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      Home-Based Versus Mobile Clinic HIV Testing and Counseling in Rural Lesotho: A Cluster-Randomized Trial

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          Abstract

          Niklaus Labhardt and colleagues investigate how different HIV testing and counseling strategies, based on home visits or mobile clinics, reach different populations in a rural African setting.

          Please see later in the article for the Editors' Summary

          Abstract

          Background

          The success of HIV programs relies on widely accessible HIV testing and counseling (HTC) services at health facilities as well as in the community. Home-based HTC (HB-HTC) is a popular community-based approach to reach persons who do not test at health facilities. Data comparing HB-HTC to other community-based HTC approaches are very limited. This trial compares HB-HTC to mobile clinic HTC (MC-HTC).

          Methods and Findings

          The trial was powered to test the hypothesis of higher HTC uptake in HB-HTC campaigns than in MC-HTC campaigns. Twelve clusters were randomly allocated to HB-HTC or MC-HTC. The six clusters in the HB-HTC group received 30 1-d multi-disease campaigns (five villages per cluster) that delivered services by going door-to-door, whereas the six clusters in MC-HTC group received campaigns involving community gatherings in the 30 villages with subsequent service provision in mobile clinics. Time allocation and human resources were standardized and equal in both groups. All individuals accessing the campaigns with unknown HIV status or whose last HIV test was >12 wk ago and was negative were eligible. All outcomes were assessed at the individual level. Statistical analysis used multivariable logistic regression. Odds ratios and p-values were adjusted for gender, age, and cluster effect.

          Out of 3,197 participants from the 12 clusters, 2,563 (80.2%) were eligible (HB-HTC: 1,171; MC-HTC: 1,392). The results for the primary outcomes were as follows. Overall HTC uptake was higher in the HB-HTC group than in the MC-HTC group (92.5% versus 86.7%; adjusted odds ratio [aOR]: 2.06; 95% CI: 1.18–3.60; p = 0. 011). Among adolescents and adults ≥12 y, HTC uptake did not differ significantly between the two groups; however, in children <12 y, HTC uptake was higher in the HB-HTC arm (87.5% versus 58.7%; aOR: 4.91; 95% CI: 2.41–10.0; p<0.001). Out of those who took up HTC, 114 (4.9%) tested HIV-positive, 39 (3.6%) in the HB-HTC arm and 75 (6.2%) in the MC-HTC arm (aOR: 0.64; 95% CI: 0.48–0.86; p = 0.002). Ten (25.6%) and 19 (25.3%) individuals in the HB-HTC and in the MC-HTC arms, respectively, linked to HIV care within 1 mo after testing positive. Findings for secondary outcomes were as follows: HB-HTC reached more first-time testers, particularly among adolescents and young adults, and had a higher proportion of men among participants. However, after adjusting for clustering, the difference in male participation was not significant anymore.

          Age distribution among participants and immunological and clinical stages among persons newly diagnosed HIV-positive did not differ significantly between the two groups. Major study limitations included the campaigns' restriction to weekdays and a relatively low HIV prevalence among participants, the latter indicating that both arms may have reached an underexposed population.

          Conclusions

          This study demonstrates that both HB-HTC and MC-HTC can achieve high uptake of HTC. The choice between these two community-based strategies will depend on the objective of the activity: HB-HTC was better in reaching children, individuals who had never tested before, and men, while MC-HTC detected more new HIV infections. The low rate of linkage to care after a positive HIV test warrants future consideration of combining community-based HTC approaches with strategies to improve linkage to care for persons who test HIV-positive.

          Trial registration

          ClinicalTrials.gov NCT01459120

          Please see later in the article for the Editors' Summary

          Editors' Summary

          Background

          Annually, about 2.3 million people become newly infected with HIV, the virus that causes AIDS by gradually destroying CD4 cells and other immune system cells, thereby leaving HIV-infected individuals susceptible to other serious infections. HIV can be transmitted through unprotected sex with an infected partner, from an HIV-positive mother to her unborn child, or through the injection of drugs with shared needles. Infection with HIV is usually diagnosed by looking for antibodies to HIV in the blood or saliva. After diagnosis, the progression of HIV infection is monitored by regularly counting the number of CD4 cells in the blood. Initiation of antiretroviral therapy (ART)—a combination of drugs that keeps HIV replication in check but that does not cure the infection—is recommended when an individual's CD4 count falls below 500 cells/µl or when he or she develops signs of advanced or severe disease, such as unusual infections.

