JAIDS Journal of Acquired Immune Deficiency Syndromes:
Implementation and Operational Research: Epidemiology and Prevention
Home-Based HIV Testing and Counseling in Rural and Urban Kenyan Communities
Dalal, Warren MSW*; Feikin, Daniel R. MD, MSPH†; Amolloh, Manase‡; Ransom, Ray MPH§; Burke, Heather MPH, MA‖; Lugalia, Fillet¶; Ouma, Alice BSC¶; Laserson, Kayla F. SCD#; Mermin, Jonathan MD, MPH#,**; Breiman, Robert F. MD‖; Bunnell, Rebecca ScD, Med*
*Global AIDS Program, Centers for Disease Control and Prevention, Nairobi, Kenya
†Global Disease Detection, Centers for Disease Control and Prevention, Kisumu, Kenya
‡Global AIDS Program, Kenya Medical Research Institute, Kisumu, Kenya
§Division of Global HIV/AIDS, CDC, Atlanta, GA
‖Global Disease Detection, Centers for Disease Control and Prevention, Nairobi, Kenya
¶Global AIDS Program, Kenya Medical Research Institute, Nairobi, Kenya
#Coordinating Office for Global Health, Centers for Disease Control and Prevention, Kisumu, Kenya
**Coordinating Office for Global Health, Centers for Disease Control and Prevention, Nairobi, Kenya.
Correspondence to: Daniel R. Feikin, MD, MSPH, 814 N Wolfe St, Suite 600, Baltimore, MD 21205 (e-mail: firstname.lastname@example.org).
Supported by the United States President's Emergency Plan for AIDS Relief; the Centers for Disease Control and Prevention; Department of Health and Human Services.The findings and conclusions in this manuscript are those of the authors and do not necessarily represent the views of the Centers for Disease Control and Prevention.
The authors have no conflicts of interest to disclose.
Received April 24, 2012
Accepted September 21, 2012
Background: In sub-Saharan Africa, most people with HIV do not know they are infected.
Methods: We conducted door-to-door home-based testing and counseling (HBTC) in rural western Kenya (Lwak) and an informal urban settlement in Nairobi (Kibera) in 2008. After consent, eligible persons (adults and adolescents aged 13 years or older and children aged 12 years or younger, whose biologic mother was HIV-infected or deceased) received parallel fingerstick HIV rapid testing and counseling. Persons newly diagnosed with HIV were referred to care services, fingerstick blood for CD4 testing was collected, and a one-month follow-up home visit was conducted.
Results: Among 24,450 people who were offered HBTC, 19,966 (81.7%) accepted; 65.4% of whom were HIV-tested for the first time. Prevalence in adults aged 18 years or older being HIV-tested for the first time was 13.5% (12.6%, Kibera; 14.2%, Lwak). Among adults who reported a previously negative test, HIV prevalence was 7.4% (7.2%, Kibera; 7.6%, Lwak). Among all persons with HIV in these communities, two-thirds were newly diagnosed through HBTC. Median CD4 count among newly diagnosed adults was 403 [interquartile range (IQR) = 252–594]. Among couples, 38.0% in Kibera and 51.7% in Lwak were counseled together. Among HIV-infected people in a couple, 34.6% had an HIV-uninfected partner. Among newly diagnosed HIV-infected persons, at the one-month follow-up visit, 53.6% in Kibera and 43.6% in Lwak reported having visited an HIV patient support center.
Conclusions: HBTC acceptance was high and most HIV-infected persons did not previously know they had HIV. HBTC can be an effective strategy for early HIV diagnosis and treatment referral.
