Uptake of Home-Based Voluntary HIV Testing in Sub-Saharan Africa: A Systematic Review and Meta-Analysis

Abstract

Kalpana Sabapathy and colleagues conduct a systematic review and meta-analysis to assess the acceptability of home-based voluntary counseling and testing for HIV in sub-Saharan Africa with some encouraging results.

Abstract

Introduction

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.

Methods and Findings

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.

Conclusions

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.

Please see later in the article for the Editors' Summary

Editors' Summary

Background

Knowledge of HIV status is crucial for both the prevention and treatment of HIV. However, according to the Joint United Nations Programme on HIV/AIDS (the UN agency responsible for HIV/AIDS), in low-and-middle-income countries only ten percent of those who need voluntary counseling and testing, because they may have been exposed to HIV infection, have access to this service. 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. To help overcome this problem, one important strategy in encouraging people to be tested for HIV is to offer them the opportunity to be counseled and tested at home—home-based voluntary counseling and testing (HBT). Using the HBT approach, people are visited in their home by health workers regardless of their perceived risk of 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.

Why Was This Study Done?

The HBT approach has received widespread international support, and the World Health Organization has recently published guidance to service providers and policy makers about the delivery of HBT. However, the acceptability of HBT, that is, whether those offered HBT actually take up the offer and are tested, remains unknown, especially in sub-Saharan Africa, the world region with the highest prevalence of HIV. So, in this study, the researchers systematically compiled all of the available studies on this topic from sub-Saharan Africa to determine the acceptability of HBT and also to and identify any factors associated with the uptake of HBT.

What Did the Researchers Do and Find?

The researchers searched several databases to identify suitable peer-reviewed studies from Africa published between January 2000 and September 2012. The researchers included studies that described any intervention to provide HIV testing at home and also reported the proportions of participants accepting HIV testing out of all individuals offered a home-based HIV test. Because different types of studies were included (such as randomized controlled trials, observational cohort studies, and cross-sectional surveys), the researchers tested the quality of included studies. Then they pooled all of the studies together to calculate the overall proportion of people who accepted HIV testing at home and the proportion who received their result.

Using these methods, the researchers included 21 studies from five African countries: Kenya, Malawi, South Africa, Uganda, and Zambia, comprising a total of 524,867 people. Overall, the proportion of people who accepted HBT ranged from 58.1% to 99.7%, with a pooled proportion of 83.3% accepting HBT (474,377 people). In the eight studies that separated data by gender, men were as likely as women to accept testing (78.5% versus 81.5%). Over three-quarters of everyone who accepted HBT received their result (77% in 16 studies reporting on this), and, importantly, the proportion of people with previously undiagnosed HIV was high (40%–79% of those diagnosed HIV-positive), emphasizing the value of HBT. The researchers also found that providing incentives, local HIV prevalence being less than 10%, and targeting HBT to household members of HIV-positive individuals may be factors associated with increased uptake of HBT, but further research is needed to verify the results of this subgroup analysis.

What Do These Findings Mean?

These findings suggest that voluntary counseling and testing for HIV at home is highly acceptable in five countries in sub-Saharan Africa, with the majority of those tested receiving their test result, highlighting the importance of this approach in the diagnosis of HIV. Therefore, by increasing uptake of testing, HBT may provide an effective tool for governments and health service providers to increase access to HIV treatment and prevention. However, testing is just the first step in the management of HIV, and this study does not address the follow-up of those who tested positive using the home-based approach, such as access to treatment, as well as repeated HBT for ongoing knowledge of HIV status. The option of self-testing was examined in only one of the studies included in this review, but the researchers identify that self-testing at home with the support HBT staff is an important area of future research. Overall, HBT has the potential to substantially increase awareness of HIV status in previously undiagnosed men and women in sub-Saharan Africa.

Additional Information

Please access these websites via the online version of this summary at http://dx.doi.org/10.1371/journal.pmed.1001351.

• The World Health Organization provides extensive information on HIV testing and counseling, and the World Health Organization's guidance on home-based testing mentioned in this summary is also available

• The Joint United Nations Programme on HIV/AIDS gives the latest facts and figures about the global status of HIV and about reducing stigma and discrimination around HIV