In settings with high HIV prevalence, guidelines recommend that household contacts of persons with active tuberculosis (TB) undergo HIV counseling and testing (HCT).1 HCT facilitates early HIV diagnosis and provides an opportunity to increase status awareness among vulnerable populations.2–6 Expanded access to HCT is critical to reaching the goal of 90% of people living with HIV (PLHIV) knowing their status.7,8
Offering home-based HCT during household contact investigation for TB eliminates some barriers to HIV testing, including the need to travel to clinics. The home may also afford more privacy and social support than a clinic, addressing some stigma-related barriers.9 However, there is limited understanding of how integrating HIV and TB evaluation may influence acceptance of HCT, especially in the context of a household visit. At a time of heightened stress after a household member's diagnosis with TB, there is risk that offering these services together could be antagonistic rather than synergistic. We performed a mixed-methods study to examine facilitators of and barriers to home-based HCT during household contact investigation for TB and to identify interventions to overcome these barriers.
This study took place in Kampala, Uganda. Uganda is a high HIV-TB-burden country; HIV prevalence is estimated at 7.1% among 15–49-year-olds and TB prevalence at 202 per 100,000.10 In previous studies, 69%–95% of Ugandans accepted HCT.11–13
We nested in-depth interviews in a household-randomized trial of enhanced TB contact investigation.
Trained lay health workers (LHWs) enrolled patients with TB at 7 public-sector TB units, then visited patients' homes to perform TB contact investigation. HIV education was delivered to the entire household. Individuals aged ≥15 years without known HIV were offered HCT, with individual pretest counseling and testing apart from others.
Each week, we randomly sampled contacts who had been offered HCT during the previous week. We stratified by sex, previous HIV testing, and HCT decision, oversampling participants who reported no other recent HIV test. During the final 2 rounds, we targeted populations by age/sex not captured during random selection. We contacted participants by telephone 2 weeks after their home visit and invited a 30-minute face-to-face interview in their preferred language, English or Luganda, at a location of their choice. We concluded sampling on reaching thematic saturation.14
Using semi-structured content analysis, we coded interview transcripts, adapting the initial code tree from an earlier study15 and generating additional codes through open coding. We applied codes independently, allowing cooccurrence, and resolved differences by consensus. After interpretation, we categorized emergent themes using the Capability, Opportunity, Motivation, and Behavior (COM-B) model and used the Behavior Change Wheel (BCW) framework to identify intervention strategies.16,17 See Supplemental Digital Content S1–S3, http://links.lww.com/QAI/B106 for additional details.
Each participant or parent/guardian provided written informed consent. Participants aged <18 years also provided written informed consent. The Makerere University School of Medicine Research Ethics Committee, Uganda National Council for Science and Technology, and Yale University Human Investigation Committee approved the study.
Twenty-eight contacts (72%) from 28 households participated; 2 declined and 9 were unreachable (Supplemental Digital Content Figure S1, Table S1, http://links.lww.com/QAI/B106). Twenty (69%) accepted HCT and 6 (21%) shared households with an index patient living with HIV. Median age was 27 years (IQR 21–34.5) and 20 (69%) were women, similar to the overall contact population (Supplemental Digital Content Tables S2 and S3, http://links.lww.com/QAI/B106).
Preexisting Desire to Confirm HIV Status
Reflecting on the home visit, most respondents who accepted testing described a preexisting desire to confirm their status (Table 1A). For these respondents, home-based HCT provided an opportunity to act on a motivation developed before the visit. Some were regular testers for whom HCT was fully normalized. Others had specific reasons to seek testing.
Desire to Support the Index Patient
Although LHWs described the visit as a service for contacts when they approached the home, many respondents associated the visit with care for the sick index patient. Respondents perceived cooperation as a way of supporting the index patient (Table 1B). Although respondents did not directly link testing to supporting the index patient, they were inclined to cooperate with visit activities.
Respondents who accepted HCT emphasized how home-based services eliminated need for transport, reduced waiting time, and enabled them to ask questions (Table 1C). Most respondents had negative perceptions of clinics.
In contrast to clinics, respondents—including those who declined testing—praised the character and interpersonal skills of LHWs (Table 1D). Although positive perceptions facilitated testing for those who were already motivated to test, they did not override motivational barriers.
Each facilitator is associated with 1 or more intervention strategies (Supplemental Digital Content Table S4, http://links.lww.com/QAI/B106).
Fear of receiving an HIV diagnosis was the most commonly repeated barrier. Respondents tended to revisit this theme throughout the interview (Table 2A). However, many respondents who expressed fear nonetheless decided to test, describing it as a barrier they ultimately overcame.
In the COM-B model, fear falls in the motivation domain because it refers to an internal influence that drives action and is “automatic” because it derives from emotion (Supplemental Digital Content S3, Table S5, http://links.lww.com/QAI/B106). Interventions that use persuasion, incentivization, modeling, or enablement target automatic motivational barriers.17 For example, providing normalizing language about HIV and HCT could reduce the impact of fear through persuasion.
Respondents who declined home testing because of fear also described themselves as psychologically incapable of acting during the visit. Several—all women—later reconsidered. For example, a woman who rejected HCT described her state of mind that day: “I was not prepared. I still had a shock.” Troubled by the revelation that her husband was infected with TB, she felt overwhelmed (Table 2B). Although too preoccupied to test during the home visit, she later traveled to a clinic for testing. Another woman who was unprepared to test during the visit said she later tested during a prenatal check-up. Her sister also reconsidered, telling the respondent that if the LHW returned, she would test.
