunodeficiency virus (HIV) testing coverage among men remains low in Ethiopia; the problem of limited HIV testing coverage is worst in rural areas. Therefore, this study aims to identify factors associated with HIV testing uptake among rural men in Ethiopia. Data from 10,187 rural men was extracted from the 2016 Ethiopian Demography and Health Survey. All analyses were performed using the complex sample analysis procedure to account for the multistage sampling. Bivariable and multivariable regression analyses were performed to identify factors associated with HIV testing uptake. Statistical significance was defined as a 95% Confidence Interval (CI) with a p-value of less than 0.05. Overall, only 40.3% of rural men have ever been tested for HIV. Being aged 31-44 years (Adjusted Odds Ratio (AOR) =1.12, 95% CI [1.01-1.42]), living in developed regions (AOR=1.43, 95% CI [1.09-1.88]), engaging in non-agricultural activities (AOR = 1.27, 95% CI [1.05-1.52]), being Muslim (AOR = 2.07; 95% CI [1.67-2.67]), having comprehensive knowledge about HIV (AOR =1.31, 95% CI [1.12-1.54]), being from a medium (AOR = 0.56, 95% CI [0.47-0.93]) and rich (AOR = 0.80, 95% CI [0.56-0.80]) households, attending primary (AOR = 0.21, 95% CI [0.16-0.28]) and secondary (AOR = 0.35, 95% CI [0.25-0.35]) school, having their first sexual experience at the age of 17 or younger (AOR = 0.26, 95% CI [0.19-0.93]), having discriminatory attitudes towards HIV patients (AOR = 0.67, 95% CI: 0.47-0.93) and having no health insurance coverage (AOR = 0.54, 95% CI [0.42-0.69]) were significantly associated with HIV testing uptake. HIV testing uptake among rural men was low. Strengthening awareness programmes on HIV and HIV testing, integrating HIV testing with all other healthcare, strengthening partner accompany and HIV testing during pregnancy and delivery, and providing home-based HIV testing may increase HIV testing uptake.

Roles, Barriers, and Recommendations for Community Health Workers Providing Community-Based HIV Care in Sub-Saharan Africa: A Review.

While the impact of Community Health Workers (CHWs) on home-based human immunodeficiency virus (HIV) care has been documented, barriers and recommendations have not been systematically reviewed. Following the reporting requirements of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, we used an aggregative narrative synthesis approach to summarize the results of qualitative studies published between January 1, 2000, and November 6, 2020 in the following databases: PubMed, CINAHL, PsychINFO, Web of Science, and Google Scholar. In total, 17 studies met the selection criteria and were included in the analysis. They reported on a range of roles played by CHWs in HIV care, including education and health promotion; HIV-specific care (HIV testing services; screening for opportunistic infections and acute illness); medication delivery; tracing persons who had defaulted from care; and support (treatment support; referral; home-based care; and psychosocial support).Many different barriers to community-based HIV care were reported and centered on the following themes: Stigma and nondisclosure; inadequate support (lack of resources, inadequate training, inadequate funding, and inadequate monitoring); and health system challenges (patients' preference for more frequent visits and poor integration of CHWs in the wider health care system). Recommendations to mitigate these barriers included: addressing HIV-related stigma; introducing updated and relevant CHW training; strengthening the supervision of CHWs; coordinating care between the home and facilities; incorporating patient-centered mHealth approaches; and committing to the funding and resources needed for successful community-based care. In summary, CHWs are providing a variety of important community-based HIV services but face challenges with regards to training, resources, and supervision.

Acceptability of Home-Based HIV Care Offered by Community Health Workers in Tshwane District, South Africa: A Survey.

