The implementation and outcome of a 2-year prospective audit and feedback based antimicrobial stewardship program at a private tertiary care hospital.

PURPOSE: Antimicrobial resistance has emerged as a major public health problem in India. Hence effective antimicrobial stewardship programs (AMSP) are needed. We report the design, implementation and results of a prospective audit and feedback based AMSP at a private tertiary care hospital. METHODS: During the study period - January 2018 to December 2019 - the prescription of restricted antimicrobials required the filling of a justification form which was reviewed by the antimicrobial stewardship committee (AMSC) at 48-72 â€‹h. Patients in whom the restricted antimicrobial was stopped earlier than 48 â€‹h were not applicable for review. The eligible prescriptions were judged as justified/unjustified by AMSC based on the patient's clinical and previous antimicrobial history, course, results of investigations/cultures, guidelines and communicated to the treating team. Compliance to the recommendations of the AMSC was measured. Days of therapy for each restricted antimicrobial/1000 patient days was calculated. Colistin resistance rates in pathogens causing central line associated blood stream infections (CLABSI) were compared with previous years. RESULTS: A total of 2397 restricted antimicrobials in 1366 patients were prescribed in the study period of which 1801 prescriptions were applicable for review (75%). Overall, 1.4% of admitted patients were prescribed restricted antimicrobials. The total days of therapy with restricted antimicrobials was 41/1000 patient days. The AMSC committee adjudged 12.5% of prescriptions as unjustified and recommendations for de-escalation were accepted in 89%. There was no significant difference in the study outcomes between 2018 and 2019. CONCLUSION: The prospective audit and feedback component of AMSP provided insight into the use of restricted antimicrobials at our hospital. This component should be considered by hospitals for inclusion in their AMSP program on an ongoing basis even if limited to a few drugs and in few areas of the hospital.

Predominance of multidrug-resistant Gram-negative organisms as cause of surgical site infections at a private tertiary care hospital in Mumbai, India.

Background: This study aims to study the incidence, microbial aetiology and antimicrobial susceptibility of surgical site infections (SSIs) at a private tertiary care hospital in Mumbai, India, and compare it with previously published data from the same institute as well as literature. Methods: This is a prospective observational study done over 6 years (January 2013-December 2018) at a 750-bed private multi-specialty hospital in Mumbai, India, among all patients undergoing clean and clean-contaminated surgeries. Standard guidelines for preventing, diagnosing and classifying SSIs were followed. The incidence rates of SSI (overall and specialty specific), microbial aetiology and antibiotic susceptibility of SSI were calculated and expressed as percentages. Results: A total of 55,553 patients underwent clean and clean-contaminated surgeries during the study period. The overall SSI rate was 1.0% (555 cases). The SSI rate in clean surgeries was 0.97% and in clean-contaminated surgeries was 1.03%. Sixty-five per cent of SSIs were due to Gram-negative bacilli, 30% were due to Gram-positive cocci and 4% were due to Candida. Klebsiella pneumoniae (19%), Escherichia coli (17%), Pseudomonas aeruginosa (13%), Staphylococcus aureus(12%) and Enterococcus (10%) were the top five organisms. The overall susceptibility rate of the Gram-negative isolates to beta-lactam-beta-lactamase inhibitor combinations was 60% and carbapenems was 73%. The prevalence of methicillin resistance in S. aureus was 44% and coagulase-negative Staphylococcus was 84%. The crude mortality rate was 1%. Conclusions: Although the SSI rate is comparable to established international benchmarks, the predominance of multidrug-resistant Gram-negative organisms is a matter of serious concern.

Prevalence of COVID-19 antibodies in healthcare workers at the peak of the pandemic in Mumbai, India: A preliminary study.

Healthcare worker (HCW) infections due to COVID-19 are of serious consequence. Testing for antibodies against COVID-19 in HCWs has been previously recommended. We conducted a serosurvey in HCWs at a private hospital in Mumbai which is treating COVID patients. A total of 244 HCWs were tested. The prevalence of infection in asymptomatic HCWs was 4.3% and in previously symptomatic untested HCWs was 70%. We recommend that HCWs with a previous history of COVID symptoms who were not tested/tested negative by reverse transcription-polymerase chain reaction should be tested for antibodies at least 2 weeks after onset of symptoms.

