The HIV epidemic remains a serious burden on people and health services across the world, with 33 million people infected and 2.7 million people becoming infected annually.1 HIV counseling and testing (HCT) is the critical first step in accessing HIV treatment and care; but despite efforts to scale up provision in resource-poor countries, an estimated 60% of people living with HIV are unaware of their HIV status.2 Lack of confidentiality, social barriers, and cost and accessibility associated with testing at clinics has been associated with low testing rates.3,4 The benefits of earlier initiation of antiretroviral treatment (ART)5 and the potential role of treatment as an HIV prevention strategy6 have added to the importance of improving uptake of HCT services.
Evidence from the South Africa region suggests that although scale-up of ART services has been successful, significant proportions still only seek care late, especially men.7 This coupled with the high HIV incidence in the area,8 and the need to address barriers to accessing HCT services, was the reason we introduced a community-based HCT service within the primary-care–based HIV treatment and care program. Although there has been considerable success with both home HCT9–11 and mobile HCT,3,12,13 we sought to compare users of the home and mobile HCT service to understand the contribution of either modality in the provision of HCT within the program.
The study was conducted between February and June 2009, when the home and mobile testing service was introduced in the Hlabisa subdistrict, KwaZulu-Natal. The HIV treatment and care program is a partnership between the Department of Health and the Africa Centre for Health and Population Studies. The area is predominantly rural with 1 local hospital and 17 primary health care (PHC) clinics serving a population of approximately 220,000 people, the mean travel time to the nearest clinic is 77 minutes,14 HIV prevalence in the area is approximately 22% in adults, and HIV incidence overall is 3% per year.15
The home and mobile testing service started February 2009. The area was divided along traditional boundaries into smaller units using a geographical information system. Units of approximately equal population size and density were visited by either the home or mobile testing unit for a period of 2–20 days. Counselor supervisors determined time spent in each area; for home, till all households had been visited; for mobile, till further uptake was unlikely. The service was developed in close consultation with the local community. Before implementation, community mobilization and education was achieved through a series of meetings with local political and traditional leaders and distribution of information leaflets and road shows to market the service.
The mobile testing unit had capacity to provide HCT for up to 6 clients at any one time in either a truck or in additional tents. The facility was set up at local community venues, chosen for convenience to the community and access to the greatest number of clients as possible, often near schools or shops. For home testing, a team of 6 HIV counselors visited every single household in the specified areas. Anyone reached by the testing units was also invited to participate in the questionnaire interview before HCT. Participants were provided with educational leaflets; condoms; and if tested HIV positive, referral letters to the local HIV clinic for further follow-up. All counseling and testing was performed in accordance with guidelines provided by the South African Department of Health.16 Ethics approval was granted by the University of KwaZulu-Natal Humanities ethics committee (reference HSS/0727/08).
Data Collection and Analysis
Questionnaires recorded participant's demographic details, area where service was offered, subsequent uptake and outcome of HCT, and past use of HIV testing services. A Zulu translation of the questionnaires was provided to participants, with counselors completing the English version. Questionnaires were anonymous, with each participant given a unique identifier. Questionnaires were checked for completeness and data entered into a secure database. Descriptive analyses compared HCT utilization between those served by the mobile or home services. HIV prevalence rates, and 95% confidence interval, were calculated across baseline characteristics and evaluated for significant differences between the 2 services. All variables were categorical, and χ2 or Fisher exact test was used to test for significant differences. Statistical analysis was performed with SPSS version 16 (SPSS, Chicago, IL).
Utilizing the Africa Centre geographical information system, we compared use of home and mobile testing services with the nearest fixed HCT facility where clients would otherwise have been tested; in 2 cases, the PHC clinic and for one, the nearest HCT facility was the regional hospital. We extracted programmatic data to determine use of HCT services at these facilities during the time period of the pilot.