          Why Was This Study Done?

          To control HIV/AIDS, HIV transmission needs to be reduced, and ART delivery needs to be increased. In settings of high HIV prevalence, universal coverage of HIV testing and counseling (HTC) is essential if these goals are to be met. Unfortunately, many people refuse “facility-based” HTC (HTC delivered at health care facilities) because they fear stigmatization and discrimination. Moreover, many people in resource-limited settings rarely visit health care facilities. Community-based HTC may be one way to increase the uptake of HTC, particularly among populations that are hard to reach, such as men and first-time testers, but which form of community-based HTC will be most effective? In this cluster-randomized trial, the researchers ask whether home-based HTC (HB-HTC)—community-based HTC in which health care workers go door-to-door to offer HTC to people in their own home—results in a higher uptake of HTC than HTC delivered through community gatherings and mobile clinics (MC-HTC) in two rural areas in Lesotho. Nearly a quarter of adults are HIV-positive in Lesotho, but only 61% of people who need ART currently receive treatment. A cluster-randomized trial compares outcomes in groups (clusters) of people chosen at random to receive different interventions.

          What Did the Researchers Do and Find?

          The researchers allocated 12 clusters, each comprising a health center and its catchment area, to the HB-HTC or MC-HTC intervention. In the HB-HTC arm (1,171 participants), HTC teams going door-to-door delivered a multi-disease campaign that included HTC to five villages in each cluster. In the MC-HTC arm (1,392 participants), the multi-disease campaign was delivered at community gatherings with subsequent service provision in mobile clinics. Overall, HTC uptake was higher in the HB-HTC arm than in the MC-HTC arm (92.5% and 86.7% uptake, respectively). Among participants aged ≥12 years, there was no significant difference in HTC uptake between the arms, whereas among children aged <12 years, HTC uptake was significantly higher in the HB-HTC arm than in the MC-HTC arm (87.5% versus 58.7%; a significant difference is a difference unlikely to have happened by chance). Among individuals who took up HTC, 3.6% and 6.2% tested positive for HIV in the HB-HTC arm and MC-HTC arm, respectively. In both arms, only a quarter of individuals who tested positive accessed HIV care within a month of their positive test result. Finally, HB-HTC reached more first-time testers (particularly among adolescents) and tended to reach more men than MC-HTC.

          What Do These Findings Mean?

          These findings suggest that, in rural Lesotho, both HB-HTC and MC-HTC delivered as part of a multi-disease campaign can achieve a high uptake of HTC. Various aspects of the trial design (for example, the small number of clusters) may limit the accuracy of the findings reported here. Notably, however, these findings suggest that the choice between HB-HTC and MC-HTC should be guided by the objective of the HTC intervention in specific settings. Where equity of access is of concern and where increased HTC coverage, particularly among groups in which HTC coverage is generally poor (including men, first-time testers, and children), is paramount, HB-HTC may be the preferred option. By contrast, the MC-HTC approach may be more appropriate in settings where the detection of new HIV infections is the major goal. Finally, and importantly, the findings of this trial highlight the need for further research into strategies designed to improve the linkage between HIV testing and enrollment into care.

          Additional Information

          Please access these websites via the online version of this summary at http://dx.doi.org/10.1371/journal.pmed.1001768.