The incidence, aetiology and antimicrobial susceptibility of central line-associated bloodstream infections in intensive care unit patients at a private tertiary care hospital in Mumbai, India.

Background: There is a need to generate accurate data on temporal trends in incidence rates, aetiology and antimicrobial susceptibility of central line-associated bloodstream infections (CLABSIs) in the Indian setting. Aim: To study the incidence, aetiology and antimicrobial susceptibility of CLABSI in adult, paediatric and neonatal intensive care units (NICUs) in a tertiary care private hospital in Mumbai, India. Materials and Methods: This is a prospective observational study conducted at the adult, paediatric and NICUs of tertiary care private hospital from 2011 to 2018. CLABSI was defined as per the Centers for Disease Control criteria. Surveillance of CLABSI in the intensive care units (ICUs) was conducted using a form adapted from the International Nosocomial Infection Control Consortium surveillance system. The incidence rates of CLABSI (per 1000 central line days), crude mortality, aetiology and antimicrobial susceptibility were calculated and reported. Results: Six hundred and eighty-six episodes of CLABSI were recorded, and the overall incidence of CLABSI was 5/1000 catheter days, 4.1 in the adult ICU, 5 in the paediatric ICU and 9 in the newborn ICU. Crude mortality in patients with CLABSI in the adult, paediatric and NICUs was 45%, 30% and 7%, respectively. Of the 752 isolates, 80% were Gram negative, 10% Gram positive and 10% yeast. The prevalence of extended-spectrum beta-lactamase producers was 80%, and rates of carbapenem resistance were on an average 50%. Conclusions: The CLABSI rates at a well-equipped tertiary care hospital are still significantly higher than the USA benchmarks. Alarming rates of drug resistance in Gram-negative pathogens were seen.

What Influences Linkage to Care After Home-Based HIV Counseling and Testing?

To maximize the benefits of test and treat strategies that utilize community-based HIV testing, clients who test positive must link to care in a timely manner. However, linkage rates across the HIV treatment cascade are typically low and little is known about what might facilitate or hinder care-seeking behavior. This qualitative study was conducted within a home-based HIV counseling and testing (HBHCT) intervention in South Africa. In-depth interviews were conducted with 30 HBHCT clients who tested HIV positive to explore what influenced their care-seeking behavior. A set of field notes for 196 additional HBHCT clients who tested HIV positive at home were also reviewed and analyzed. Content analysis showed that linkage to care is influenced by a myriad of factors at the individual, relationship, community, and health system levels. These factors subtly interact and at times reinforce each other. While some factors such as belief in test results, coping ability, social support, and prior experiences with the health system affect clients' desire and motivation to seek care, others such as limited time and resources affect their agency to do so. To ensure that the benefits of community-based testing models are realized through timely linkage to care, programs and interventions must take into account and address clients' emotions, motivation levels, living situations, relationship dynamics, responsibilities, and personal resources.

An assessment of quality of home-based HIV counseling and testing performed by lay counselors in a rural sub-district of KwaZulu-Natal, South Africa.

HIV counseling and testing (HCT) has been prioritized as one of the prevention strategies for HIV/AIDS, and promoted as an essential tool in scaling up and improving access to treatment, care and support especially in community settings. Home-based HCT (HBHCT) is a model that has consistently been found to be highly acceptable and has improved HCT coverage and uptake in low- and middle-income countries since 2002. It involves trained lay counselors going door-to-door offering pre-test counseling and providing HCT services to consenting eligible household members. Currently, there are few studies reporting on the quality of HBHCT services offered by lay counselors especially in Sub-Saharan Africa, including South Africa. This is a quantitative descriptive sub-study of a community randomized trial (Good Start HBHCT trial) which describes the quality of HBHCT provided by lay counselors. Quality of HBHCT was measured as scores comparing observed practice to prescribed protocols using direct observation. Data were collected through periodic observations of HCT sessions and exit interviews with clients. Counselor quality scores for pre-test counseling and post-test counseling sessions were created to determine the level of quality. For the client exit interviews a continuous score was created to assess how satisfied the clients were with the counseling session. A total of 196 (3%) observational assessments and 406 (6%) client exit interviews were completed. Overall, median scores for quality of counseling and testing were high for both HIV-negative and HIV-positive clients. For exit interviews all 406 (100%) clients had overall satisfaction with the counseling and testing services they received, however 11% were concerned about the counselor keeping their discussion confidential. Of all 406 clients, 393 (96.8%) intended to recommend the service to other people. In ensuring good quality HCT services, ongoing quality assessments are important to monitor quality of HCT after training.

