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Community-based intervention to increase HIV testing and case detection in people aged 16–32 years in Tanzania, Zimbabwe, and Thailand (NIMH Project Accept, HPTN 043): a randomised study

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Summary

Background

In developing countries, most people infected with HIV do not know their infection status. We aimed to assess whether HIV testing could be increased by combination of community mobilisation, mobile community-based voluntary counselling and testing (VCT), and support after testing.

Methods

Project Accept is underway in ten communities in Tanzania, eight in Zimbabwe, and 14 in Thailand. Communities at each site were paired according to similar demographic and environmental characteristics, and one community from each pair was randomly assigned to receive standard clinic-based VCT (SVCT), and the other community was assigned to receive community-based VCT (CBVCT) plus access to SVCT. Randomisation and assignment of communities to intervention groups was done by the statistics centre by computer; no one was masked to treatment assignment because the interventions were community based. Intervention was provided for about 3 years (2006–09). The primary endpoint of HIV incidence is pending completion of assessments after the intervention. In this interim analysis, we examined the secondary endpoint of uptake in HIV testing, differences in characteristics of clients receiving their first HIV test, and repeat testing. Analyses were limited to clients aged 16–32 years. This study is registered with ClinicalTrials.gov, number NCT00203749.

Findings

The proportion of clients receiving their first HIV test during the study was higher in CBVCT communities than in SVCT communities in Tanzania (2341 [37%] of 6250 vs 579 [9%] of 6733), Zimbabwe (5437 [51%] of 10 700 vs 602 [5%] of 12 150), and Thailand (7802 [69%] of 11 290 vs 2319 [23%] 10 033). The mean difference in the proportion of clients receiving HIV testing between CBVCT and SVCT communities was 40·2% (95% CI 15·8–64·7; p=0·019) across three community pairs (one per country). HIV prevalence was higher in SVCT communities than in CBVCT communities, but CBVCT detected almost four times more HIV cases than did SVCT across the three study sites (952 vs 264; p=0·003). Repeat HIV testing in CBVCT communities increased in all sites to reach 28% of all those testing for HIV by the end of the intervention period.

Interpretation

CBVCT should be considered as a viable intervention to increase detection of HIV infection, especially in regions with restricted access to clinic-based VCT and support services after testing.

Funding

US National Institute of Mental Health, HIV Prevention Trials Network (via US National Institute of Allergy and Infectious Diseases), and US National Institutes of Health.

Introduction

HIV counselling and testing can reduce anxiety about infection and assist individuals in making informed reproductive health and breastfeeding decisions. Importantly, HIV counselling and testing lowers risk behaviours,1, 2 especially in people infected with HIV and couples who are tested together.3, 4, 5, 6 Gaining knowledge of HIV infection status is also the gateway to lifesaving HIV/AIDS treatment,7, 8, 9 which substantially reduces HIV transmission.10 Findings of statistical modelling suggest that treatment of high proportions of people infected with HIV in a community could slow or even stop an HIV epidemic.11 However, more than 33 million people are infected with HIV, mostly in developing countries,12 of whom fewer than 30% are aware of their own infection status, and only 10% are aware of their partner's HIV infection status.13

HIV counselling and testing reduced behavioural risk in a randomised trial published in 2000.2 Since then, and with the advent of expanded AIDS treatment in developing countries, bold efforts have been made to expand HIV testing with major increases in financial support for voluntary counselling and testing (VCT) programmes, evolving strategies to increase uptake, and improvements in the linkage between HIV testing and treatment. Strategies include expansion of freestanding VCT clinics, home-based testing,14, 15 VCT clinics for adolescents,16, 17 expansion of HIV testing for pregnant women,18 provider-initiated testing in health-care settings,19, 20 and mass testing campaigns.21 Nevertheless, the proportion of people aware of their HIV infection status has remained well below that which is needed to substantially affect the epidemic in terms of reduction in behavioural risk, linkage to care and treatment, community awareness of the scope of the epidemic, and reduction in HIV-related stigma and discrimination. With so few people aware of their HIV infection status and thus unable to access treatment, the potential for antiretroviral treatment to reduce HIV infectivity is also compromised. Mobile VCT could help to expand knowledge of personal HIV infection status.22, 23 However, rigorous studies examining the benefit of mobile VCT in reaching large proportions of vulnerable populations have not been done.

Easily accessible mobile VCT services coupled with community mobilisation programmes and psychosocial support after testing could increase rates of HIV testing and diagnosis, reduce individual risk behaviours, improve reproductive health decision making, increase access to treatment, reduce HIV/AIDS-related stigma and discrimination, and ultimately lower HIV incidence. In this analysis, we focus on the effect of mobile services on uptake of VCT for HIV infection and HIV case detection.

Section snippets

Study sites and participants

The Project Accept trial is underway in ten communities in Tanzania (Kisarawe District), eight communities in Zimbabwe (Mutoko District), 14 communities in Thailand (Chiang Mai Province), and sixteen communities across two sites in South Africa (eight in KwaZulu-Natal and eight in Soweto). Ethnographic mapping was done during the formative phase of the study and the findings were used to select pairs of communities with similar access to health services, economic activities, population density,

Results

In all study sites, the number of people receiving their first HIV test during the study was much larger in CBVCT communities than in SVCT communities (table 1), with a difference of four times in Tanzania, about nine times in Zimbabwe, and about three times in Thailand. However, data for repeat testing could not be excluded for SVCT venues in Thailand so the actual difference might have been higher. Clients testing in CBVCT communities were slightly younger than were those testing in SVCT

Discussion

Communities can be mobilised to learn their HIV infection status, including in remote rural communities with little infrastructure across different regions, epidemic settings, and cultures (panel). The numbers of clients receiving their first test for HIV infection from Project Accept in CBVCT communities was four times higher in Tanzania, ten times higher in Zimbabwe, and about three times higher in Thailand than in SVCT communities. We believe that the extremely high uptake of HIV testing in

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