- Email: [email protected]
Maximising the benefits of home-based HIV testing
Comment
Maximising the benefits of home-based HIV testing 10 years ago, when access to HIV treatment was not as widespread as it is now, an urgent priority for the HIV community was to get more people on to treatment to reduce mortality.1 As treatment programmes expanded, an additional concern was ensuring that, once on treatment, people stayed on treatment.2 Attention then shifted to the number of patients lost to HIV care before starting antiretroviral treatment2 and subsequently to the need to minimise losses across the entire cascade of care from testing to long-term virological suppression.3 Findings from most studies have provided an incomplete picture of this process, either because researchers focused on only part of the cascade or because they presented cross-sectional estimates of retention from each step rather than longitudinal assessments of cohorts. In The Lancet HIV, Becky Genberg and colleagues present the findings of their population-based observational study done in a subcounty of western Kenya.4 The Article makes for sobering reading. Of the 1360 individuals newly diagnosed with HIV at home-based HIV counselling and testing (HBCT), only 209 (15%) had contact with an HIV care provider within 3 years of their diagnosis. By contrast, of the 2122 people with known HIV infection at HBCT, 1778 (84%) had engaged with HIV care services, of whom 1686 (81%) were already receiving antiretroviral treatment. Respondent and survival bias account for part of this difference, but true differences between the populations (ie, those newly diagnosed at home vs those previously diagnosed via a range of approaches including voluntary counselling and testing and provider-initiated counselling and testing) are also likely to contribute. As the investigators rightly point out, whereas HBCT targets an entire population, voluntary programmes select for a population of motivated patients and provider-initiated services select for a population who have positive health-seeking behaviour or who are ill and seeking treatment. WHO recommends HBCT as a strategy to improve testing coverage5 because it does not rely on an individual to actively seek HIV testing. However, as Genberg and colleagues’ study shows, simply informing individuals that they are HIV positive does not necessarily result in their seeking and engaging in care, especially if they have never done so before. Linkage to care was particularly low in men and young people (aged www.thelancet.com/hiv Vol 2 January 2015
13–27 years), an observation that substantiates previous findings6 across the continuum of HIV care.7,8 Such limitations of HBCT are important to report because negative findings often go unreported despite the opportunity for lessons to be learned.9 These findings should remind policy makers and programme implementers about the need to accompany efforts to increase access to testing with efforts to improve subsequent linkage to care. A more detailed analysis beyond the usual sociodemographic risk factors could have informed future interventions. Most HIV infections in sub-Saharan Africa are acquired sexually, resulting in strong spatial clustering of HIV within households.10 As well as individual factors, community and household factors also affect health-seeking behaviour.11,12 Cases of both diagnosed and treated HIV, therefore, could be spatially clustered within households and even communities. One person being diagnosed with HIV and retained on treatment might trigger others in the same household to be tested and linked to care, whereas undiagnosed and untreated individuals might similarly cluster in households and hotspots within the community. Such analyses are possible in this specific study and are encouraged, particularly because none of the African demographic surveillance sites has ever done spatial clustering analyses. Social, economic, and structural contexts affect access to and engagement with health services and such information can inform interventions to improve linkage to care specifically targeted at underserved households. In Genberg and colleagues’ study, use of HBCT enabled the identification of many previously undiagnosed HIV-positive individuals, but the yield of linkage to care was less than 0·1% in the 30 000 individuals tested. Unless paired with interventions targeted at hard-to-reach populations, the diagnosing of undiagnosed individuals in many settings will not be cost effective and will have little effect on individual and population viral suppression.
See Articles page e20
Rashida Ferrand, Nathan Ford, Katharina Kranzer London School of Hygiene & Tropical Medicine, London WC1E 7HT, UK (RF, KK); and HIV/AIDS Department, WHO, Geneva, Switzerland (NF) [email protected] We declare no competing interests.