Human immunodeficiency virus (HIV) remains the biggest public health challenge faced by South Africa (SA). To alleviate overcrowding in health facilities, ward-based primary health care outreach teams, consisting of community health workers (CHWs) led by a nurse, were introduced. The aim of this study was to assess the acceptability of community-based HIV services offered by CHWs. A survey was conducted in 10 clinics across Tshwane district, Gauteng, SA, between November 2020 and May 10, 2021. CHWs conducted interviewer-administered standardized questionnaires with 674 adult participants. Overall, 95.5% of participants thought that home-based HIV care is a good initiative and rated screening for illnesses and referral to health facilities highly. Although the vast majority (>94%) were willing to disclose their status to health professionals in clinics, women were more willing to do so. Only 53.6% of participants were willing to disclose their HIV status to a CHW from the same neighborhood and 28.8% would find it problematic if CHWs visited them at home with branded cars. Participants had different preferences, mostly determined by region, how long they had been on antiretroviral treatment, whether they had been informed about CHWs, age, and gender. More work is needed to understand and accommodate regional differences and individual preferences.

Reaching hard-to-reach men through home-based couple HIV testing among pregnant women and their male partners in western Kenya: a qualitative study

BackgroundGlobally only 79% of adults living with HIV (human immunodeficiency virus) know their status and men in sub-Saharan Africa are considered a particularly hard-to-reach population for HIV testing. Home-based HIV couple testing during the antenatal period is a safe and effective method that has been used to test male partners of pregnant women. The goal of this qualitative study was to identify elements that made couple testing successful and describe important characteristics of this home-based intervention from couples’ perspectives.MethodsCouples who received scheduled home-based couple testing during pregnancy in Kisumu, Kenya, were purposively sampled based on HIV status from January to May 2015. An interviewer administered all of the in-depth interviews and two coders were directly involved in the data analysis and reconciled codes several times in the process.ResultsTwenty-one couples were enrolled: 9 concordant HIV-negative couples, 8 HIV discordant couples, 3 HIV concordant HIV-positive couples, and 1 whose concordance status was unknown. Median age at the time of home-based couple testing was 24 and 28 years for women and men, respectively. Median relationship duration was 3 years and couples had a median of two pregnancies. The major themes that emerged were that home-based couple testing 1) removed the female burden of requesting couple testing, 2) overcame logistical barriers associated with clinic-based testing, 3) encouraged participants to overcome their fear of testing and disclosure, 4) provided privacy in the home, and 5) provided quality time with the health advisors. Importantly, some women appreciated individual testing at the clinic before couple testing and some couples preferred skilled, anonymous health advisors delivering the intervention rather than known community health workers.ConclusionsThe results of this qualitative study suggest that home-based couple testing during pregnancy overcame many of the barriers that limit men’s access to and uptake of clinic-based testing. It encouraged participants to overcome their fear of testing and disclosure through a setting that afforded privacy and quality time with skilled health advisors. These qualitative results may help design effective partner and couple HIV testing programs in the antenatal setting and alongside or within other assisted partner notification services.Trial RegistrationClinicaltrials.gov registry: NCT01784783. Registered prospectively on June 15, 2012.

Engagement in Care, Viral Suppression, Drug Resistance, and Reasons for Nonengagement After Home-Based Same-Day Antiretroviral Therapy Initiation in Lesotho: A Two-Year Follow-up of the CASCADE Trial.

BackgroundThe CASCADE trial showed that compared with usual care (UC), offering same-day (SD) antiretroviral therapy (ART) during home-based human immunodeficiency virus testing improved engagement in care and viral suppression 12 months after diagnosis. However, questions remain regarding long-term outcomes and the risk of propagating drug resistance.MethodsAfter completion of the primary endpoint at 12 months, participants not in care in both arms were traced and encouraged to access care. At 24 months, the following outcomes were assessed in both arms: engagement in care, viral suppression, and reasons for nonengagement. Furthermore, we explored the acquisition of drug resistance mutations (DRMs) among SD arm nonlinkers.ResultsAt 24 months, 64% (88/137) in the SD arm vs 59% (81/137) in the UC arm were in care (absolute difference [AD], 5%; 95% confidence interval [CI], −6 to16; P = .38) and 57% (78/137) vs 54% (74/137) had documented viral suppression (AD, 3%; 95% CI, −9 to 15; P = .28). Among 36 participants alive and not in care at 24 months with ascertained status, the majority rejected contact with the health system or were unwilling to take ART. Among 8 interviewed SD arm nonlinkers, 6 had not initiated ART upon enrollment, and no acquired DRMs were detected. Two had taken the initial 30-day ART supply and acquired DRMs.ConclusionsSD ART resulted in higher rates of engagement in care and viral suppression at 12 months but not at 24 months. Leveling off between both arms was driven by linkage beyond 12 months in the UC arm. We did not observe compensatory long-term disengagement in the SD arm. These long-term results endorse SD ART initiation policies.Clinical Trials RegistrationNCT02692027.