A click chemistry approach for the synthesis of mono and bis aryloxy linked coumarinyl triazoles as anti-tubercular agents.

A series of mono and bis-triazole coumarin hybrids 6a-u and 9a-f respectively have been synthesized using 4-(azidomethyl)-2H-chromen-2-ones 5a-i and aryl propargyl ethers 2a-c/8 employing Click chemistry modified protocol for Azide-Alkyne cycloadditions(CuAAC). Anti-tubercular screening showed moderate activity for mono aryloxy compounds 6a-u with MIC 50-100 µg/mL, whereas the bis compounds 9a-f were more effective with MICs between 0.2 and 12.5 µg/mL. Molecular modeling and 3D-QSAR measurements using CoMFA and Topomer CoMFA further supported the observed results. The bis compound 9b showed excellent activity with MIC value as low as 0.2 µg/mL.

A Cost-Effectiveness Analysis of a Home-Based HIV Counselling and Testing Intervention versus the Standard (Facility Based) HIV Testing Strategy in Rural South Africa.

INTRODUCTION: There is growing evidence concerning the acceptability and feasibility of home-based HIV testing. However, less is known about the cost-effectiveness of the approach yet it is a critical component to guide decisions about scaling up access to HIV testing. This study examined the cost-effectiveness of a home-based HIV testing intervention in rural South Africa. METHODS: Two alternatives: clinic and home-based HIV counselling and testing were compared. Costs were analysed from a provider's perspective for the period of January to December 2010. The outcome, HIV counselling and testing (HCT) uptake was obtained from the Good Start home-based HIV counselling and testing (HBHCT) cluster randomised control trial undertaken in KwaZulu-Natal province. Cost-effectiveness was estimated for a target population of 22,099 versus 23,864 people for intervention and control communities respectively. Average costs were calculated as the cost per client tested, while cost-effectiveness was calculated as the cost per additional client tested through HBHCT. RESULTS: Based on effectiveness of 37% in the intervention (HBHCT) arm compared to 16% in control arm, home based testing costs US$29 compared to US$38 per person for clinic HCT. The incremental cost effectiveness per client tested using HBHCT was $19. CONCLUSIONS: HBHCT was less costly and more effective. Home-based HCT could present a cost-effective alternative for rural 'hard to reach' populations depending on affordability by the health system, and should be considered as part of community outreach programs.

Linkage to care following a home-based HIV counselling and testing intervention in rural South Africa.

INTRODUCTION: Efforts to increase awareness of HIV status have led to growing interest in community-based models of HIV testing. Maximizing the benefits of such programmes requires timely linkage to care and treatment. Thus, an understanding of linkage and its potential barriers is imperative for scale-up. METHODS: This study was conducted in rural South Africa. HIV-positive clients (n=492) identified through home-based HIV counselling and testing (HBHCT) were followed up to assess linkage to care, defined as obtaining a CD4 count. Among 359 eligible clients, we calculated the proportion that linked to care within three months. For 226 clients with available data, we calculated the median CD4. To determine factors associated with the rate of linkage, Cox regression was performed on a subsample of 196 clients with additional data on socio-demographic factors and personal characteristics. RESULTS: We found that 62.1% (95% CI: 55.7 to 68.5%) of clients from the primary sample (n=359) linked to care within three months of HBHCT. Among those who linked, the median CD4 count was 341 cells/mm(3) (interquartile range [IQR] 224 to 542 cells/mm(3)). In the subsample of 196 clients, factors predictive of increased linkage included the following: believing that drugs/supplies were available at the health facility (adjusted hazard ratio [aHR] 1.78; 95% CI: 1.07 to 2.96); experiencing three or more depression symptoms (aHR 2.09; 95% CI: 1.24 to 3.53); being a caregiver for four or more people (aHR 1.93; 95% CI: 1.07 to 3.47); and knowing someone who died of HIV/AIDS (aHR 1.68; 95% CI: 1.13 to 2.49). Factors predictive of decreased linkage included the following: younger age - 15 to 24 years (aHR 0.50; 95% CI: 0.28 to 0.91); living with two or more adults (aHR 0.52; 95% CI: 0.35 to 0.77); not believing or being unsure about the test results (aHR 0.48; 95% CI: 0.30 to 0.77); difficulty finding time to seek health care (aHR 0.40; 95% CI: 0.24 to 0.67); believing that antiretroviral treatment can make you sick (aHR 0.56; 95% CI: 0.35 to 0.89); and drinking alcohol (aHR 0.52; 95% CI: 0.34 to 0.80). CONCLUSIONS: The findings highlight barriers to linkage following an increasingly popular model of HIV testing. Further, they draw attention to ways in which practical interventions and health education strategies could be used to improve linkage to care.