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          Most cited references24

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

          Introduction Testing for HIV is the first step in the cascade of care for HIV-positive individuals who need treatment. Knowledge of HIV status is also an important part of HIV prevention, for both HIV-negative and HIV-positive individuals, and developing innovative means to increase uptake of testing has recently been identified as an international policy priority [1]–[4]. Despite some progress, knowledge of HIV status remains low in sub-Saharan Africa (SSA), where HIV prevalence is highest [5]. 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 (from 31% in Congo to 69% in Kenya) [5]. Men have consistently been shown to be less likely to have been tested for HIV than women [5],[6]. Out-of-facility approaches to offering testing in the community [7],[8] and the workplace [9],[10] are means of bringing access to testing closer to clients. By removing distance as a barrier, these methods could be complementary means to scale up HIV testing [11]. 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]–[14]. The World Health Organization has recently published a handbook to guide service providers and policy makers in delivering HBT [14]. HBT may reach individuals that community venue-based testing and workplace testing do not because it does not require clients to come forward [14]. In HBT it is the test provider who approaches the client, regardless of his/her perceived risk of having HIV [15]. However, there is uncertainty about HBT and concern that it may be poorly accepted or even harmful, partly owing to the enduring climate of stigma and discrimination around HIV/AIDS in many settings [16],[17]. We carried out a systematic review and meta-analysis of the available evidence regarding the acceptability of HBT in SSA, and assessed a number of potential determinants of uptake and programme success. Methods 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). The specific objectives of the study were to summarise the following proportions: “accepted” (or uptake), defined as the proportion of all individuals offered HBT who accepted and had an HIV test performed at home; “received”, defined as the proportion of all individuals who accepted a home-based HIV test who subsequently obtained the result of the test; and “overall”, defined as the proportion of individuals who received a test result among all those offered HBT (including refusals). We also planned sub-group analyses as outlined below. Search Strategy We aimed to summarise studies that described uptake of HIV testing provided at home in SSA. We screened studies published between 1 January 2000 (the onset of programmes providing antiretroviral therapy in SSA) and 24 September 2012. The following study designs were permitted: randomised controlled trials, observational cohort studies, cross-sectional surveys, and programme evaluations. Any study that described an intervention to provide HIV testing at home and reported proportions accepting HIV testing out of all individuals offered a home-based HIV test was included. Where acceptance of testing was reported, it was assumed that testing was performed unless stated otherwise. To avoid duplication we excluded reports that pooled data from previously published studies, and where there was substantial overlap of study participants, we included the study with the most complete information. No language or age restriction was applied to the literature search. To identify studies for this systematic review, we searched the online databases PubMed, Embase, and Global Health (Ovid) and manually searched the bibliographies of relevant articles. We included only peer-reviewed journal articles; conference abstracts were excluded. Anticipating overlap between studies reporting HBT and other community-based strategies, we developed a broad compound search strategy that combined terms for “HIV”, “voluntary counselling and testing”, “home based”, “mobile”, “community”, “workplace”, “couples”, and “self”. We then combined these terms with the individual names of countries in SSA (Text S2). Finally, we excluded all studies that did not report home-based delivery of HIV testing. Eligibility of abstracts and journal articles was determined by one investigator (K. S.) and verified by a second researcher (R. V. d. B.). Two investigators (K. S. and R. V. d. B.) then independently extracted data on study characteristics and outcomes using a standardised form. Any disagreements regarding eligibility or outcome data were resolved by a third investigator (N. F.). The rigour of study processes and research methods was examined using pre-defined criteria, but studies were not excluded for quality reasons. Data Synthesis and Analysis We calculated the proportion of people who accepted HIV testing at home, and the proportion who received their test result out of those (i) who were offered and (ii) who accepted testing. The variance of raw proportions was stabilised using a Freeman–Tukey arcsine square-root transformation, and proportions were then pooled using a DerSimonian–Laird random-effects model [19]–[21]. Pooled odds ratios were calculated for proportions stratified by gender, also using a random-effects model. We report the I 2 statistic to assess the proportion of variability due to between-study heterogeneity, but as this estimate is known to increase as the number of participants contributing to the meta-analysis increases [21], we also report τ2 as a measure of between-study variance (reported on the arcsine square-root scale). We explored potential sources of heterogeneity through univariate sub-group analysis to determine the potential influence of the following covariates: HIV prevalence ( 13 y and eligible childrenb Counsellors trained for purpose Yes No FP RDTs (Determine and Bioline) 26%c Kranzer, 2008 Malawi, rural district 2005–2006 2,047 Factors associated with HBT refusal 11.4% 18–59 y Trained local VCT counsellors No No Venous blood sampling for ELISA and particle agglutination testing in laboratory 36% Lugada, 2010 Uganda, five rural districts 2005–2007 4,798 Uptake of HBT versus clinic-based testing in household members of HIV-positive index patient 5.6% Any Trained lay field workers No No FP RDTs (Determine screening, Unigold confirmation) Not specified Maheswaran, 2012 South Africa, rural district 2009 1,726 Uptake of HBT and community mobile HIV testing and factors associated with HBT versus mobile testing 22% ≥15 y HIV Counsellors No No Not specifiedd 40% Matovu, 2002 Uganda, rural district 1999–2000 11,709 Uptake of HBT and effects on sexual risk behaviour and HIV acquisition 5.6% 15–49 y Counsellors No No Venous blood sampling for ELISA (×2) testing in laboratory 55% Menzies, 2009 Uganda, setting not specified 2003–2005 49,470 Comparison of four testing approaches: door-to-door HBT, household member (of index HIV patient) targeted HBT, stand-alone, hospital-based VCT 5.6% Any Not specified Yes No FP RDTs (screening test followed by confirmation if HIV-positive; tests not specified) 10% Michelo, 2006 Zambia, one rural, one urban district 2003 5,445 HIV prevalence survey 20.4% 15–59 y Not specified