Male Partner Linkage to Clinic-Based Services for Sexually Transmitted Infections and Human Immunodeficiency Virus Services Following Couple Home-Based Education and Testing

Home-based human immunodeficiency virus (HIV) testing and education has increased HIV test uptake and access to health services among men. We studied how a home-based antenatal intervention influenced male partner utilization of clinic-based HIV and sexually transmitted infection (STI) services, linkage to HIV care and medical circumcision. We conducted a secondary analysis within a randomized controlled trial of pregnant women attending antenatal care in Kenya. Women and their male partners received either a home-based couple intervention or an invitation letter for clinic-based couple HIV testing. The home-based intervention included education on STI symptoms, STI and HIV treatment and male circumcision for HIV prevention. Male self-reported outcomes were compared using relative risks at 6 months postpartum. Among 525 women, we reached 487 (93%) of their male partners; 247 men in the intervention arm and 240 men in the control arm. Men who received the intervention were more likely to report an STI consultation (n = 47 vs. 16; relative risk, 1.59; 95% confidence interval, 1.33-1.89). Among 23 men with newly diagnosed HIV, linkage to HIV care was reported by 4 of 15 in the intervention (3 men had missing linkage data) and 3 of 5 men in the control arms (relative risk, 0.66; 95% confidence interval, 0.34-1.29). Although the intervention identified 3 times more men with new HIV infection, the study lacked power to find significant differences in linkage to HIV care. Few eligible men sought medical circumcision (4 of 72 intervention and 2 of 88 control). Home-based couple education and testing increased STI consultations among male partners of pregnant women, but appeared insufficient to overcome the barriers involved in linkage to HIV care and medical circumcision.

Effect of Universal Testing and Treatment on HIV Incidence — HPTN 071 (PopART)

BackgroundA universal testing and treatment strategy is a potential approach to reduce the incidence of human immunodeficiency virus (HIV) infection, yet previous trial results are inconsistent.MethodsIn the HPTN 071 (PopART) community-randomized trial conducted from 2013 through 2018, we randomly assigned 21 communities in Zambia and South Africa (total population, approximately 1 million) to group A (combination prevention intervention with universal antiretroviral therapy [ART]), group B (the prevention intervention with ART provided according to local guidelines [universal since 2016]), or group C (standard care). The prevention intervention included home-based HIV testing delivered by community workers, who also supported linkage to HIV care and ART adherence. The primary outcome, HIV incidence between months 12 and 36, was measured in a population cohort of approximately 2000 randomly sampled adults (18 to 44 years of age) per community. Viral suppression (<400 copies of HIV RNA per milliliter) was assessed in all HIV-positive participants at 24 months.ResultsThe population cohort included 48,301 participants. Baseline HIV prevalence was 21% or 22% in each group. Between months 12 and 36, a total of 553 new HIV infections were observed during 39,702 person-years (1.4 per 100 person-years; women, 1.7; men, 0.8). The adjusted rate ratio for group A as compared with group C was 0.93 (95% confidence interval [CI], 0.74 to 1.18; P=0.51) and for group B as compared with group C was 0.70 (95% CI, 0.55 to 0.88; P=0.006). The percentage of HIV-positive participants with viral suppression at 24 months was 71.9% in group A, 67.5% in group B, and 60.2% in group C. The estimated percentage of HIV-positive adults in the community who were receiving ART at 36 months was 81% in group A and 80% in group B.ConclusionsA combination prevention intervention with ART provided according to local guidelines resulted in a 30% lower incidence of HIV infection than standard care. The lack of effect with universal ART was unanticipated and not consistent with the data on viral suppression. In this trial setting, universal testing and treatment reduced the population-level incidence of HIV infection. (Funded by the National Institute of Allergy and Infectious Diseases and others; HPTN 071 [PopArt] ClinicalTrials.gov number, NCT01900977.)