A 4-year prospective study to determine the incidence and microbial etiology of surgical site infections at a private tertiary care hospital in Mumbai, India.

BACKGROUND: There is limited single-center data on the incidence and microbial etiology of surgical site infections (SSIs) from developing countries. METHODS: This is a prospective observational study over 4-year period (April 2009-March 2013) at a 750-bed private multispecialty hospital in Mumbai, India, among patients undergoing clean and clean-contaminated surgeries. Standard guidelines for preventing, classifying, and diagnosing SSI were followed. RESULTS: A total of 24,355 patients underwent clean and clean-contaminated surgeries during the study period. The overall SSI rate was 1.6% (389 cases). The SSI rate in clean surgeries was 1.57%, and the SSI rate in clean-contaminated surgeries was 1.64%. Of the SSIs, 66% were caused by gram-negative bacilli (GNB) (Escherichia coli [22.9%], Klebsiella [18.2%], Pseudomonas [12.7%], and Acinetobacter [6.0%] were the top 4), 31.7% were caused by gram-positive bacilli (Staphylococcus: 70.5%, Enterococcus: 23.8%, Streptococcus: 1.8%), and 2.1% were caused by Candida. A total of 64% of the E coli and Klebsiella isolates were extended spectrum ß-lactamase producing, 6% of the GNB were carbapenem resistant, and only 17.3% of S aureus isolates were methicillin resistant. CONCLUSION: Although the SSI rate is comparable with established international benchmarks, increasing prevalence of antimicrobial resistance in GNB is a matter of serious concern.

Surgical site infection rates in six cities of India: findings of the International Nosocomial Infection Control Consortium (INICC).

BACKGROUND: Surgical site infections are a threat to patient safety. However, in India, data on their rates stratified by surgical procedure are not available. METHODS: From January 2005 to December 2011, the International Nosocomial Infection Control Consortium (INICC) conducted a cohort prospective surveillance study on surgical site infections in 10 hospitals in 6 Indian cities. CDC National Healthcare Safety Network (CDC-NHSN) methods were applied and surgical procedures were classified into 11 types, according to the ninth edition of the International Classification of Diseases. RESULTS: We documented 1189 surgical site infections, associated with 28 340 surgical procedures (4.2%; 95% CI: 4.0-4.4). Surgical site infections rates were compared with INICC and CDC-NHSN reports, respectively: 4.3% for coronary bypass with chest and donor incision (4.5% vs 2.9%); 8.3% for breast surgery (1.7% vs 2.3%); 6.5% for cardiac surgery (5.6% vs 1.3%); 6.0% for exploratory abdominal surgery (4.1% vs 2.0%), among others. CONCLUSIONS: In most types of surgical procedures, surgical site infections rates were higher than those reported by the CDC-NHSN, but similar to INICC. This study is an important advancement towards the knowledge of surgical site infections epidemiology in the participating Indian hospitals that will allow us to introduce targeted interventions.

Comparison of culture and polymerase chain reaction techniques in the identification of Tannerella forsythia in periodontal health and disease, an in vitro study.