No No Bionor saliva test and “serum test” for saliva-positive or second saliva test Not specified Molesworth, 2010 Malawi, rural district 2007–2008 16,894 To assess the performance of HIV RDTs in a HIV prevalence survey 11.6% ≥15 y Non-laboratory basic health personnel Yes No Venous blood sampling for RDTs (Determine and Unigold in parallel pre-May 2008, serially post-May 2008) Not specified Negin, 2009 Kenya, rural province 2008 2,033 Feasibility, acceptability, and cost of HBT 7.8% 15–49 y Lay counsellors Yes No FP RDTs (Determine and Bioline) Not specified Sekandie, 2011 Uganda, urban district 2009 588 Uptake of HBT and factors associated with HBT 6.5% ≥15 y Trained nurse counsellors No No FP RDTs (Determine screening, Statpak confirmation) 61% Shisana, 2004 South Africa, nationwide 2002 9,963 HIV prevalence survey 26.5% ≥2 y Nurses No Yes—money provided to head of household FP onto filter paper; ELISA (×2) testing in laboratory Not specified Tumwesigye, 2010 Uganda, rural district 2004–2007 282,857 Acceptability and uptake of HBT 5.4% >14 y and eligible children >18 mof Counsellor and laboratory assistant teams Yes Yes—HIV-positive provided with condoms, insecticide-treated bednets, and home water treatment equipment FP RDTs (Determine screening, Statpak confirmation) 9% Welz (1), 2007 South Africa, rural district 2003–2004 19,867 HIV prevalence survey (residents) 27.9% Women 15–49 y; men 15–54 y Trained fieldworkers No No FP onto filter paper; ELISA (×2) testing in laboratory Not specified Welz (2), 2007 As above As above 916 HIV prevalence survey (subset of migrants in the community) As above As above As above No No As above Not specified Were, 2003 Uganda, rural district Not specified 2,373 Uptake of VCT and HBT 4.1% Any Not specified No No Venous sampling, tests not specified Not specified Were, 2006 Uganda, two rural districts 2003–2004 3,338 HIV prevalence and acceptability of HBT among household members of HIV-positive index patient 4.1% Any Counsellors No No FP onto filter paper; ELISA (×2) testing in laboratory; for children 200 cells/mm3) [30],[32]. 10.1371/journal.pmed.1001351.t002 Table 2 Assessment of study rigour. First Author, Publication Year Study Process Quality Indicators Research Method Quality Indicators Pre-Test Counselling Donea Consent Provided Test Offered with the Intention of Giving Results to Clientsb Confirmatory Laboratory Testing Done Discordant Results Addresseda Repeat Sampling if Discordant Repeat Visits if Absenteeism Specific Advice if HIV Result Negative Linkage to Care for HIV-Infected Sampling Strategy Described Selective Outcome Reporting Angotti, 2009 Yes Yes Yes No Not specified No No Yes—retest in 3 mo time Yes Yes No Choko, 2011 Yes Yes No No Yes Yes No No Yes Yes No Helleringer, 2009 Yes Yes No No Not specified Yes Yes No No Yes No Kimaiyo, 2010 Yes Yes Yes No Yes Yes Yes Yes—behaviour change and “ABCs” of HIV prevention Yes No No Kranzer, 2008 Yes Yes Yes Yes Yes Yes Yes No No Yes No Lugada, 2010 Yes Yes Yes No Yes Yes Yes No Yes Yes No Maheswaran, 2012 Yes Yes Yes No Not specified No No No Yes No No Matovu, 2002 Yes Yes No Yes Yes Yes Yes No No No No Menzies, 2009 Yes Yes Yes Yes Not specified Yes No No Yes No No Michelo, 2006 Yes Yes Yes Yes Yes Yes No No No Yes No Molesworth, 2010 Yes Yes Yes Yes Yes Yes No No Yes Yes No Negin, 2009 Yes Yes Yes No Yes Yes No No Yes No No Sekandi, 2011 Yes Yes Yes No Yes Yes No Yes—HIV prevention counselling Yes Yes No Shisana, 2004 Not specified Yes No Yes Not specified Yes Yes No No Yes No Tumwesigye, 2010 Yes Yes Yes Yes Yes Yes No No Yes No No Welz, 2007 Not specified Yes Yes Yes Not specified Yes Yes No No Yes No Were, 2003 Yes Yes No No Not specified No Yes No No No No Were, 2006 Not specified Yes Yes Yes Yes Yes No No No No No Wolff, 2005 Not specified Yes No Yes Yes Yes No No No Yes No a Where no information is available “not specified” is indicated for these variables, as we considered it possible that these activities were done but not reported in the paper. b Some studies offered testing but results were not promised, e.g., results available only if client sought the result separately; some studies were entirely blinded, e.g., where testing was done for anonymous population HIV prevalence estimation. Proportion of Individuals Accepting Testing and Receiving Results A total of 524,867 people were offered HBT across the 21 studies, which ranged in size from 216 [36] to 282,857 [32] people. Twelve studies disaggregated data on offer of HBT by gender, with 180,942 men and 198,042 women offered testing overall [27]–[33],[36]–[38],[43]. The proportion of those offered testing who were men (in the studies that reported on gender) ranged from 22% to 49%, with an overall proportion of 47%. Across all 21 studies the proportion of people who accepted HBT ranged from 58.1% (95% CI: 57.5%–58.8%) to 99.7% (95% CI: 99.7%–99.8%), with a pooled proportion of 83.3% (95% CI: 80.4%–86.1%) accepting to be tested (n = 474,377) (Figure 2). Heterogeneity was high (τ2 = 0.11). In studies that reported on acceptance of HBT by gender (eight studies) [22],[27],[31]–[33],[38],[43], men were as likely as women to accept testing (78.5% [95% CI: 71.1%–86.0%] versus 81.5% [95% CI: 72.9%–90.1%]). The pooled odds ratio of men accepting HBT was 0.84 (95% CI: 0.56–1.26) compared to women (τ2 = 0.33). Studies that offered targeted HBT to household members of index HIV-positive individuals [28],[33] achieved higher proportions of uptake than the other studies: 94.0% (95% CI: 82.4%–100%) versus 80.6% (95% CI: 77.2%–84.0%) (p 350 cells/mm3 (and 68% >200 cells/mm3) [32]. Similarly, Menzies et al. found that 69% of HIV-positive individuals identified through HBT had CD4 count >200 cells/mm3. In this latter study, which compared approaches of HIV testing, the proportions of HIV-positive individuals identified with a CD4 count <50 cells/mm3 through stand-alone voluntary counselling and testing and hospital-based testing were 20% and 24%, respectively, while the corresponding proportion was 12% for HBT targeted to household members of known HIV-positive individuals, and 6% for untargeted HBT [30]. This is consistent with other findings that suggest HBT is a useful approach for earlier detection of HIV, initiation of treatment, and better prognosis [13],[48], as well as for higher impact with treatment as prevention [49],[50]. A recent pilot study in South Africa found a reduction in mean community viral load 6 mo after the introduction of a HBT campaign [51]. While women are disproportionately affected by HIV in SSA [5], men have long been known to under-utilise HIV services and to present later for care than women, and consequently they have worse outcomes on treatment [45],[52],[53]. In the studies reviewed here, an overall proportion of 47% of those offered testing were men. This compares favourably with facility-based testing, where testing of males attending the clinic may be as low as 9% [45]. In our meta-analysis of HBT, an almost equivalent proportion of men were offered a test as women, and they were as likely to accept testing, an outcome that gives promise of greatly improving awareness of HIV status for both sexes. Studies that provided results at a distant site even if testing was