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The impact of lay counselors on HIV testing rates

quasi-experimental evidence from lay counselor redeployment in KwaZulu-Natal, South Africa

Hu, Janicea,b,*; Geldsetzer, Pascalb,*; Steele, Sarah Janec; Matthews, Philippad; Ortblad, Katrinab; Solomon, Tsionc; Shroufi, Amirc; van Cutsem, Gillese,f; Tanser, Frankd,g; Wyke, Sallyd,h; Vollmer, Sebastianb,i; Pillay, Deenand,j; McConnell, Margaretb; Bärnighausen, Tillb,d,k

doi: 10.1097/QAD.0000000000001924
Epidemiology and Social

Objectives: This study aimed to determine the causal effect of the number of lay counselors removed from a primary care clinic in rural South Africa on the number of clinic-based HIV tests performed.

Design: Fixed-effects panel analysis.

Methods: We collected monthly data on the number of lay counselors employed and HIV tests performed at nine primary care clinics in rural KwaZulu-Natal from January 2014 to December 2015. Using clinic-level and month-level fixed-effects regressions, we exploited the fact that lay counselors were removed from clinics at two quasi-random time points by a redeployment policy.

Results: A total of 24 526 HIV tests were conducted over the study period. Twenty-one of 27 lay counselors were removed across the nine clinics in the two redeployment waves. A 10% reduction in the number of lay counselors at a clinic was associated with a 4.9% [95% confidence interval (CI) 2.8–7.0, P < 0.001] decrease in the number of HIV tests performed. In absolute terms, losing one lay counselor from a clinic was associated with a mean of 29.7 (95% CI 21.2–38.2, P < 0.001) fewer HIV tests carried out at the clinic per month.

Conclusion: This study provides some evidence that lay counselors play an important role in the HIV response in rural South Africa. More broadly, this analysis adds some empirical support to plans to increase the involvement of lay health workers in the HIV response.

aSchool of Medicine, Duke University, Durham, North Carolina

bDepartment of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA

cMédecins Sans Frontières, eShowe

dAfrica Health Research Institute, Mtubatuba, KwaZulu-Natal

eSouthern African Medical Unit, Médecins Sans Frontières, Cape Town

fCentre for Infectious Disease Epidemiology and Research, University of Cape Town

gSchool of Nursing and Public Health, University of KwaZulu-Natal, Durban, KwaZulu-Natal, South Africa

hInstitute of Health and Wellbeing, University of Glasgow, Glasgow, UK

iDepartment of Economics & Centre for Modern Indian Studies, University of Goettingen, Göttingen, Germany

jDivision of Infection and Immunity, University College London, London, UK

kInstitute of Public Health, Faculty of Medicine, Heidelberg University, Heidelberg, Germany.

Correspondence to Pascal Geldsetzer, Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, MA 02115, USA Tel: +1 617 432 1232; e-mail:

Received 8 November, 2017

Revised 1 March, 2018

Accepted 12 March, 2018

Copyright © 2018 Wolters Kluwer Health, Inc.