From February to June 2009, 2774 participants completed the questionnaire, of whom 2598 (94%) accepted HIV testing (Table 1). Although high in both, a greater proportion of participants offered HCT proceeded to HIV testing with mobile than home testing (96.6% vs. 91.8%, 1013 vs. 1585; P < 0.001), whereas overall numbers of clients tested each day were higher in the home testing service (15.1 vs. 13.7; P < 0.001). Women accounted for a greater proportion of clients tested in both services; mobile services tested a higher proportion of men than home services (40.8% vs. 30.1%; P < 0.001). The mobile service tested a greater proportion of clients who were single (65.9% vs. 49.9%; P < 0.001), aged 15–24 years (52.8% v 27.6%; P < 0.001), and who had never previously had a HIV test (62.0% vs. 55.3%; P < 0.001); the home service tested a greater proportion of clients with a partner (42.8% vs. 29.8%; P < 0.001) and over the age of 25 years (72.4% vs. 47.2%; P < 0.001) (Table 1). HIV prevalence was comparable in clients receiving HCT through the home and mobile services (18.2% vs. 16.4%; P = 0.257), with no significant differences in HIV prevalence by gender, age, marital, or employment status.
Table 2 shows that in the region visited, where the nearest HCT facility was the hospital, the mobile and home services were seeing as many clients daily as the hospital. In the regions where the nearest HCT facility was at the PHC clinic, the home and mobile services were testing 5 times as many clients daily.
This study evaluated the characteristics of users of a home and mobile HCT service in a rural region of South Africa. The 2 services were seeing about 15 participants daily, with more than 90% consenting for a HIV test. Previous studies have compared home or mobile HCT services to fixed HCT services but not to each other. Consent rates following contacts in our study were comparable to rates in similar settings.3,9 We found that a greater proportion of clients tested in the mobile HCT services were male, young, single, or never previously tested, whereas a greater proportion of clients tested in home HCT services were older, married/partner, or unemployed. Importantly, there was no evidence of significant differences by service type in HIV prevalence.
Young people younger than 25 years account for nearly 41% of new infections,17 and for HIV prevention strategies to be effective, this age group needs to be targeted.18 Over a half of the mobile testing clients were younger than 25 years and two-thirds were single which would suggest that utilizing mobile testing units as a vehicle for providing additional sexual health education, beyond that provided through HCT, may prove an effective prevention strategy.
Previous studies have shown that compared with traditional HCT services, home and mobile HCT attract a greater proportion of new testers but a lower proportion of clients who are HIV positive but unaware of their status.10,12 We found that mobile HCT attracted a greater proportion of new testers than home HCT. The HIV prevalence amongst clients of our home and mobile services was comparable, and although similar to household surveillance data from the region,15 was lower than amongst the clients of hospital and PHC clinics. Importantly, the home and mobile services were testing more clients daily than HCT services at the PHC clinics and comparable to HCT services at the hospital. The HCT service attached to the hospital, where a combination of provider-initiated and client-initiated testing takes place, is likely to test a large number of clients daily. The hospital is busy, serves the whole region, and provides care to sicker individuals.
This was a service evaluation and no client identifiers were recorded to allow investigation of linkage into HIV care and treatment services and further understanding of this is needed, especially whether linkage rates differ across modalities and whether linkage could be increased through providing simple interventions alongside posttest counseling. It is possible that those accessing the home and mobile services may have otherwise accessed HCT through their PHC clinic; however review of programmatic data suggests uptake of HCT through PHC clinics was relatively static.
The lower uptake in some areas, especially with the mobile services, may be due adverse weather conditions deterring clients or units spending insufficient time in each location. The lower uptake in some areas visited by the home services may be due to residents not being at home on visits. In providing the mobile testing service, we tried to be adaptive and responded to usage. Mobile testing teams may have to accept that on certain days, use is minimal, but this should not deter from returning to the location on subsequent days. The 2 services were provided during standard working hours; and in providing a home testing service, it may be necessary to adapt service provision times if uptake is low.