conducted at home were associated with lower proportions of people receiving results out of those who accepted testing. While this emphasises the benefits of HBT including immediate provision of results in raising awareness of HIV status, it may be of less concern given that rapid diagnostic tests with immediate results are now the norm for voluntary HIV testing globally. Examination of trends by country suggest lower uptake of testing in South Africa, where three out of five studies reported uptake of ≤70% (note that two of these studies were in the same setting in KwaZulu-Natal) (Figure 1) [27],[38]. However, the most recent study from South Africa found very high uptake of HBT (91.8%) [44]. Based on the paucity of countries and the number of studies per country available for this review, it would be unwise to draw conclusions about country differences and acceptability of HBT. While the results of sub-group analyses need to be interpreted with caution, they suggest that the running of pre-test sensitisation campaigns may be of little benefit in terms of uptake of HBT. However, these are essentially “ecological” comparisons, which may be confounded by many other differences between the study populations examined. Also, the number of studies where incentives were given was very small (Table 1), and strong conclusions cannot be drawn. Nevertheless, the fact that most of the studies demonstrated similar proportions of uptake of HBT perhaps argues against a strong effect. The finding that studies with a lower proportion of individuals previously tested for HIV (<30%) had a higher frequency of test uptake points to the value of HBT as an effective approach to engage those not previously aware of their HIV status in testing. It could suggest that HBT is effective in achieving initial diagnosis but less so for repeat testing. Targeted HBT of index HIV-positive clients' household members may be an effective way to achieve higher acceptance in settings where more general HBT is not feasible because of resource limitations. Uptake of HBT may be influenced by availability of treatment, as indicated by the fact that the study with the lowest overall success (only 25% of people offered a test received their result) was done at a time when antiretroviral treatment was not available in the communities studied [34] (although overall there was no effect of “study period”). However, there may be other confounding factors involved, and this study was based on a small sample size; in sensitivity analysis, excluding it from the analysis did not change the pooled estimate of uptake of HBT (data not shown). Three other studies were notable for having <70% receipt of results amongst those who accepted HBT (Figure S1). Two of these studies offered the option of receiving results at a later date [26],[29], while the third [28] offered the option of receiving results on the same day. Human rights protections should be an integral part of any testing campaign, and every effort should be made to avoid physical, social, and psychological harm to individuals [16],[17]. However, the high level of uptake we have found overall seems to indicate acceptability of HBT in the communities studied. There are several strengths and limitations to this review. We used a broad search strategy that allowed us to capture 21 studies (published in 19 articles), resulting in a large overall sample size and giving increased confidence in the pooled estimates. There was high statistical heterogeneity, as expected for pooled proportions in observational studies. We limited our search to studies conducted in SSA over the last decade in order to improve comparability, and used a random-effects model to pool data. We undertook a number of sensitivity and sub-group analyses to explore potential sources of heterogeneity. The non-uniformity of the studies, which were nonetheless looking at uptake of a “uniform” activity (the offer of an HIV test at home), could be considered both a strength and limitation of our review. While it may be a limitation for pooling results, it could be considered a strength that even in a range of study contexts, HBT consistently achieved higher uptake than is seen in facility-based testing. Another limitation was that, as a trade-off to using a broad search strategy, our search was limited to just three databases and to published articles in peer-reviewed journals. We therefore cannot rule out the possibility that we may have missed some studies, or the possibility of publication bias leading to the non-publication of studies with lower uptake. The limited number of studies that provided data on the health status of those identified as HIV-positive by HBT is a further shortcoming that this review was unable to address. Our findings do, however, indicate a number of directions for future research. In particular, key areas for research include linkage to care following HBT, retention in care of those identified HIV-positive through HBT (who are more likely to be clinically well when diagnosed), as well as repeated HBT for ongoing knowledge of HIV status. The option of self-testing with support from HBT staff is an area of research that is highly topical given recent developments in self-testing [54]. The suggestion from this review that the conduct of sensitisation campaigns has little or no impact on uptake of HBT and receipt of results has important implications for programme cost and efficiency and deserves further evaluation. More data are needed on the effectiveness of HBT in detecting previously undiagnosed HIV infection. Sustainability and cost considerations (short- and long-term) are important to help guide policy, and further work on cost-effectiveness is required. Further research on individual-level factors associated with participation in HBT, such as that recently published by Cherutich et al. [6], would inform implementers on individuals who require further engagement to encourage uptake. A key finding of our review is that HBT is able to reach wide sections of communities in a diverse range of contexts and settings. HBT provides the opportunity to acquire knowledge of HIV status at the doorstep for those who may not otherwise have sought testing, and may be pivotal in providing an effective tool for governments and health service providers to increase access to HIV treatment and prevention, by increasing uptake of testing. We conclude that HBT has the potential to dramatically increase awareness of HIV status in previously undiagnosed men and women in SSA. HBT is a gateway to accessing care early, and the benefits for individual and public health, both for treatment and prevention, make it an invaluable tool in the fight against HIV. Supporting Information Figure S1 Proportion receiving result of HBT. (TIFF) Click here for additional data file. Table S1 Studies reporting individual-level predictors of uptake of HBT. (DOCX) Click here for additional data file. Text S1 PRISMA statement. (DOCX) Click here for additional data file. Text S2 Search protocol. (DOCX) Click here for additional data file.
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            Voluntary HIV counselling and testing among men in rural western Uganda: Implications for HIV prevention

