Researchers show that optional home initiation of HIV care after self-testing substantially improves linkage into HIV care.
Atlanta, 5 March 2013
In a study reported today at the 20th Conference on Retroviruses and Opportunistic Infections (CROI) in Atlanta, USA, researchers from the Liverpool School of Tropical Medicine, London School of Hygiene & Tropical Medicine, Malawi-Liverpool-Wellcome Clinical Research Programme, and College of Medicine, Malawi, have shown that the offer of home-based assessment and initiation of HIV care substantially increased willingness to report positive self-test results, and led to a 3-fold higher rate of ART initiation in the first 6 months of HIV self-testing availability.
Trained resident volunteers offered HIV self-testing with counselling to their neighbours in 14 poor urban neighbourhoods in Blantyre from February 2012, covering a total of 16,660 adults. Seven neighbourhoods were randomly assigned to optional home-initiation of HIV care, which required reporting results to the trained volunteers, while HIV care was entirely clinic-based in the other 7 neighbourhoods.
Clients requesting home-initiation of HIV care had two home visits a few days apart by a nurse to confirm their HIV result, provide counselling, assess ART eligibility, screen for TB, and provide a 2 week supply of drugs together with a referral for registration at an HIV clinic. Clients in both study arms had facilitated access to ART assessment and registration compared to standard-of-care, as study nurses were available for self-test clients at each of the 3 clinics serving the study population.
Within 6 months, 58% of adult residents self-tested in private at home (no significant difference by trial arm). 6.0% of all adult residents in the home-initiation arm reported positive self-test results, compared to 3.3% in the facility-care arm (risk ratio 1.86, 95% CI 1.16 to 2.97).
ART uptake was significantly increased by home-initiation, with 2.2% of all adult residents (or an estimated 46% of all adult PLHIV eligible for ART) starting ART, compared to 0.7% of all adult residents (an estimated 15% of all adult PLHIV eligible for ART) in the facility-care arm (risk ratio: 2.94, 95% CI: 2.10-4.12). The different between arms was still increasing at 6-months.
Dr Peter MacPherson of Liverpool School of Tropical Medicine and the Malawi-Liverpool-Wellcome Clinical Research Programme said:
"Less than a quarter of African adults test for HIV each year, making better access to HIV-testing in the community a critical area for improvement. Self-testing has a lot of promise, but there is little to be gained if people who test positive do not access treatment. Loss to follow-up before accessing HIV care is a real danger following any positive HIV test, especially in poor communities like our study site in Malawi. Self-testing is only just now coming to Africa, with understandable concerns around linkage into HIV care that are still very much unknown. We are excited by these results, showing that high uptake of ART can be achieved through self-testing, provided that the right kind of support is available. This is an approach that could be rapidly scaled-up as part of community HIV testing programmes to improve access to ART. Importantly, our results suggest that most people who have self-tested positive do need extra help to get them into HIV care in a timely fashion --- so that this type of additional intervention may need to be factored in from the start. "
To interview Dr MacPherson, or to receive a copy of the presentation, please contact:
Peter MacPherson (Principal Investigator), Malawi-Liverpool-Wellcome Trust Clinical Research Programme, Malaw i& Liverpool School of Tropical Medicine, UK. Email: p.macpherson@liverpool.ac.uk
or
Diderik van Halsema, Liverpool School of Tropical Medicine Press Office, Email: dvh@liverpool.ac.uk,
Phone: +44 151 705 3104
Institutional descriptions:
Liverpool School of Tropical Medicine (LSTM) has been engaged in the fight against infectious, debilitating and disabling diseases since 1898 and continues that tradition today working in over 60 countries worldwide; a research portfolio in excess of £200 million and a teaching programme attracting students from over 50 countries. www.lstmliverpool.ac.uk
Since its inception in 1995, the Malawi-Liverpool-Wellcome Trust Clinical Research Programme has maintained partnership with College of Medicine at the University of Malawi, the University of Liverpoolthrough the Liverpool School of Tropical Medicine and our major funder the Wellcome Trust in order to achieve the following mission and vision: To conduct biomedical research and also provide research training for clinical and laboratory scientists from Malawi and abroad. http://www.mlw.medcol.mw/
The London School of Hygiene & Tropical Medicine is a world-leading centre for research and postgraduate education in public and global health, with 4000 students and more than 1300 staff working in over 100 countries. The School is one of the highest-rated research institutions in the UK, and was recently cited as one of the world’s top universities for collaborative research. The School's mission is to improve health and health equity in the UK and worldwide; working in partnership to achieve excellence in public and global health research, education and translation of knowledge into policy and practice. www.lshtm.ac.uk