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Hogg R, Cahn P, Katabira ET, et al. Time to act: global apathy towards HIV/ AIDS is a crime against humanity. Lancet 2002; 360: 1710–11. Rosen S, Fox MP. Retention in HIV care between testing and treatment in sub-Saharan Africa: a systematic review. PLoS Med 2011; 8: e1001056. UNAIDS. 90-90-90—an ambitious treatment target to help end the AIDS epidemic. http://www.unaids.org/sites/default/files/media_ asset/90-90-90_en_0.pdf (accessed Dec 9, 2014). Genberg BL, Naanyu V, Wachira J, et al. Linkage to and engagement in HIV care in western Kenya: an observational study using population-based estimates from home-based counselling and testing. Lancet HIV 2015; 2: e20–26. WHO. Consolidated guidelines on the use of antiretroviral drugs for treating and preventing HIV infection Geneva. http://apps.who.int/iris/ bitstream/10665/85321/1/9789241505727_eng.pdf last (accessed Dec 10, 2014). Govindasamy D, Ford N, Kranzer K. Risk factors, barriers and facilitators for linkage to antiretroviral therapy care: a systematic review. AIDS 2012; 26: 2059–67. Cornell M, Schomaker M, Garone DB, et al. Gender differences in survival among adult patients starting antiretroviral therapy in South Africa: a multicentre cohort study. PLoS Med 2012; 9: e1001304.
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WHO. Global update on HIV treatment 2013: results, impact and opportunities: WHO report in partnership with UNICEF and UNAIDS. http://www.unaids.org/en/media/unaids/contentassets/documents/ unaidspublication/2013/20130630_treatment_report_en.pdf (accessed Sept 28, 2014). Malicki M, Marusic A. Is there a solution to publication bias? Researchers call for changes in dissemination of clinical research results. J Clin Epidemiol 2014; 67: 1103–10. Grabowski MK, Lessler J, Redd AD, et al. The role of viral introductions in sustaining community-based HIV epidemics in rural Uganda: evidence from spatial clustering, phylogenetics, and egocentric transmission models. PLoS Med 2014; 11: e1001610. Stephenson R, Miriam Elfstrom K, Winter A. Community influences on married men’s uptake of HIV testing in eight African countries. AIDS Behav 2013; 17: 2352–66. Gourlay A, Birdthistle I, Mburu G, Iorpenda K, Wringe A. Barriers and facilitating factors to the uptake of antiretroviral drugs for prevention of mother-to-child transmission of HIV in sub-Saharan Africa: a systematic review. J Int AIDS Soc 2013; 16: 18588.
www.thelancet.com/hiv Vol 2 January 2015
Maximising the benefits of home-based HIV testing 10 years ago, when access to HIV treatment was not as widespread as it is now, an urgent priority for the HIV community was to get more people on to treatment to reduce mortality.1 As treatment programmes expanded, an additional concern was ensuring that, once on treatment, people stayed on treatment.2 Attention then shifted to the number of patients lost to HIV care before starting antiretroviral treatment2 and subsequently to the need to minimise losses across the entire cascade of care from testing to long-term virological suppression.3 Findings from most studies have provided an incomplete picture of this process, either because researchers focused on only part of the cascade or because they presented cross-sectional estimates of retention from each step rather than longitudinal assessments of cohorts. In The Lancet HIV, Becky Genberg and colleagues present the findings of their population-based observational study done in a subcounty of western Kenya.4 The Article makes for sobering reading. Of the 1360 individuals newly diagnosed with HIV at home-based HIV counselling and testing (HBCT), only 209 (15%) had contact with an HIV care provider within 3 years of their diagnosis. By contrast, of the 2122 people with known HIV infection at HBCT, 1778 (84%) had engaged with HIV care services, of whom 1686 (81%) were already receiving antiretroviral treatment. Respondent and survival bias account for part of this difference, but true differences between the populations (ie, those newly diagnosed at home vs those previously diagnosed via a range of approaches including voluntary counselling and testing and provider-initiated counselling and testing) are also likely to contribute. As the investigators rightly point out, whereas HBCT targets an entire population, voluntary programmes select for a population of motivated patients and provider-initiated services select for a population who have positive health-seeking behaviour or who are ill and seeking treatment. WHO recommends HBCT as a strategy to improve testing coverage5 because it does not rely on an individual to actively seek HIV testing. However, as Genberg and colleagues’ study shows, simply informing individuals that they are HIV positive does not necessarily result in their seeking and engaging in care, especially if they have never done so before. Linkage to care was particularly low in men and young people (aged www.thelancet.com/hiv Vol 2 January 2015