In 2009, an estimated 22.5 million people in sub-Saharan Africa were infected with HIV, representing 68% of the global total number of people living with HIV.1 The vast majority of persons in low- and middle-income countries who have been exposed to HIV have not accessed HIV testing and counseling services.1 In Kenya, in 2007, 84% of HIV-infected persons nationally were unaware of their status.2 While knowledge of personal HIV status continues to be limited,3,4 even fewer people know their sexual partner's HIV status5 despite the common belief that it is important to know one's status and their partners' status.6 Knowledge of status among people living with HIV has been associated with reductions in HIV transmission risk behavior of more than 60% in the United States7 and in East Africa.8 Furthermore, once diagnosed, many HIV-infected persons access treatment, which is associated with more than a 90% reduction in HIV transmission risk.9–13 Populations with high rates of undiagnosed HIV infection face formidable barriers to HIV prevention.
To address this concern, United Nations Member States renewed their commitment to halt and reverse the spread of HIV by outlining a UNAIDS strategy for 2011–2015.1,14 Achieving these goals depends on the success of reaching and diagnosing HIV in persons living with HIV and who are unaware of their status.14
Expanding current HIV testing and counseling programs by bringing services to households could remove perceived barriers to testing,15–19 increase coverage to rates close to universal access goals for testing,20,21 and effectively reach those with undiagnosed HIV infection.22,23 In Kenya, 83% of a nationally representative sample of adults stated that they would participate in home-based testing and counseling (HBTC) for HIV if it were available.2 Similar acceptance rates have been documented in HBTC studies and programs in mostly rural African sites.24–31 However, less is known about HBTC in densely populated urban settings, and little data exist on care and treatment referral success rates from such interventions. To inform future HIV testing and prevention efforts, we implemented a large HBTC program in rural and urban Kenya and assessed acceptance, prevalence, and treatment referral success rates.
From January 2008 to December 2008, we provided HBTC services for residents in 2 areas of Kenya who were participating in a population-based infectious disease surveillance (PBIDS) program.32 Lwak is a rural location in Nyanza Province in western Kenya along Lake Victoria, where residents of 33 villages participate in the surveillance program. The other surveillance site contains 2 villages that consist of 10 clusters in the densely populated Kibera informal settlement in Nairobi, one of Africa's largest urban slums. Both sites are populated primarily by the Luo ethnic group, one of the few ethnic groups in Kenya that does not practice traditional male circumcision. In the 2009 Kenya Demographic and Health Survey, the HIV prevalence among Luos aged 15–49 years was 20% compared with the national average of 6.3%.33 Combined, the 2 sites represent the range of Luo community types from urban to rural.
All PBIDS enrollee adults (18 years or older) were offered the option to consent and participate in HBTC. Written consent was obtained for linking HIV testing data and CD4 count results with PBIDS databases. All children aged 13 years or younger, whose biologic mothers were HIV-positive or were deceased, were offered HBTC with the approval and consent of their parent or guardian. Youth (13–17 years old) were also offered the opportunity to participate in HBTC but required parental consent and independent assent if they were living with their parents and were not pregnant. Emancipated minors between the ages of 13–17 years, who were living as independent mature minors, were allowed to give individual consent and were classified as such if they lived together with a consensual sexual partner or if they were pregnant or a mother.
Home-Based HIV Testing and Counseling
Community mobilizers (CMs) who were familiar with the community were identified by community opinion leaders to work on HBTC in each village cluster. CMs were trained on community mobilization, basic information on HIV, and a mobilization protocol for home-based testing services. CMs made appointments for HBTC, guided HBTC counselors to homes, and briefly introduced the counselor, who was not a local resident, to participants. CMs left the homes before the actual testing sessions.
The HBTC counselors received a 3-week voluntary counseling and testing training following Kenya's national guidelines,34 had at least one year of experience as a voluntary counseling and testing counselor, and received 2 weeks of HBTC training. Counselors filled a modified version of the standard Kenyan national voluntary counseling and testing data collection tool for each consenting participant and offered HIV testing as per the program algorithm. Data were collected on previous test results and on access to care and treatment. Previously tested persons, both HIV-positive and HIV-negative, were offered an opportunity for retesting. Regardless of whether individuals previously diagnosed with HIV chose to be retested, information was collected on their previous positive test result and if they sought care. Couple members were offered the option of receiving results individually or as a couple. Testing was performed in as private a location as possible within the household or homestead to ensure confidentiality. Code numbers were used as identifiers instead of names on all forms to protect the identities of the participants. Individuals found in participating households who were not participants in PBIDS were offered HIV testing, but their data were not included in any aggregate analysis presented in this report.
