Abstract

Objective To assess the effect of home based HIV counselling and testing on the prevalence of HIV testing and reported behavioural changes in a rural subdistrict of South Africa.

Design Cluster randomised controlled trial.

Setting 16 communities (clusters) in uMzimkhulu subdistrict, KwaZulu-Natal province, South Africa.

Participants 4154 people aged 14 years or more who participated in a community survey.

Intervention Lay counsellors conducted door to door outreach and offered home based HIV counselling and testing to all consenting adults and adolescents aged 14-17 years with guardian consent. Control clusters received standard care, which consisted of HIV counselling and testing services at local clinics.

Main outcome measures Primary outcome measure was prevalence of testing for HIV. Other outcomes were HIV awareness, stigma, sexual behaviour, vulnerability to violence, and access to care.

Results Overall, 69% of participants in the home based HIV counselling and testing arm versus 47% in the control arm were tested for HIV during the study period (prevalence ratio 1.54, 95% confidence interval 1.32 to 1.81). More couples in the intervention arm had counselling and testing together than in the control arm (2.24, 1.49 to 3.03). The intervention had broader effects beyond HIV testing, with a 55% reduction in multiple partners (0.45, 0.33 to 0.62) and a stronger effect among those who had an HIV test (0.37, 0.24 to 0.58) and a 45% reduction in casual sexual partners (0.55, 0.42 to 0.73).

Conclusions Home based HIV counselling and testing increased the prevalence of HIV testing in a rural setting with high levels of stigma. Benefits also included higher uptake of couple counselling and testing and reduced sexual risk behaviour.

Discussion

A home based HIV counselling and testing intervention had a significant effect on the prevalence of HIV testing and couple counselling and testing. Furthermore, there was a significant reduction in multiple partners (particularly among those who had been tested) and casual partners in the intervention group compared with control group. The intervention included pretest and post-test counselling on reduction in sexual risk behaviour as well as follow-up of those who were HIV positive. There were no reports of violence or abuse towards the lay counsellors who offered home testing, and participants reported high acceptability of the approach.

We found an increase in HIV testing between the baseline and post-intervention surveys in our control areas. This possibly results from the National HIV counselling and testing campaign, which was launched by the department of health in 2010. Cointerventions taking place in control areas of cluster randomised trials are recognised challenges of pragmatic trials undertaken in real world settings.²⁰ Although the campaign achieved increased individual HIV testing, the home based HIV counselling and testing approach resulted in additional benefits, including reaching more people who had never previously been tested for HIV and most importantly reaching more couples. Furthermore, HIV testing campaigns are one off or repeated resource intensive activities, with no provision for continuity of care. Some people in the intervention arm still chose to be tested for HIV in a health facility (40%). The relative contribution of the community mobilisation and lay counsellor home visits in raising awareness and increasing willingness to go and be tested at a health facility is difficult to distinguish. Clearly different options are needed for different individuals; home based HIV counselling and testing in addition to health facility testing services and mobile outreach is necessary to achieve high population level coverage of HIV testing.

The World Health Organization’s latest guidelines for couple counselling and testing²¹encourage greater public health emphasis on couple counselling and testing. Transmission between partners in discordant couples (that is, where one partner is HIV positive) explains a major share of the incidence of new HIV infections in sub-Saharan Africa.²² Modelling suggests that mutual knowledge of HIV status would reduce the annual incidence of HIV among discordant cohabiting couples from 20% to as low as 7% in Zambia and 3% in Rwanda.²³ Home based HIV counselling and testing could also act as an entry point for pre-exposure prophylaxis for discordant couples, which has recently been approved by the US Food and Drug Administration.²⁴ The effect of home based HIV counselling and testing on couple counselling and testing may possibly be even larger in an urban area where couples are more likely to live together and do not migrate for work.

This rural region of South Africa was one of the first rural areas to have an antiretroviral treatment programme and is known to have high levels of stigma towards people with HIV/AIDS.²⁵ This study also found moderately high levels of stigma, with over a third of control participants reporting that people with HIV are treated badly owing to their status and almost half observing stigmatising behaviour towards someone with HIV/AIDS in the previous year. The positive effect of this intervention on HIV testing, despite the levels of stigma, is encouraging.

Our overall HIV prevalence of 8% is lower than expected when compared with the HIV prevalence of 25.8% among those aged 15-49 years in Kwazulu-Natal province.¹⁸ This may be explained in part by the fact that the mean age of our study population was 41, two thirds were women, the prevalence of high risk sexual behaviour was low, and the area is rural with considerable migration of men for work.

Source: BMJ