A comparison of HIV detection rates using routine opt-out provider-initiated HIV testing and counseling versus a standard of care approach in a rural African setting

Abstract

Background: Routine opt-out provider-initiated HIV testing and counseling (PITC) remains underutilized in sub-Saharan Africa. By selectively targeting clients who either volunteer or have clinical indications of HIV disease, standard approaches to HIV counseling and testing are presumed more cost-efficient than PITC.

Methods: One thousand two hundred twenty-one patients aged 15– 49 years were seen by 22 practitioners in a mobile clinic in southern Zambia. A random sample of physicians was assigned to administer PITC, whereas the remaining practitioners offered standard non- PITC (ie, voluntary or diagnostic). Questionnaires assessed patient demographics and attitudes toward HIV. HIV detection rates were stratified by referral type, demographics, and HIV-related knowledge and attitudes.

Results: HIV prevalence was 10.6%. Infection rates detected using PITC [11.1%; 95% confidence interval (CI): 8.8% to 13.5%] and standard non-PITC (10.0%; 95% CI: 7.5% to 12.5%) did not significantly differ (odds ratio = 1.01; 95% CI: 0.67 to 1.52; P = 0.95). Patients who did not request testing or demonstrate clinical indicators of HIV did not have significantly higher HIV prevalence than those who did (odds ratio = 0.83; 95% CI: 0.55 to 1.24; P = 0.36). Implementation of PITC was highly acceptable and produced a 3-fold increase in patients tested per practitioner compared with standard non-PITC (114 vs. 34 patients per practitioner, respectively).

Conclusions: PITC detected a comparable HIV infection rate as a standard non-PITC approach among rural adults seeking primary care services. Widespread implementation of PITC may therefore lead to significantly more cases of HIV detected.

Figure 1

Patient referral characteristics in the provider-initiated HIV testing and counseling (PITC) group of providers and in the standard non-PITC group, rural Southern Province, Zambia, July 2008. Reasons for referral include client request (client), clinical risk factors (clinical), or routine, opt-out referral (opt-out).