In summary, we found that the home and mobile testing services were equally and highly acceptable amongst the population, especially amongst first-time users of HCT services. Importantly, clients of a home testing service differ from clients of a mobile testing service in terms of their age, gender, and marital status, with both being effective in reaching new testers and HIV-positive individuals who are unaware of their status. If the benefits of ART to prevent onward transmission6,19 are to be realized, universal and regular HIV testing is essential. Achieving this may require both home and mobile testing services to be offered to communities.
The authors would like to acknowledge the contribution of Lungile Cira, program coordinator, and all the staff involved in the home and mobile testing service. The authors are grateful to all the Department of Health and Africa Centre staff working in the clinics and at the Centre—their dedication is humbling. Finally, the authors thank the community of Hlabisa subdistrict for hosting our initiatives.
3. Morin SF, Khumalo-Sakutukwa G, Charlebois ED, et al.. Removing barriers to knowing HIV status: same-day mobile HIV testing in Zimbabwe. J Acquir Immune Defic Syndr. 2006;41:218–224.
4. Matovu JK, Makumbi FE. Expanding access to voluntary HIV counselling and testing in sub-Saharan Africa: alternative approaches for improving uptake, 2001–2007. Trop Med Int Health. 2007;12:1315–1322.
5. Severe P, Juste MA, Ambroise A, et al.. Early versus standard antiretroviral therapy for HIV-infected adults in Haiti. N Engl J Med. 2010;363:257–265.
6. Granich RM, Gilks CF, Dye C, et al.. Universal voluntary HIV testing with immediate antiretroviral therapy as a strategy for elimination of HIV transmission: a mathematical model. Lancet. 2009;373:48–57.
7. Mutevedzi PC, Lessells RJ, Heller T, et al.. Scale-up of a decentralized HIV treatment programme in rural KwaZulu-Natal, South Africa: does rapid expansion affect patient outcomes? Bull World Health Organ. 2010;88:593–600.
8. Barnighausen T, Tanser F, Gqwede Z, et al.. High HIV incidence in a community with high HIV prevalence in rural South Africa: findings from a prospective population-based study. AIDS. 2008;22:139–144.
9. Were W, Mermin J, Bunnell R, et al.. Home-based model for HIV voluntary counselling and testing. Lancet. 2003;361:1569.
10. Menzies N, Abang B, Wanyenze R, et al.. The costs and effectiveness of four HIV counseling and testing strategies in Uganda. AIDS. 2009;23:395–401.
11. Helleringer S, Kohler HP, Frimpong JA, et al.. Increasing uptake of HIV testing and counseling among the poorest in sub-Saharan countries through home-based service provision. J Acquir Immune Defic Syndr. 2009;51:185–193.
12. Grabbe KL, Menzies N, Taegtmeyer M, et al.. Increasing access to HIV counseling and testing through mobile services in Kenya: strategies, utilization, and cost-effectiveness. J Acquir Immune Defic Syndr. 2010;54:317–323.
13. Sweat M, Morin S, Celentano D, et al.. Community-based intervention to increase HIV testing and case detection in people aged 16–32 years in Tanzania, Zimbabwe, and Thailand (NIMH Project Accept, HPTN 043): a randomised study. Lancet Infect Dis. 2011;11:525–532.
14. Tanser F, Gijsbertsen B, Herbst K. Modelling and understanding primary health care accessibility and utilization in rural South Africa: an exploration using a geographical information system. Soc Sci Med. 2006;63:691–705.
15. Welz T, Hosegood V, Jaffar S, et al.. Continued very high prevalence of HIV infection in rural KwaZulu-Natal, South Africa: a population-based longitudinal study. AIDS. 2007;21:1467–1472.
18. Piot P, Bartos M, Larson H, et al.. Coming to terms with complexity: a call to action for HIV prevention. Lancet. 2008;372:845–859.
19. Cohen MS, Chen YQ, McCauley M, et al.. Prevention of HIV-1 infection with early antiretroviral therapy. N Engl J Med. 2011;365:493–505.