Community-based testing increased rates of HIV testing and detection in resource-limited settings

HIV testing rates in rural areas of resource-limited countries can be substantially increased using an intervention that involves community-based testing, mobilising targeted communities, and the provision of post-testing support, investigators report in The Lancet Infectious Diseases.

The intervention was associated with testing rates that were up to nine times higher than those achieved by standard voluntary counselling and testing (VCT) services, and led to the diagnosis of more cases of HIV.

“Bringing VCT directly to communities and linking VCT with mobilisation efforts and support services after HIV testing results in substantially greater uptake of both HIV testing and case detection than does standard voluntary counselling and testing,” write the investigators.

The study – called Project Accept – was undertaken because of the high rates of undiagnosed HIV infection in many resource-limited settings.

Investigators wanted to see if community-based HIV testing combined with community mobilisation and good post-testing support increased the number of individuals coming forward for screening.

They therefore designed a study involving communities in Tanzania (ten communities in Kisarawe District), Thailand (14 communities in Chiang Mai Province), and Zimbabwe (eight communities in the Mutoko District).

Communities in each of these regions were randomised to receive the community-based intervention or standard VCT services, based at a clinic or health centre. The study was conducted between 2006-09.

Investigators wished to see if the intervention was associated with higher rates of testing, the diagnosis of more cases of HIV, and an increased likelihood of repeat testing. Their current analysis was limited to individuals aged 16 and 32 years. This was because of this age group’s high risk of HIV and low testing rates.

In each of the regions, the proportion of individuals receiving their first HIV test was higher in the districts that received the community-based intervention than those using standard VCT (Tanzania: 37% vs. 9%; Thailand: 69% vs. 23%; Zimbabwe 51% vs. 5% - all p < 0.001).

“We believe that the CBVCT [community based VCT] strategy achieved HIV testing in an average of 55% of community residents aged 16-32 years across the three sites because of the multicomponent, comprehensive, and integrated nature of the intervention,” comment the investigators.

They add: “Ease of access for HIV testing services has a major effect on uptake” and suggest “both community mobilisation and social networking dynamics promoted uptake of HIV testing in CBVCT communities.”

However, testing rates for couples were higher at standard VCT centres. The investigators suggest that this is because of their linkage with antenatal services.

HIV prevalence rates were lower at the community-based sites (Tanzania 4% vs. 7%; Thailand: 2% vs. 3%; Zimbabwe 13% vs. 22% - all p < 0.001). Nevertheless, because of the community sites tested more people, they detected more HIV infections than the standard VCT sites (952 vs. 264, p = 0.003).

Rates of repeat HIV testing at the community-based sites were high and increased during the study reaching 28%.

The investigators believe that the benefits of community-based VCT extend beyond increasing the number of tested individuals and HIV cases diagnosed, and could help combat the stigma the surrounds HIV.

“As increasing numbers of people learn their serostatus, an untested person is more likely to personally know someone who has tested, instilling trust in the safety and benefits of learning their serostatus.”

Furthermore, high rates of repeat testing at community services could benefit HIV prevention.

“As a CBVCT programme matures, the epidemiological benefits…also evolve from case detection towards behavioural reinforcement and prevention.”

They conclude: “Within a short period, Project Accept mobilised large proportions of the study population to go through the difficult process of learning their HIV infection status, proving that local communities respond to HIV epidemics when comprehensive, user-friendly services are provided.”