Among those who accepted HBTC, 48.7% were men, one-third (33.8%) were aged 15–24 years, 29.7% had never been married or cohabited, 52.0% reported secondary education or higher, and 64.9% resided in the rural areas. Most (70.7%) had been tested for HIV in the past, with 54.4% reporting that their last HIV test was conducted in the past 12 months. Over 85% of respondents who accepted HBTC felt they were at no (42.3%) to low (43.1%) risk for HIV, while only 4.7% felt they were at great risk for HIV. Among participants who accepted HBTC, 1.9% reported a previous HIV-positive diagnosis. The proportion of HIV-infected persons who were unaware of their HIV infection and accepted HBCT was 68.6% (data not shown).
Overall, 4.1% participants tested HIV-positive in HBTC. Of those, 26.6% (n = 78) were on ART, and 73.4% (n = 258) were not on ART (data not shown). Among those who accepted point-of-care CD4 testing and were not on ART (n = 244), 42.5% had CD4 cell counts ≤350 cells per microliter, and 18.4% had CD4 cell counts ≤200 cells per microliter.
In 2012, over 70% of Kenyans aged 15–64 years had ever had an HIV test, double the rate observed in 2007 when only 36.6% of adults reported ever having been tested for HIV.6 Among women, testing rates increased from 40.7% in 2007 to 80.4% in 2012, achieving the universal access target for testing. Among men, a substantial increase in HIV testing was also observed from 24.9% in 2007 to 62.5% in 2012, but this still remained below the universal access target.
Routine HIV testing for pregnant women attending antenatal clinics (ANC) for prenatal care has played a major role in increasing HIV testing rates among women. In 2012, over 90% of women who had given birth in the past 5 years received an HIV test at an ANC visit for their last pregnancy.15 Still, approximately 5% of women do not attend ANC for prenatal care and require alternative approaches for accessing HTC, linkages to ART, and prevention of mother-to-child transmission of HIV services.
We found that men who had ever been tested were more likely to have been tested in community-based settings (eg, VCT facility and mobile VCT) compared with other venues. Community testing programs, therefore, could play an important role in expanding testing to underserved men such as those who are less educated and economically disadvantaged. Furthermore, innovative testing strategies for men in clinical settings may be needed, irrespective of whether they are at the clinic for their own care or accompanying a family member, including in antenatal care settings.
Only one-third of testers had ever tested together with a sexual partner. Approximately 4 in 10 new infections in the country occur within steady heterosexual partnerships,16 and the majority of persons in discordant relationships are unaware of their HIV status. Expansion of couples-centered HTC can offer major prevention benefit by identifying discordant couples and presenting options for reducing risk and transmission within these relationships.17,18 The World Health Organization recommends that couple testing be expanded in settings where routine HIV testing is offered, with support for mutual disclosure to empower couples to make informed decisions about HIV prevention and family planning.19 As Kenya begins to implement these recommendations, there will be need to assess their feasibility, acceptability, and behavioral and clinical impact among couples.
More than half of HIV-infected Kenyans were unaware of their infection, presenting a major barrier to HIV prevention and treatment in the country. Over 90% of persons who were unaware of their infection had reported that they were HIV-negative based on their last HIV test result; over half of these had been tested in the past year. A number of reasons may explain the discrepancies between self-reported HIV-negative status and laboratory-confirmed HIV infection, including recently acquired HIV infection since the last HIV test, reluctance in reporting HIV-positive status in a survey setting, false-negative results on previous HIV tests, or lack of understanding of previous positive test results. HIV-infected persons who were unaware of their HIV infection perceived themselves to be at no or low risk for HIV infection despite recent testing behavior. The national HTC guidelines recommend annual testing for persons with ongoing risk and more frequent testing after known occurences of HIV exposure.7 Counseling messages during HTC should include comprehensive risk assessment measures and provide recommendations on when to re-test for HIV infection.
Through HBTC, 72.0% of survey participants were tested and received their HIV test results within the privacy of their homes. Furthermore, 69% of HIV-infected persons who were unaware of their infection learned their HIV status through HBTC. In KAIS 2007 where HIV testing was conducted at a central laboratory, test results were made available at a nearby health facility approximately 6 weeks after survey teams had visited the households. As a result, only 49% of participants who agreed to HIV testing in the survey accessed their test results.5 The successful implementation of HBTC in KAIS 2012 demonstrates the feasibility of its inclusion in surveys with important benefits to survey participants, including immediate knowledge of HIV status, counseling, and early linkage to HIV care.
The proportion of participants who tested HIV-positive in HBTC was 4.1%, lower than the prevalence of HIV infection reported in the survey (5.6%).20 Around 28% of survey participants did not accept HBTC and of these, 14.2% were HIV-positive based on central laboratory HIV testing. These data suggest that some individuals with previously known HIV infection declined to participate in HBTC. Although HBTC provides an essential service to survey participants, use of HBTC data alone for estimating HIV prevalence in the broader population may be subject to bias.