            Background Voluntary HIV counselling and testing (VCT) is one of the key strategies in the prevention and control of HIV/AIDS in Uganda. However, the utilization of VCT services particularly among men is low in Kasese district. We therefore conducted a study to determine the prevalence and factors associated with VCT use among men in Bukonzo West health sub-district, Kasese district. Methods A population-based cross-sectional study employing both quantitative and qualitative techniques of data collection was conducted between January and April 2005. Using cluster sampling, 780 men aged 18 years and above, residing in Bukonzo West health sub-district, were sampled from 38 randomly selected clusters. Data was collected on VCT use and independent variables. Focus group discussions (4) and key informant interviews (10) were also conducted. Binary logistic regression was performed to determine the predictors of VCT use among men. Results Overall VCT use among men was 23.3% (95% CI 17.2–29.4). Forty six percent (95% CI 40.8–51.2) had pre-test counselling and 25.9% (95%CI 19.9–31.9) had HIV testing. Of those who tested, 96% returned for post-test counselling and received HIV results. VCT use was higher among men aged 35 years and below (OR = 2.69, 95%CI 1.77–4.07), the non-subsistence farmers (OR = 2.37, 95%CI 2.37), the couple testing (OR = 2.37, 95%CI 1.02–8.83) and men with intention to disclose HIV test results to sexual partners (OR = 1.64, 95%CI 1.04–2.60). The major barriers to VCT use among men were poor utilization of VCT services due to poor access, stigma and confidentiality of services. Conclusion VCT use among men in Bukonzo West, Kasese district was low. In order to increase VCT use among men, the VCT programme needs to address HIV stigma and improve access and confidentiality of VCT services. Among the more promising interventions are the use of routine counselling and testing for HIV of patients seeking health care in health units, home based VCT programmes, and mainstreaming of HIV counselling and testing services in community development programmes.
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              Leveraging Rapid Community-Based HIV Testing Campaigns for Non-Communicable Diseases in Rural Uganda