The rapid HIV testing protocols followed Kenya's national guidelines. Every participant 18 months of age or older undergoing testing had 0.5 mL of blood collected by a finger stick for rapid HIV antibody testing. Two test kits approved by the Kenyan Ministry of Health, Determine (Abbott Laboratories, Abbot Park, IL) and Bioline were used for each specimen and run in parallel. For discordant results, a third rapid test, Uni-gold (Trinity Biotech PLC, Bray, Ireland) was processed as a tiebreaker to determine the final result. For both children and adults, dried blood samples were taken on filter paper. ELISA was performed at the Kenya Medical Research Institute (KEMRI)/Centers for Disease Control and Prevention (CDC) laboratories on a 5% sample of dried blood samples for quality control. The ELISA result was communicated to the participant if discrepant from the rapid testing result. For all exposed children 18 months old or younger, polymerase chain reaction (PCR) was done on all who were positive by rapid antibody testing, and the PCR result was considered the final HIV status of the child. The PCR test result was given to their parent or guardian during a return visit by the HBTC counselor within 4 weeks. All adults received their HIV test results and risk reduction counseling immediately in their homes. Those diagnosed with HIV were provided education about HIV care, treatment, and prevention and a referral note to the nearest facility for free HIV care and treatment services.
CD4 Testing and Follow-Up for HIV-Positive Participants
On testing positive in the home, all HIV-positive persons were given the option of the counselor taking a second finger prick for CD4 count testing, using EDTA-containing (microvials). CD4 count testing was performed within 24 hours at the KEMRI/CDC laboratories. CD4 testing results were available at the PBIDS referral clinics' patient support centers (PSCs) if participants wanted them before their follow-up home visit. For all HIV-infected individuals, a single follow-up visit was attempted approximately one month post testing by the same counselor who provided their initial HBTC service. At this visit, the counselor delivered CD4 results, addressed participants' questions and concerns about their diagnosis, administered a brief questionnaire about whether the client accessed the PSC, and referred participants again to the nearest PSC if not receiving care.
We defined acceptance rates as all participants enrolled in PBIDS who were contacted and consented to participate (19,966) in HBTC among those contacted and offered HBTC (24,450). Those who declined were defined as those participants who were contacted and refused to participate in the HBTC program. Missing participants were defined as those PBIDS participants who were never contacted after at least 3 attempts, had out migrated from the PBIDS areas, or were deceased by the time of HBTC.
For the analysis of overall HIV prevalence, previous positive HIV test results reported by participants were considered valid without retesting during HBTC. However, previous HIV negative tests were not included in the analysis, regardless of when the test was done. Separate analyses of HIV prevalence were done limiting the results to those who previously tested HIV-negative, and to those who were first-time testers. The SAS System was used to calculate χ2 test statistics and to assess factors independently associated with HIV infection and knowledge of status. The protocol and written consent forms were reviewed and approved by the ethical review committees of the KEMRI/CDC.
Uptake of HBTC
We offered HBTC to 24,450 participants registered in PBIDS in Kibera and Lwak, among whom 19,966 (81.7%) accepted. Of all those eligible, 8836 (82.8%) of 10,673 in Kibera and 11,130 (80.8%) of 13,777 in Lwak accepted (Table 1). Among adults, acceptance was higher among women than men (Kibera 82.6% vs. 79.9%, P < 0.0001; Lwak 80.3% vs. 75.4%, P < 0.0001; Table 1). Acceptance rates were higher among children and youth than among adults. Acceptance rates varied by cluster and village, from 71.0%–87.8% in Kibera and 65.3%–96.7% in Lwak.