Acceptability of Home-Based Human Immunodeficiency Virus Testing and Counseling in Low- and Middle-Income Countries

Acceptability of Home-Based Human Immunodeficiency Virus Testing and Counseling in Low- and Middle-Income Countries

Efficacy of an enhanced linkage to HIV care intervention at improving linkage to HIV care and achieving viral suppression following home-based HIV testing in rural Uganda: study protocol for the Ekkubo/PATH cluster randomized controlled trial

BackgroundThough home-based human immunodeficiency virus (HIV) counseling and testing (HBHCT) is implemented in many sub-Saharan African countries as part of their HIV programs, linkage to HIV care remains a challenge. The purpose of this study is to test an intervention to enhance linkage to HIV care and improve HIV viral suppression among individuals testing HIV positive during HBHCT in rural Uganda.MethodsThe PATH (Providing Access To HIV Care)/Ekkubo Study is a cluster-randomized controlled trial which compares the efficacy of an enhanced linkage to HIV care intervention vs. standard-of-care (paper-based referrals) at achieving individual and population-level HIV viral suppression, and intermediate outcomes of linkage to care, receipt of opportunistic infection prophylaxis, and antiretroviral therapy initiation following HBHCT. Approximately 600 men and women aged 18-59 who test HIV positive during district-wide HBHCT in rural Uganda will be enrolled in this study. Villages (clusters) are pair matched by population size and then randomly assigned to the intervention or standard-of-care arm. Study teams visit households and participants complete a baseline questionnaire, receive HIV counseling and testing, and have blood drawn for HIV viral load and CD4 testing. At baseline, standard-of-care arm participants receive referrals to HIV care including a paper-based referral and then receive their CD4 results via home visit 2 weeks later. Intervention arm participants receive an intervention counseling session at baseline, up to three follow-up counseling sessions at home, and a booster session at the HIV clinic if they present for care. These sessions each last approximately 30 min and consist of counseling to help clients: identify and reduce barriers to HIV care engagement, disclose their HIV status, identify a treatment supporter, and overcome HIV-related stigma through links to social support resources in the community. Participants in both arms complete interviewer-administered questionnaires at six and 12 months follow-up, HIV viral load and CD4 testing at 12 months follow-up, and allow access to their medical records.DiscussionThe findings of this study can inform the integration of a potentially cost-effective approach to improving rates of linkage to care and HIV viral suppression in HBHCT. If effective, this intervention can improve treatment outcomes, reduce mortality, and through its effect on individual and population-level HIV viral load, and decrease HIV incidence.Trial registrationNCT02545673

The effectiveness of home-based HIV counseling and testing on reducing stigma and risky sexual behavior among adults and adolescents: A systematic review and meta-analyses.