              Background The high burden of undiagnosed HIV in sub-Saharan Africa limits treatment and prevention efforts. Community-based HIV testing campaigns can address this challenge and provide an untapped opportunity to identify non-communicable diseases (NCDs). We tested the feasibility and diagnostic yield of integrating NCD and communicable diseases into a rapid HIV testing and referral campaign for all residents of a rural Ugandan parish. Methods A five-day, multi-disease campaign, offering diagnostic, preventive, treatment and referral services, was performed in May 2011. Services included point-of-care screening for HIV, malaria, TB, hypertension and diabetes. Finger-prick diagnostics eliminated the need for phlebotomy. HIV-infected adults met clinic staff and peer counselors on-site; those with CD4≤100/µL underwent intensive counseling and rapid referral for antiretroviral therapy (ART). Community participation, case-finding yield, and linkage to care three months post-campaign were analyzed. Results Of 6,300 residents, 2,323/3,150 (74%) adults and 2,020/3,150 (69%) children participated. An estimated 95% and 52% of adult female and male residents participated respectively. Adult HIV prevalence was 7.8%, with 46% of HIV-infected adults newly diagnosed. Thirty-nine percent of new HIV diagnoses linked to care. In a pilot subgroup with CD4≤100, 83% linked and started ART within 10 days. Malaria was identified in 10% of children, and hypertension and diabetes in 28% and 3.5% of adults screened, respectively. Sixty-five percent of hypertensives and 23% of diabetics were new diagnoses, of which 43% and 61% linked to care, respectively. Screening identified suspected TB in 87% of HIV-infected and 19% of HIV-uninfected adults; 52% percent of HIV-uninfected TB suspects linked to care. Conclusions In an integrated campaign engaging 74% of adult residents, we identified a high burden of undiagnosed HIV, hypertension and diabetes. Improving male attendance and optimizing linkage to care require new approaches. The campaign demonstrates the feasibility of integrating hypertension, diabetes and communicable diseases into HIV initiatives.
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                PLoS Med
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                plosmed
                PLoS Medicine
                Public Library of Science (San Francisco, USA )
                1549-1277
                1549-1676
                December 2014
                16 December 2014
                : 11
                : 12
                : e1001768
                Affiliations
                [1 ]Clinical Research Unit, Medical Services and Diagnostic, Swiss Tropical and Public Health Institute, University of Basel, Basel, Switzerland
                [2 ]SolidarMed Lesotho, Seboche Hospital, Butha-Buthe, Lesotho
                [3 ]Faculty of Medicine, University of Geneva, Geneva, Switzerland
                [4 ]SolidarMed Switzerland, Lucerne, Switzerland
                [5 ]SolidarMed Lesotho, Paray Hospital, Thaba-Tseka, Lesotho
                McGill University Health Centre, Canada
                Author notes