Among individuals who accepted HBTC, planning for the future was overwhelmingly cited (84.9%) as their main motivation for accepting the service. Participants' reasons for refusal included fear of knowing one's HIV status (17.4%), previously known HIV status (15.2%), preferring to test away from home (13.5%), and wanting to test later (13.1%).
Previous HIV Testing
Of those who accepted interviews, in Kibera 3,698 (41.9%) and in Lwak 3,221 (28.9%) reported testing previously for HIV. Of those previously tested, 406 (11.0%) in Kibera and 520 (16.1%) in Lwak reported a previous HIV-positive result. Of those reporting an HIV-positive result, 143 (35.2%) in Kibera and 127 (24.4%) in Lwak chose to be retested, of whom 264 (97.8%) of 270 tested positive on retesting. For the 6 persons with discrepant results, the same counseling protocol that the Kenyan Ministry of Health had developed for the Kenya AIDS Indicator Survey was used.2
Overall, HIV prevalence among adults was 16.3% with significantly higher rates in females (18.9%) than males (12.8%) (P < 0.0001; Table 2). Overall, among adults, 14.9% were infected in Kibera and 17.6% in Lwak. In Kibera, prevalence peaked among 35–44 year olds for both males (19.3%) and females (27.1%). For Lwak, males aged 35–44 years (31.6%) and females aged 25–34 years (31.6%) had the highest prevalence.
HIV prevalence among first-time tester adults was 12.6% in Kibera and 14.2% in Lwak (Table 2). Among first-time testers, prevalence among children was 10.3% in both Kibera and Lwak and among youths, 0.8% in Kibera and 3.0% in Lwak (Table 2). Of all consenting adults, 5400 (34.8%) reported a previous negative test. Of these, 225 (7.2%) in Kibera and 172 (7.6%) in Lwak were positive when tested in HBTC. The prevalence among 13–17 year old females in Kibera was 3.3%, and in Lwak, it was 9.1%.
Couples HIV Testing and Counseling
Among adult men (59.4%) and women (62.7%) in Kibera who reported being in a married or cohabitating relationship, 38.0% chose to be counseled and tested together in HBTC. Of those choosing couples testing, 7.9% were HIV-discordant, 7.8% were HIV-concordant positive, and 84.3% were HIV-concordant negative. In Lwak, 36.2% of men and 46.5% of women reported a married or cohabitating relationship and 51.7% of these chose couple counseling and testing in HBTC. Among these, 12.1% were HIV-discordant, 9.9% were HIV-concordant positive, and 77.9% were HIV-concordant negative. Among all HIV-infected people in a couple, 34.6% had an HIV-uninfected partner.
Care and Support
Of the 773 participants newly diagnosed with HIV infection in Kibera and 1066 in Lwak; 544 (70.4%) and 872 (81.8%), respectively, had never been previously tested for HIV (77% combined). Of these newly diagnosed persons, 67.5% in Kibera and 63.1% in Lwak had CD4 finger prick specimens for testing collected at the same home visit when they found out their HIV status to be tested in the KEMRI/CDC laboratories. For newly diagnosed adults, the median CD4 was 395 [interquartile range (IQR) = 241–598] in Kibera and 408 (IQR = 259–585) in Lwak (Table 3 and Fig. 1). Among newly diagnosed adults, 26.6% in Kibera and 23.6% in Lwak had CD4 counts <250 cells/mm, which was the threshold for antiretroviral therapy (ART) at the time in Kenya (Table 3). In both Kibera and Lwak, 35% of newly diagnosed persons had CD4 counts >500 cells/mm.
At the one-month follow-up visit for newly diagnosed participants of all ages, 362 (46.8%) were contacted in Kibera and 596 (55.9%) in Lwak. Of those contacted, 194 (53.6%) reported attending a PSC since their HBTC HIV test in Kibera and 260 (43.6%) in Lwak. Of those who visited a PSC, 175 (88.8%) received cotrimoxazole prophylaxis in Kibera and 234 (90.0%) in Lwak. Among those with CD4 counts <250, 20 (34.5%) had initiated ART treatment in Kibera and 23 (34.3%) in Lwak (Table 4).