Through point-of-care CD4 testing, we were able to determine that over 40% of HIV-positive persons identified through HBTC were in need of immediate treatment based on the current immunologic criterion for HIV treatment (CD4 ≤350 cells per microliter)21; 17% had CD4 ≤200 cells per microliter, indicative of advanced HIV disease. Sub-Saharan Africa is particularly challenged by high rates of late HIV diagnosis of persons in advanced stage of HIV disease, late enrollment into HIV care, and delayed initiation of ART leading to poor clinical outcomes and higher mortality.22,23 Continued expansion of HTC toward universal access, routine re-testing of persons at high-risk for HIV exposure, and point-of-care CD4 testing at the point of HIV diagnosis can help to increase identification of HIV-infected persons and improve early linkages to HIV care for better health outcomes.
This analysis had a few limitations. Our main outcome variables relied on self-report of HIV testing behavior and HIV status. It is possible that participants answered according to what they perceived to be socially desirable, resulting in a dilution of observed findings. Additionally, we relied on historical data around the respondent's last HIV test, including when and where the last HIV test was conducted, allowing for the potential for recall bias. Third, because of regional insecurity at the time of the survey, North Eastern region was not included in the KAIS 2012 sample, and therefore, results are not generalizable to the country as a whole. However, North Eastern region is sparsely populated and the least affected by HIV of all regions of Kenya, with an estimated prevalence of HIV infection of less than 1%.5 It is thus unlikely that exclusion of North Eastern region biased our results substantially. Finally, HBTC and point-of-care CD4 testing were provided to participants who wanted to learn their HIV status on the day of the survey. As a result, the estimates presented on HBTC are specific for a limited sample and not generalizable to the broader Kenyan adult population.
Despite these limitations, the results presented in this analysis provide an acceptably representative picture of the status of HIV testing in Kenya. KAIS 2012 found high testing rates among adult and adolescent Kenyans, nearly achieving the national testing goal for the country. Yet, the majority of HIV infection remains unidentified, contributing to ongoing HIV transmission and disease progression in the country. We recommend that the national HTC program expands all testing modalities to rapidly identify HIV-infected persons so that they can access the care they need immediately. Greater emphasis is required on increasing uptake of HTC among couples, promoting retesting among those at high risk for HIV infection, and increasing HIV testing in men. The inclusion of HBTC and point-of-care CD4 testing in this national survey was demonstrated to be feasible, improved knowledge of HIV status among participants, and identified a group in need of treatment that would have otherwise not sought care. These data will be essential as new strategies for HTC are implemented, moving Kenya closer to achieving its universal access targets of prevention, care, and treatment.
The authors thank the fieldworkers and supervisors for their work during KAIS data collection. They also acknowledge all the individuals that participated in this survey. The authors thank Kevin DeCock, George Rutherford, Mike Grasso, and Joy Mirjahangir for reviewing and providing input on the article; and the KAIS Study Group for their contribution to the design of the survey and collection of the data set: Willis Akhwale, Sehin Birhanu, John Bore, Angela Broad, Robert Buluma, Thomas Gachuki, Jennifer Galbraith, Anthony Gichangi, Beth Gikonyo, Margaret Gitau, Joshua Gitonga, Mike Grasso, Maya Harper, Andrew Imbwaga, Muthoni Junghae, Mutua Kakinyi, Samuel Mwangi Kamiru, Nicholas Owenje Kandege, Lucy Kanyara, Yasuyo Kawamura, Timothy Kellogg, George Kichamu, Andrea Kim, Lucy Kimondo, Davies Kimanga, Elija Kinyanjui, Stephen Kipkerich, Danson Kimutai Koske, Boniface O. K'Oyugi, Veronica Lee, Serenita Lewis, William Maina, Ernest Makokha, Agneta Mbithi, Joy Mirjahangir, Ibrahim Mohamed, Rex Mpazanje, Silas Mulwa, Nicolas Muraguri, Patrick Murithi, Lilly Muthoni, James Muttunga, Jane Mwangi, Mary Mwangi, Sophie Mwanyumba, Francis Ndichu, Anne Ng'ang'a, James Ng'ang'a, John Gitahi Ng'ang'a, Lucy Ng'ang'a, Carol Ngare, Bernadette Ng'eno, Inviolata Njeri, David Njogu, Bernard Obasi, Macdonald Obudho, Edwin Ochieng, Linus Odawo, Jacob Odhiambo, Caleb Ogada, Samuel Ogola, David Ojakaa, James Kwach Ojwang, George Okumu, Patricia Oluoch, Tom Oluoch, Kenneth Ochieng Omondi, Osborn Otieno, Yakubu Owolabi, Bharat Parekh, George Rutherford, Sandra Schwarcz, Shanaaz Sharrif, Victor Ssempijja, Lydia Tabuke, Yuko Takanaka, Mamo Umuro, Brian Eugene Wakhutu, Celia Wandera, John Wanyungu, Wanjiru Waruiru, Anthony Waruru, Paul Waweru, Larry Westerman, and Kelly Winter.
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Keywords:© 2014 by Lippincott Williams & Wilkins
HIV testing and counseling; Kenya; home-based testing and counseling; PIMA CD4 Analyzer