The impact of home-based HIV counseling and testing on care-seeking and incidence of common infectious disease syndromes in rural western Kenya.

BACKGROUND: In much of Africa, most individuals living with HIV do not know their status. Home-based counseling and testing (HBCT) leads to more HIV-infected people learning their HIV status. However, there is little data on whether knowing one's HIV-positive status necessarily leads to uptake of HIV care, which could in turn, lead to a reduction in the prevalence of common infectious disease syndromes. METHODS: In 2008, Kenya Medical Research Institute (KEMRI) in collaboration with the Centers for Disease Control and Prevention (CDC) offered HBCT to individuals (aged ≥13 years) under active surveillance for infectious disease syndromes in Lwak in rural western Kenya. HIV test results were linked to morbidity and healthcare-seeking data collected by field workers through bi-weekly home visits. We analyzed changes in healthcare seeking behaviors using proportions, and incidence (expressed as episodes per person-year) of acute respiratory illness (ARI), severe acute respiratory illness (SARI), acute febrile illness (AFI) and diarrhea among first-time HIV testers in the year before and after HBCT, stratified by their test result and if HIV-positive, whether they sought care at HIV Patient Support Centers (PSCs). RESULTS: Of 9,613 individuals offered HBCT, 6,366 (66%) were first-time testers, 698 (11%) of whom were HIV-infected. One year after HBCT, 50% of HIV-infected persons had enrolled at PSCs - 92% of whom had started cotrimoxazole and 37% of those eligible for antiretroviral treatment had initiated therapy. Among HIV-infected persons enrolled in PSCs, AFI and diarrhea incidence decreased in the year after HBCT (rate ratio [RR] 0.84; 95% confidence interval [CI] 0.77 - 0.91 and RR 0.84, 95% CI 0.73 - 0.98, respectively). Among HIV-infected persons not attending PSCs and among HIV-uninfected persons, decreases in incidence were significantly lower. While decreases also occurred in rates of respiratory illnesses among HIV-positive persons in care, there were similar decreases in the other two groups. CONCLUSIONS: Large scale HBCT enabled a large number of newly diagnosed HIV-infected persons to know their HIV status, leading to a change in care seeking behavior and ultimately a decrease in incidence of common infectious disease syndromes through appropriate treatment and care.

Early uptake of HIV clinical care after testing HIV-positive during home-based testing and counseling in western Kenya.

Home-based HIV testing and counseling (HBTC) has the potential to increase access to HIV testing. However, the extent to which HBTC programs successfully link HIV-positive individuals into clinical care remains unclear. To determine factors associated with early enrollment in HIV clinical care, adult residents (aged ≥13 years) in the Health and Demographic Surveillance System in Kisumu, Kenya were offered HBTC. All HIV-positive residents were referred to nearby HIV clinical care centers. Two to four months after HBTC, peer educators conducted home visits to consenting HIV-positive residents. Overall, 9,895 (82 %) of 12,035 residents accepted HBTC; 1,087 (11 %) were HIV-positive; and 737 (68 %) received home visits. Of those receiving home visits, 42 % reported HIV care attendance. Factors associated with care attendance included: having disclosed, living with someone attending HIV care, and wanting to seek care after diagnosis. Residents who reported their current health as excellent or who doubted their HBTC result were less likely to report care attendance. While findings indicate that HBTC was well-received in this setting, less than half of HIV-positive individuals reported current care attendance. Identification of effective strategies to increase early enrollment and retention in HIV clinical care is critical and will require coordination between testing and treatment program staff and systems.

Home-based HIV testing and counseling in rural and urban Kenyan communities.

BACKGROUND: In sub-Saharan Africa, most people with HIV do not know they are infected. METHODS: We conducted door-to-door home-based testing and counseling (HBTC) in rural western Kenya (Lwak) and an informal urban settlement in Nairobi (Kibera) in 2008. After consent, eligible persons (adults and adolescents aged 13 years or older and children aged 12 years or younger, whose biologic mother was HIV-infected or deceased) received parallel fingerstick HIV rapid testing and counseling. Persons newly diagnosed with HIV were referred to care services, fingerstick blood for CD4 testing was collected, and a one-month follow-up home visit was conducted. RESULTS: Among 24,450 people who were offered HBTC, 19,966 (81.7%) accepted; 65.4% of whom were HIV-tested for the first time. Prevalence in adults aged 18 years or older being HIV-tested for the first time was 13.5% (12.6%, Kibera; 14.2%, Lwak). Among adults who reported a previously negative test, HIV prevalence was 7.4% (7.2%, Kibera; 7.6%, Lwak). Among all persons with HIV in these communities, two-thirds were newly diagnosed through HBTC. Median CD4 count among newly diagnosed adults was 403 [interquartile range (IQR) = 252-594]. Among couples, 38.0% in Kibera and 51.7% in Lwak were counseled together. Among HIV-infected people in a couple, 34.6% had an HIV-uninfected partner. Among newly diagnosed HIV-infected persons, at the one-month follow-up visit, 53.6% in Kibera and 43.6% in Lwak reported having visited an HIV patient support center. CONCLUSIONS: HBTC acceptance was high and most HIV-infected persons did not previously know they had HIV. HBTC can be an effective strategy for early HIV diagnosis and treatment referral.