Among the 504 (52.6%) newly diagnosed participants who did not attend a PSC between the time of HBTC and the follow-up visit, 255 (50.6%) reported that they were planning to go later, 135 (26.8%) did not have time, and 86 (17.1%) were waiting for the counselor to return. There were no differences between Kibera and Lwak in the order of the most frequently reported reasons for not visiting the PSC.
In both urban and rural Kenya, HBTC implemented by trained lay counselors was an effective strategy for achieving high coverage of HBTC and of reaching people with previously undiagnosed HIV infection. Overall acceptance of HBTC was high, with more than three-quarters of participants in both sites participating and 65% of participants never having been tested for HIV before the program. Overall, HIV prevalence among adults in these communities was high: 14.9% in Kibera and 17.6% in Lwak. Our programmatic findings suggest that HBTC is a promising strategy for greatly increasing population level coverage of HIV prevention, care, and treatment.
Our findings of high acceptance are consistent with nationally representative data that indicated that 83.5% of Kenyans would accept HBTC.2 Although acceptance among adult men (77.7%) was slightly lower than among women (81.4%), and youth were more likely to accept testing than older adults, we found that acceptance was consistently high across all population groups in both settings. While similarly high, or higher, acceptance rates have been documented in other rural settings in Africa, few programs have reported data from home-based testing in very densely populated urban settings where concerns about potential low acceptance have previously limited program implementation.
A nationally representative survey in 2007 showed that only 9%2 of married Kenyans knew their spouses' HIV status. Our program suggests that HBTC can significantly increase knowledge of partner's status; participation in couples testing was 38% in Kibera and 52% in Lwak. Couple HIV counseling and testing is an effective prevention intervention35–37 that increases knowledge of partners' status and reduces transmission risk within HIV-discordant couples.38,39 Incidence of HIV infection is high among couples in a married or long-term relationship,36 although perception of risk is traditionally low among this population. Approaching couples in their homes may facilitate couples testing and help circumvent societal norm barriers that inhibit couples from seeking couples testing together in public settings.40
There was a high acceptance rate (96%) of parents agreeing to test their children younger than the age of 13 years who were eligible for HBTC in both sites of the project. The high acceptance rate is contrary to a similar program in western Kenya in 2008 that showed acceptance rates for parents to test their children younger than the age of 13 years in home to be low (57%)30 which could be attributed to the larger inclusion criteria for eligible children to be tested. HIV prevalence was 10.3% among children younger than the age of 13 years who had never been tested before for HIV in both sites, highlighting the high burden of undiagnosed infection in this high-risk population (ie, children whose mothers are HIV-positive or are deceased) and the importance of including screening high-risk children as part of HBTC programs.
We identified many HIV-infected persons in the early stage of their disease. The HBTC program was completed within 1 year and although our study did not incorporate a cost study, data from elsewhere in sub-Saharan Africa suggests that HBTC provides a feasible and cost-effective strategy for achieving population-wide coverage of testing.23 The median CD4 counts among adults of approximately 400 cells/mm3 was considerably higher than those at HIV diagnosis in most HIV test settings in sub-Saharan Africa.41 Earlier diagnosis and initiation of preventive treatment is associated with slower disease progression. ART has also been shown to dramatically reduce HIV transmission risk.13 Models have estimated that universal testing and initiation of ART would halt the HIV epidemic, even in sub-Saharan Africa where the epidemic is most severe.10 Our findings suggest that implementation of universal testing through HBTC is feasible in remote rural and densely populated urban settings in sub-Saharan Africa.