Feeling unprepared to act falls in the psychological capability domain because it refers to the capacity to perform a behavior and in the “reflective” motivation domain because it involves beliefs about capability (Supplemental Digital Content S3, Table S5, http://links.lww.com/QAI/B106). Education, training, modeling, enablement, or persuasion can target barriers in 1 or both of these domains. For example, providing information earlier to facilitate planning could reduce the impact of this barrier.
Four participants reported not being invited to test. In most cases, respondents said that the LHW did not have the necessary supplies (Table 2C). Some said that the LHW nonetheless motivated them to go to the clinic for testing.
Respondents described the influence of other household members as both facilitator and barrier. Observing others who accepted testing emboldened some respondents to follow suit. Some referenced the affirmative decision of a partner when recounting their own choice:
I had actually refused to be tested. I had feared to be tested… My husband was around and he immediately accepted and (then) I felt there was no need for me to refuse (Female, 30).
Here, the husband's decision to test increased the wife's confidence and facilitated testing. In other cases, distrust motivated direct requests:
It was my wife who went first. I think it is because she was not trusting me because most of the times I am away on duty… She first showed me the (consent form) she had been given and then she told me to also have the test done before health workers leave the home. I was also tested… (Male, 24).
Anticipated distrust also influenced decisions: one man worried that declining after his wife consented would suggest that he was unsure of his status and so chose to test.
Social influence could also impede testing. A respondent from a household where all members declined observed,
You cannot accept to test when the rest have refused to do so (Female, 20).
Although results were confidential and tests were offered privately, respondents alluded to difficulty concealing the decision to test. In this environment, some participants rejected privacy altogether. One respondent described how a lone son in his large household accepted, but only if the test was conducted in the presence of the family.
These findings complement a growing literature that finds high levels of acceptance and satisfaction regarding home-based HCT.11–13,18–23 Most respondents say their home is a more private setting for testing than a health facility.12 However, a substantial minority of clients consistently decline home-based HCT. Our study contextualizes the test decision within the interaction with the LHW, household, and wider community. We have characterized the facilitators and barriers that drive home-based HCT acceptance and linked them to strategies for intervention using a behavioral framework.
Surveys suggest that home-based HCT may be an effective way to increase status awareness.12 In our study, however, we found that some household contacts of patients with TB felt emotionally unprepared and declined testing. Moreover, the contacts who felt unprepared were the very individuals who believed that a positive result was possible. This suggests that participants who are unready when initially offered HCT may be a critical, unreached group.
We identified 2 strategies to improve uptake: giving contacts time to form an intention to test and reframing home-based testing with normalizing language. These strategies can be enacted through minor changes to home-based HCT service provision, protocols, and communication efforts.
Several participants indicated that they or a family member changed their mind after declining. To “give time” to hesitant contacts without losing them from the testing cascade, we suggest 3 interventions. First, preeducating index patients and their supporters that HCT will be provided during home visits could better prepare contacts to test. Second, offering a follow-up opportunity to test could improve uptake for contacts who have not formed an intention to test at the initial visit. Finally, selective distribution of self-test kits may improve uptake, provided there are mechanisms to ensure linkage to care.24,25
We also recommend reframing home-based testing as a default procedure to reduce the psychological burden associated with choosing to test. In clinical settings, uptake is higher when testing is framed as the default course of action, rather than as an opt-in choice.26–28 LHWs could use normalizing “opt-out” language to introduce home-based testing as a standard procedure, similar to that used in some clinical settings.29–34 As there is evidence that clients may perceive opt-out testing as compulsory,35,36 this adaptation must be approached with care.
Furthermore, we found that the decisions of other household members influenced individual testing decisions. Others have found that distrust can contribute to couples' decisions to decline joint HCT.37,38 Our analysis showed little evidence that distrust negatively influenced acceptance. Rather, respondents described how distrust between marriage partners drove the decision to accept rather than decline the test opportunity. More generally, social influences within households can normalize testing when influential family members participate or inhibit testing when one member's refusal discourages others.
Finally, sometimes HCT was not offered. This is a reminder that barriers faced by clients are intertwined with the barriers faced by those delivering services. The LHWs conducting visits provided a bundle of services. Failure to offer HCT may reflect a paradox of complex interventions: as more services are provided, they become more appealing to clients but also more challenging to deliver consistently.
Our study has some strengths. We integrated demographic data and information about previous testing with participants' own reflections on their testing decision. Our study also leverages a strength of qualitative inquiry: the ability to explore unanticipated participant responses. Our sampling process allowed us to explore emerging themes until we reached saturation.
This study also has certain limitations. First, there was at least a two-week lag between the HCT opportunity and interview. This may increase the risk of recall error. Second, we were unable to reach several selected household contacts, although only 2 declined. Those not reached were more likely to have declined HCT or to reside with a PLHIV.
Home-based HCT can reach populations who are unmotivated or unable to visit clinics. Preexisting motivation, psychological readiness to test, and the influence of other household members are important contributors to the decision to test for HIV at home. Uptake might be improved by providing information about HCT before the visit, by building multiple HCT offers into contact investigation activities, by offering self-tests with follow-up counseling, and by introducing HCT with “opt-out” language.
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