Human immunodeficiency virus counselling and testing is a critical and essential gateway to Human immunodeficiency virus prevention, treatment, care and support services. Though some primary studies indicate that home-based counselling and testing is more effective than facility based counselling and testing to reduce stigma and risky sexual behavior, to the best of the author's knowledge, no systematic review has tried to establish consistency in the findings across populations. The objective of this review was to determine the effectiveness of home-based Human immunodeficiency virus counselling and testing in reducing Human immunodeficiency virus-related stigma and risky sexual behavior among adults and adolescents. All adults and adolescents aged 13 years or above. TYPE OF INTERVENTION: This review considered any studies that evaluated home-based Human immunodeficiency virus counseling and testing as an intervention. TYPES OF STUDIES: This review considered quantitative (experimental and observational) studies. TYPES OF OUTCOMES: This review considered studies that included the following outcome measures: stigma, violence, sexual behavior and clinical outcomes. The search strategy aimed to find both published and unpublished studies reported in English Language from 2001 to 2014 in MEDLINE, Web of Science, EMBASE, Scopus and CINAHL. The search for unpublished studies included: WHO International Clinical Trials Registry Platform, Clinicaltrials.gov, Mednar, Google Scholar, AIDSinfo and ProQuest Dissertations and Theses Database. Papers selected for retrieval were assessed by two independent reviewers for methodological validity prior to inclusion in the review using standardized critical appraisal instruments from the Joanna Briggs Institute. Data were extracted from papers included in the review using the standardized data extraction tool from the Joanna Briggs Institute Qualitative Assessment and Review Instrument. Quantitative data were pooled using the meta-analysis software provided by Joanna Briggs Institute. Effect sizes were calculated using fixed effects model. Where the findings could not be pooled using meta-analyses, results were presented in a narrative form. Nine studies were included in this review, five of them reporting on stigma and related outcomes, three of them on sexual behavior and four of them on clinical outcomes. Meta-analysis indicated that the risk of observing any stigmatizing behavior in the community was 16% (RR=0.84, 95% CI 0.79 to 0.89] lower among the participants exposed to home-based HCT when compared to the risk among those participants not exposed to home-based HCT. The risk of experiencing any stigmatizing behavior by HIV positive patients was 37% (RR 0.63, 95% CI 0.45 to 0.88) lower among the intervention population compared to the risk among the control population. The risk of intimate partner violence was 34% (RR 0.66, 95% CI 0.49 to 0.89) lower among participants exposed to home-based HCT when compared to the risk among participants in the control arm. Compared to the control arm, the risk of reporting more than one sexual partner was 58% (RR 0.42, 95% CI 0.31 to 0.58) lower among participants exposed to home-based HCT. The risk of having any casual sexual partner in the past three months was 51% (RR 0.49, 95% CI 0.40 to 0.59) lower among the population exposed to home-based HCT when compared to the risk among those participants not exposed to home-based HCT. The risk of having ever been forced for sex among participants exposed to home-based HCT was 20% (RR 0.8, 0.56 to 1.14) lower when compared to the risk among the control arm; however this result was not statistically significant and the wide confidence interval indicates that the risk estimate was imprecise. Home-based HCT is protective against intimate partner violence, stigmatizing behavior, having multiple sexual partners, and having casual sexual partners. The low quality of studies included makes it difficult to formulate clear recommendations regarding the effectiveness of home-based HCT on the above outcomes as compared to other models of HCT. However, the current findings may help in designing HIV prevention programs, especially in high prevalence settings and where stigma is higher and there is limited access or barriers to utilizing facility-based services. Randomized controlled trials that assess the effectiveness of home-based HCT on stigma, sexual behavior, viral load and viral suppression are needed.

Cost effectiveness of facility and home based HIV voluntary counseling and testing strategies in rural Uganda

In Uganda, the main stay for provision of human immunodeficiency virus (HIV) voluntary counseling and testing (VCT) has been at health facilities. Home based VCT on the other hand, was initiated in the country to improve service coverage. To evaluate the cost effectiveness of facility- and home-based HIV VCT strategies in rural southwestern Uganda. Data on costs and effectiveness of facility- and home-based HIV VCT intervention strategies was collected in two sub-Counties in rural southwestern Uganda. Costing was performed using the ingredients approach. Effectiveness was measured as the number of HIV sero-positive clients identified. Incremental Cost-Effectiveness Ratios (ICERs) were calculated from the provider perspective. The cost per client tested were US$6.4 for facility based VCT and US$5.0 for home based VCT. The corresponding costs per positive case identified were US$86.5 and US$54.7 respectively. The incremental cost to providers per additional positive case identified by facility based VCT was US$3.5. Home based VCT was the least costly strategy per client tested and was also cost effective in identifying HIV sero-positive clients in rural areas. This strategy should therefore be promoted to improve service coverage and thereby facilitate early and extensive detection of clients eligible for treatment.

RAPID HOME-BASED HIV TESTING TO REDUCE COSTS IN A LARGE TUBERCULOSIS COHORT STUDY.

To reduce costs in a large tuberculosis household contact cohort study in Lima, Peru, we replaced laboratory-based HIV testing with home-based rapid testing. We developed a protocol and training course to prepare staff for the new strategy; these included role playing for home-based deployment of the Determine® HIV 1/2 Ag/Ac Combo HIV test. Though the rapid HIV test produced more false-positives, the overall cost per participant tested, refusal rate and time to confirmatory HIV testing were lower with the home-based rapid testing strategy compared to the original approach. Rapid testing could be used in similar research or routine care settings.