Our project identified just more than 1800 new HIV-positive cases that were all offered a CD4 test and a one-month follow-up visit. In sub-Saharan Africa, where transport costs are a major barrier to seeking HIV care and treatment services,28,42 our strategy of providing CD4 results to referral facilities in advance of the patients' first visit aimed to reduce the number of required facility visits before treatment initiation. Our program strategy had not achieved optimal improvements in initiation of ART by the one-month follow-up visit, perhaps because the visit occurred too soon after testing or because participants were unfamiliar with the potential benefits of providing a second sample in the home for CD4 testing and because the new system of sending CD4 results to facilities in advance of patient's first visit had not been fully operationalized within referral facilities. Cotrimoxazole prophylaxis initiation rates were close to 90% for those who attended the PSC within the follow-up period, suggesting that most newly diagnosed patients were reaching referral facilities, but that further systems changes and provider training may be needed to ensure use of CD4 results at the first visit rather than second visit which was previous standard procedure. Further program evaluation should assess barriers and approaches to improving rates for CD4 testing acceptance, visiting a referral facility, and rapidly initiating ART.
Our findings have several potential limitations. We assessed an HBTC program in the context of a population already engaged in ongoing public health research. As such, the acceptance rates we documented might not have been representative of the general population. On the one hand, participants might have been more likely to participate in HBTC because of their previous familiarity with public health research. On the other hand, acceptance rates might have been lower because of study fatigue and concerns about lack of confidentiality in research setting where their HIV results were linked to ongoing surveillance data. Another limitation was that at the beginning of the HBTC project, Kenya was still experiencing the effects of the postelection violence of the December 2007 presidential elections.43 Due to the unstable situation, many people were migrating in or out of both Kibera and Lwak, which delayed the onset of the program and affected the refusal rate for HBTC, particularly in the early part of the study.
Third, we were unable to verify self-reports of previous HIV test results. Accuracy of those who reported a prior HIV-positive status was high (98%) among those who decided to retest in HBTC, so it is unlikely that we overestimated HIV prevalence by including self-reported positive tests in our prevalence calculation. It is possible that persons falsely reported that they were HIV-negative to confirm a previous positive test; this would have increased the prevalence of HIV in HBTC among those previously tested. However, the prevalence (7.4%) we found, among those previously tested negative and who retested, is consistent with other studies of repeat testers in Kenya.2 Fourth, follow-up visits were made to homes of all newly diagnosed HIV-positive individuals but only one attempt was made to locate them. Therefore, our follow-up rate was relatively low, and we may have overestimated linkage to care rates if those we did not locate were also less likely to have sought care and treatment services. Identifying facilitating factors and ensuring follow-up care services for people diagnosed with HIV is an important component of HBTC programs.
In addition, we encountered some implementation challenges. Although counselors were not local residents, concerns about confidentiality and community rumors were common at the beginning of our implementation but lessened as the HBTC became better known and accepted in the community. We visited homes during weekends but still we had difficulty encountering both couple members at the same time. While home-based services are popular among Kenyan adults, we used creative approaches, such as pregroup counseling sessions and special stations, to provide education, counseling, and testing services out of earshot of parents for adolescents. In countries where parental consent is required for adolescents to receive HIV testing, more innovative targeted approaches may be required to address the privacy and availability of HBTC to ensure that sexually active adolescents have a confidential and accessible venue for receiving HIV services.
In spite of these challenges and limitations, our HBTC program was widely accepted, successfully reached many previously undiagnosed individuals, couples, and children and provided an important practice base for achieving 80% universal testing goals as outlined by the Kenya National AIDS Strategic Plan III.44 Knowledge of HIV status is the lynchpin for HIV prevention, care, and treatment. Three decades into the HIV epidemic in sub-Saharan Africa, the vast majority of HIV-infected persons are still undiagnosed.1,2 HBTC provides an effective approach for fulfilling the public health imperative of universal access for HIV testing.
The authors thank the people of Kibera and Lwak for their continued support and participation with KEMRI/CDC. This article is published with the approval of the director of KEMRI. The findings and conclusions are those of the authors and do not necessarily represent the views of the Centers for Disease Control and Prevention.
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HIV; home-based counseling and testing; universal access; Kenya; discordant couples; HIV prevention; CD4 count
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