13–27 years), an observation that substantiates previous findings6 across the continuum of HIV care.7,8 Such limitations of HBCT are important to report because negative findings often go unreported despite the opportunity for lessons to be learned.9 These findings should remind policy makers and programme implementers about the need to accompany efforts to increase access to testing with efforts to improve subsequent linkage to care. A more detailed analysis beyond the usual sociodemographic risk factors could have informed future interventions. Most HIV infections in sub-Saharan Africa are acquired sexually, resulting in strong spatial clustering of HIV within households.10 As well as individual factors, community and household factors also affect health-seeking behaviour.11,12 Cases of both diagnosed and treated HIV, therefore, could be spatially clustered within households and even communities. One person being diagnosed with HIV and retained on treatment might trigger others in the same household to be tested and linked to care, whereas undiagnosed and untreated individuals might similarly cluster in households and hotspots within the community. Such analyses are possible in this specific study and are encouraged, particularly because none of the African demographic surveillance sites has ever done spatial clustering analyses. Social, economic, and structural contexts affect access to and engagement with health services and such information can inform interventions to improve linkage to care specifically targeted at underserved households. In Genberg and colleagues’ study, use of HBCT enabled the identification of many previously undiagnosed HIV-positive individuals, but the yield of linkage to care was less than 0·1% in the 30 000 individuals tested. Unless paired with interventions targeted at hard-to-reach populations, the diagnosing of undiagnosed individuals in many settings will not be cost effective and will have little effect on individual and population viral suppression.
See Articles page e20
Rashida Ferrand, Nathan Ford, Katharina Kranzer London School of Hygiene & Tropical Medicine, London WC1E 7HT, UK (RF, KK); and HIV/AIDS Department, WHO, Geneva, Switzerland (NF) [email protected] We declare no competing interests.
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Comment
1 2 3
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Hogg R, Cahn P, Katabira ET, et al. Time to act: global apathy towards HIV/ AIDS is a crime against humanity. Lancet 2002; 360: 1710–11. Rosen S, Fox MP. Retention in HIV care between testing and treatment in sub-Saharan Africa: a systematic review. PLoS Med 2011; 8: e1001056. UNAIDS. 90-90-90—an ambitious treatment target to help end the AIDS epidemic. http://www.unaids.org/sites/default/files/media_ asset/90-90-90_en_0.pdf (accessed Dec 9, 2014). Genberg BL, Naanyu V, Wachira J, et al. Linkage to and engagement in HIV care in western Kenya: an observational study using population-based estimates from home-based counselling and testing. Lancet HIV 2015; 2: e20–26. WHO. Consolidated guidelines on the use of antiretroviral drugs for treating and preventing HIV infection Geneva. http://apps.who.int/iris/ bitstream/10665/85321/1/9789241505727_eng.pdf last (accessed Dec 10, 2014). Govindasamy D, Ford N, Kranzer K. Risk factors, barriers and facilitators for linkage to antiretroviral therapy care: a systematic review. AIDS 2012; 26: 2059–67. Cornell M, Schomaker M, Garone DB, et al. Gender differences in survival among adult patients starting antiretroviral therapy in South Africa: a multicentre cohort study. PLoS Med 2012; 9: e1001304.
8
9
10
11
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WHO. Global update on HIV treatment 2013: results, impact and opportunities: WHO report in partnership with UNICEF and UNAIDS. http://www.unaids.org/en/media/unaids/contentassets/documents/ unaidspublication/2013/20130630_treatment_report_en.pdf (accessed Sept 28, 2014). Malicki M, Marusic A. Is there a solution to publication bias? Researchers call for changes in dissemination of clinical research results. J Clin Epidemiol 2014; 67: 1103–10. Grabowski MK, Lessler J, Redd AD, et al. The role of viral introductions in sustaining community-based HIV epidemics in rural Uganda: evidence from spatial clustering, phylogenetics, and egocentric transmission models. PLoS Med 2014; 11: e1001610. Stephenson R, Miriam Elfstrom K, Winter A. Community influences on married men’s uptake of HIV testing in eight African countries. AIDS Behav 2013; 17: 2352–66. Gourlay A, Birdthistle I, Mburu G, Iorpenda K, Wringe A. Barriers and facilitating factors to the uptake of antiretroviral drugs for prevention of mother-to-child transmission of HIV in sub-Saharan Africa: a systematic review. J Int AIDS Soc 2013; 16: 18588.
www.thelancet.com/hiv Vol 2 January 2015