BACKGROUND AND OBJECTIVES: Various bacterial species from subgingival biofilm have demonstrated aetiological relevance in the initiation and progression of periodontitis. The aim of this study was to detect the presence of Tannerella forsythia (Tf) in subgingival plaque of periodontally healthy subjects and chronic periodontitis patients by using both culture and PCR technique and compare the two techniques. MATERIALS AND METHODS: Pooled subgingival plaque samples were taken using sterile curettes from predetermined sites in 50 periodontally healthy subjects and from 50 periodontitis subjects. Samples were analyzed for the presence of T. forsythia using both techniques. Statistical analysis of the results was done using Chi-square test, sensitivity, and specificity tests. RESULTS: Both techniques could detect T. forsythia in subgingival plaque samples from healthy and periodontitis subjects. Periodontally healthy individuals and individuals with chronic periodontitis using the culture technique showed the presence of T. forsythia in 14 and 34%, respectively. PCR technique showed the presence of T. forsythia in 20% healthy and 40% chronic periodontitis patients. T. forsythia detection in the periodontitis group was statistically significantly higher when compared to the healthy group by both culture and PCR technique (P = 0.019 and P = 0.029). PCR demonstrated high sensitivity and low specificity when compared to the culture technique. CONCLUSION: The results indicated that T. forsythia was more prevalent in periodontitis patients when compared with healthy subjects. The PCR was found to be more sensitive than culture technique for detection of T. forsythia from the subgingival plaque samples.

Can MTA be: Miracle trioxide aggregate?

Mineral trioxide aggregate (MTA) has been used for more than 10 years in the dental community and has often been thought of as a material of choice for the endodontist. The dental pulp is closely related to periodontal tissues through apical foramina, accessory canals, and dentinal tubules. Due to this interrelationship, pulpal diseases may influence periodontal health and periodontal infections may affect pulpal integrity. It is estimated that pulpal and periodontal problems are responsible for more than 50% of tooth mortality. Thus, these associations recommend an interdisciplinary approach. MTA appears to exhibit significant results even in periodontal procedures as it is the first restorative material that consistently allows for over-growth of cementum and may facilitate periodontal tissue regeneration. Thus, in the present review, an attempt is made to discuss the clinical applications of MTA as an interdisciplinary approach.

Quality of home-based rapid HIV testing by community lay counsellors in a rural district of South Africa.

INTRODUCTION: Lack of universal, annual testing for human immunodeficiency virus (HIV) in health facilities suggests that expansion of HIV testing and counselling (HTC) to non-clinical settings is critical to the achievement of national goals for prevention, care and treatment. Consideration should be given to the ability of lay counsellors to perform home-based HTC in community settings. METHODS: We implemented a community cluster randomized controlled trial of home-based HTC in Sisonke District, South Africa. Trained lay counsellors conducted door-to-door HIV testing using the same rapid tests used by the local health department at the time of the study (SD Bioline and Sensa). To monitor testing quality and counsellor skill, additional dry blood spots were taken and sent for laboratory-based enzyme-linked immunosorbent assay (ELISA) testing. Sensitivity and specificity were calculated using the laboratory result as the gold standard. RESULTS AND DISCUSSION: From 3986 samples, the counsellor and laboratory results matched in all but 23 cases. In 18 cases, the counsellor judged the result as indeterminate, whereas the laboratory judged 10 positive, eight negative and three indeterminate, indicating that the counsellor may have erred on the side of caution. Sensitivity was 98.0% (95% CI: 96.3-98.9%), and specificity 99.6% (95% CI: 99.4-99.7%), for the lay counsellor field-based rapid tests. Both measures are high, and the lower confidence bound for specificity meets the international standard for assessing HIV rapid tests. CONCLUSIONS: These findings indicate that adequately trained lay counsellors are capable of safely conducting high-quality rapid HIV tests and interpreting the results as per the kit guidelines. These findings are important given the likely expansion of community and home-based testing models and the shortage of clinically trained professional staff.

Impact of an international nosocomial infection control consortium multidimensional approach on central line-associated bloodstream infection rates in adult intensive care units in eight cities in India.

OBJECTIVE: To evaluate the impact of the International Nosocomial Infection Control Consortium (INICC) multidimensional infection control approach on central line-associated bloodstream infection (CLABSI) rates in eight cities of India. METHODS: This was a prospective, before-and-after cohort study of 35650 patients hospitalized in 16 adult intensive care units of 11 hospitals. During the baseline period, outcome surveillance of CLABSI was performed, applying the definitions of the CDC/NHSN (US Centers for Disease Control and Prevention/National Healthcare Safety Network). During the intervention, the INICC approach was implemented, which included a bundle of interventions, education, outcome surveillance, process surveillance, feedback on CLABSI rates and consequences, and performance feedback. Random effects Poisson regression was used for clustering of CLABSI rates across time periods. RESULTS: During the baseline period, 9472 central line (CL)-days and 61 CLABSIs were recorded; during the intervention period, 80898 CL-days and 404 CLABSIs were recorded. The baseline rate was 6.4 CLABSIs per 1000 CL-days, which was reduced to 3.9 CLABSIs per 1000 CL-days in the second year and maintained for 36 months of follow-up, accounting for a 53% CLABSI rate reduction (incidence rate ratio 0.47, 95% confidence interval 0.31-0.70; p=0.0001). CONCLUSIONS: Implementing the six components of the INICC approach simultaneously was associated with a significant reduction in the CLABSI rate in India, which remained stable during 36 months of follow-up.