Current strategies for improving access and adherence to antiretroviral therapies in resource-limited settings.

The rollout of antiretroviral therapy (ART) significantly reduced human immunodeficiency virus (HIV)-related morbidity and mortality, but good clinical outcomes depend on access and adherence to treatment. In resource-limited settings, where over 90% of the world’s HIV-infected population resides, data on barriers to treatment are emerging that contribute to low rates of uptake in HIV testing, linkage to and retention in HIV care systems, and suboptimal adherence rates to therapy. A review of the literature reveals limited evidence to inform strategies to improve access and adherence with the majority of studies from sub-Saharan Africa. Data from observational studies and randomized controlled trials support home-based, mobile and antenatal care HIV testing, task-shifting from doctor-based to nurse-based and lower level provider care, and adherence support through education, counseling and mobile phone messaging services. Strategies with more limited evidence include targeted HIV testing for couples and family members of ART patients, decentralization of HIV care, including through home- and community-based ART programs, and adherence promotion through peer health workers, treatment supporters, and directly observed therapy. There is little evidence for improving access and adherence among vulnerable groups such as women, children and adolescents, and other high-risk populations and for addressing major barriers. Overall, studies are few in number and suffer from methodological issues. Recommendations for further research include health information technology, social-level factors like HIV stigma, and new research directions in cost-effectiveness, operations, and implementation. Findings from this review make a compelling case for more data to guide strategies to improve access and adherence to treatment in resource-limited settings.

Self reported risk reduction behavior associated with HIV counseling and testing: A comparative analysis of facility- and home-based models in rural Uganda

Home-based human immunodeficiency virus (HIV) voluntary counseling and testing (VCT) in Uganda is being promoted to increase coverage, in addition to main stay approach of service provision through health facilities. The aim of this study was to compare self reported risk reduction behavior among clients receiving facility and home-based HIV VCT within a rural context. Pre-post intervention client surveys were conducted in November 2007 (baseline) and March 2008 (follow up) in southwestern Uganda. The facility-based VCT intervention was provided to 500 clients and home-based VCT to 494 clients at baseline, in 2 different sub-counties. A total of 76% (759/994) of these clients were interviewed at the follow up visit. The respondents who received facility-based VCT were more likely to report abstinence (adjusted Odds Ratio [aOR]=1.47, 95% CI 1.074, 2.02), reducing multi sexual relationships (aOR=3.23, 95% CI 2.02, 5.16) and more frequent use of condoms (aOR=3.14, 95% CI 1.60, 6.18). However, they were less likely to report, discussing HIV (aOR=0.63, 95% CI 0.46, 0.85) with their sexual partner/s and having sex with only one partner (aOR=0.72, 95% CI 0.519–0.99). While facility-based VCT appears to promote abstinence and condom use home-based VCT on the other hand promotes faithfulness and disclosure. VCT services should, therefore, be provided through both models in a complementary relationship and not as surrogates within given settings.

Home-Based HIV Counseling and Testing as a Gateway to Earlier Initiation of Antiretroviral Therapy