                The authors have declared that no competing interests exist.

                Conceived and designed the experiments: NDL JE MM KP MK MH. Performed the experiments: NDL MM MK. Analyzed the data: NDL MH BC. Contributed reagents/materials/analysis tools: NDL BC MM MK. Wrote the first draft of the manuscript: NDL. Wrote the paper: NDL MK MM KP BC MH JE. ICMJE criteria for authorship read and met: NDL MK MM KP BC MH JE. Agree with manuscript results and conclusions: NDL MK MM KP BC MH JE. Enrolled patients: MM MK.

                Article
                PMEDICINE-D-13-02959
                10.1371/journal.pmed.1001768
                4267810
                25513807
                77e831e5-6cc8-4228-afe0-0864ccca987e
                Copyright @ 2014

                This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

                History
                : 13 September 2013
                : 3 November 2014
                Page count
                Pages: 11
                Funding
                The trial was part of the SolidarMed ART-project in Lesotho (SMART 3). Except the salary of the nurses of the study-team who were employees of the Ministry of Health of Lesotho or the Christian Health Association of Lesotho (CHAL), all other costs to implement the study (as listed in Table S1) were covered by the SolidarMed project cost. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.
                Categories
                Research Article
                Medicine and Health Sciences
                Health Care
                Health Services Research
                Infectious Diseases
                Viral Diseases
                AIDS
                Sexually Transmitted Diseases
                Public and Occupational Health
                Global Health
                Health Screening
                Preventive Medicine

                Medicine
                Medicine

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