ArticlesCommunity-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
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.
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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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