Timely access to combination antiretroviral therapy (ART) represents the single most effective intervention in reducing mortality and morbidity among patients with human immunodeficiency virus (HIV) infection or AIDS. Until recently, the threshold for initiating ART in resource-limited settings was set at a CD4 T-cell count #200 cells/mm, a conservative threshold that had been abandoned in wealthier settings several years earlier [1]. Randomized trial data [2] and cohort evaluations [3] that demonstrate improved survival when ART is initiated earlier provided convincing evidence for the World Health Organization to revise guidance for resource-limited settings to initiate ART at a CD4 T-cell count #350 cells/mm. Most developing countries have now adopted or strive for this target threshold. More recent studies have validated this shift by demonstrating the broader benefits of earlier initiation of ART, including reduced incidence of tuberculosis [4], reduced rates of hospitalization [5], reduced likelihood of HIV transmission [6], and increased life expectancy [7]. Changing the threshold for initiation was seen as a daunting task, and a common refrain in discussions about early ART initiation in resource-limited settings was that raising the threshold would overwhelm healthcare systems by increasing the number of new patients requiring a clinician’s time [8]. It has often been pointed out that most patients in sub-Saharan Africa present too late as it is, with an average CD4 T cell count of only 111 cells/mm [9]. For the most part, however, the reasons that patients present late to care have nothing to do with initiation thresholds at the clinic. Rather, they are related to a lack of awareness of their HIV status [10] or disincentives to accessing care, such as high costs [11] or distances from clinics [12]. There is no convincing evidence that individuals arrive late to care because they have been ‘‘crowded out’’ by patients who are not as sick. Earlier treatment means that patients do not become as sick and thus need less-complex care. Evidence from programs to date suggests that earlier initiation supports access to care by promoting delivery of ART by nurse-led primary care clinics and reducing demands for more-specialized and inpatient clinical care [5]. Although considerable research attention has been paid to demonstrating the relative merits of earlier ART initiation, the question of how to encourage persons to seek treatment earlier has to date been almost entirely neglected. Recently, the need for better retention in care between testing and initiation of treatment for eligible patients has been recognized [13]. An important prior concern is to identify patients as early as possible, both to decrease the likelihood of transmission between partners and to provide an early opportunity to engage patients into care. Home-based counseling and testing (HBCT) represent an important strategy for identifying patients before their CD4 T cells are severely depleted. It is also a strategy to engage underrepresented populations in HIV/AIDS testing. Populations such as men, the elderly, and adolescents [14, 15] are regularly excluded from testing campaigns and are thus underrepresented in ART treatment programs, leading to worse overall mortality for these groups [16]. Designers of targeted HBCT that aim to broadly involve either the entire population in a setting or an accurate sample of it need to consider whether these groups are likely to be identified through HBCT or more likely to be located outside the home [17]. The study by Wachira and colleagues provides compelling evidence that widespread HIV counseling HBCT helps identify Received 21 September 2011; accepted 26 September 2011. Correspondence: Edward J. Mills, PhD, University of Ottawa, 43 Templeton, Ottawa, Ontario, K1N 6X1, Canada 778317 8530 (edward.mills@uottawa.ca). Clinical Infectious Diseases 2012;54(2):282–4 The Author 2011. Published by Oxford University Press on behalf of the Infectious Diseases Society of America. All rights reserved. For Permissions, please e-mail: journals.permissions@ oup.com. DOI: 10.1093/cid/cir812

What Is the Impact of Home-Based HIV Counseling and Testing on the Clinical Status of Newly Enrolled Adults in a Large HIV Care Program in Western Kenya?

This article describes the effect point of entry into the human immunodeficiency virus (HIV) care program had on the clinical status of adults presenting for the first time to USAID-AMPATH (US Agency for International Development-Academic Model Providing Access to Healthcare) Partnership clinics for HIV care. All patients aged ≥ 14 years enrolled between August 2008 and April 2010 were included. Points of entry to USAID-AMPATH clinics were home-based counseling and testing (HBCT), provider-initiated testing and counseling (PITC), HIV testing in the tuberculosis clinic, and voluntary counseling and testing (VCT). Tests for trend were calculated, and multivariable logistic regression was used to compare the effect of HBCT versus other points of entry on primary outcomes controlling for age and sex. There were 19,552 eligible individuals. Of these, 946 tested in HBCT, 10,261 in VCT, 8073 in PITC, and 272 in the tuberculosis clinic. The median (interquartile range) enrollment CD4 cell counts among those who tested HIV positive was 323 (194-491), 217 (87-404), 190 (70-371), and 136 cells/mm(3) (59-266) for HBCT, VCT, PITC, and the tuberculosis clinic, respectively (P < .001). Compared with those patients whose HIV infection was diagnosed in the tuberculosis clinic, those who tested positive in HBCT were, controlling for age and sex, less likely to have to have World Health Organization stage III or IV HIV infection at enrollment (adjusted odds ratio [AOR], 0.04; 95% confidence interval [CI], .03-.06), less likely to enroll with a CD4 cell count of <200 cells/mm(3) (AOR, 0.20; 95% CI, .14-.28), and less likely to enroll into care with a chief complaint (AOR, 0.08; 95% CI, .05-.12). HBCT is effective at getting HIV-infected persons enrolled in HIV care before they become ill.