Effect of home based HIV counselling and testing intervention in rural South Africa: cluster randomised trial.

OBJECTIVE: To assess the effect of home based HIV counselling and testing on the prevalence of HIV testing and reported behavioural changes in a rural subdistrict of South Africa. DESIGN: Cluster randomised controlled trial. SETTING: 16 communities (clusters) in uMzimkhulu subdistrict, KwaZulu-Natal province, South Africa. PARTICIPANTS: 4154 people aged 14 years or more who participated in a community survey. INTERVENTION: Lay counsellors conducted door to door outreach and offered home based HIV counselling and testing to all consenting adults and adolescents aged 14-17 years with guardian consent. Control clusters received standard care, which consisted of HIV counselling and testing services at local clinics. MAIN OUTCOME MEASURES: Primary outcome measure was prevalence of testing for HIV. Other outcomes were HIV awareness, stigma, sexual behaviour, vulnerability to violence, and access to care. RESULTS: Overall, 69% of participants in the home based HIV counselling and testing arm versus 47% in the control arm were tested for HIV during the study period (prevalence ratio 1.54, 95% confidence interval 1.32 to 1.81). More couples in the intervention arm had counselling and testing together than in the control arm (2.24, 1.49 to 3.03). The intervention had broader effects beyond HIV testing, with a 55% reduction in multiple partners (0.45, 0.33 to 0.62) and a stronger effect among those who had an HIV test (0.37, 0.24 to 0.58) and a 45% reduction in casual sexual partners (0.55, 0.42 to 0.73). CONCLUSIONS: Home based HIV counselling and testing increased the prevalence of HIV testing in a rural setting with high levels of stigma. Benefits also included higher uptake of couple counselling and testing and reduced sexual risk behaviour. TRIAL REGISTRATION: Current Controlled Trials ISRCTN31271935.

Client characteristics and acceptability of a home-based HIV counselling and testing intervention in rural South Africa.

BACKGROUND: HIV counselling and testing (HCT) is a critical gateway for addressing HIV prevention and linking people to treatment, care, and support. Since national testing rates are often less than optimal, there is growing interest in expanding testing coverage through the implementation of innovative models such as home-based HIV counselling and testing (HBHCT). With the aim of informing scale up, this paper discusses client characteristics and acceptability of an HBHCT intervention implemented in rural South Africa. METHODS: Trained lay counsellors offered door-to-door rapid HIV testing in a rural sub-district of KwaZulu-Natal, South Africa. Household and client data were captured on cellular phones and transmitted to a web-based data management system. Descriptive analysis was undertaken to examine client characteristics, testing history, HBHCT uptake, and reasons for refusal. Chi-square tests were performed to assess the association between client characteristics and uptake. RESULTS: Lay counsellors visited 3,328 households and tested 75% (5,086) of the 6,757 people met. The majority of testers (73.7%) were female, and 57% had never previously tested. With regard to marital status, 1,916 (37.7%), 2,123 (41.7%), and 818 (16.1%) were single, married, and widowed, respectively. Testers ranged in age from 14 to 98 years, with a median of 37 years. Two hundred and twenty-nine couples received couples counselling and testing; 87.8%, 4.8%, and 7.4% were concordant negative, concordant positive, and discordant, respectively. There were significant differences in characteristics between testers and non-testers as well as between male and female testers. The most common reasons for not testing were: not being ready/feeling scared/needing to think about it (34.1%); knowing his/her status (22.6%), being HIV-positive (18.5%), and not feeling at risk of having or acquiring HIV (10.1%). The distribution of reasons for refusal differed significantly by gender and age. CONCLUSIONS: These findings indicate that HBHCT is acceptable in rural South Africa. However, future HBHCT programmes should carefully consider community context, develop strategies to reach a broad range of clients, and tailor intervention messages and services to meet the unique needs of different sub-groups. It will also be important to understand and address factors related to refusal of testing.