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Observational Study
. 2016 Mar;3(3):e111-9.
doi: 10.1016/S2352-3018(15)00251-9. Epub 2016 Jan 26.

A hybrid mobile approach for population-wide HIV testing in rural east Africa: an observational study

Gabriel Chamie  1 , Tamara D Clark  2 , Jane Kabami  3 , Kevin Kadede  4 , Emmanuel Ssemmondo  3 , Rachel Steinfeld  2 , Geoff Lavoy  3 , Dalsone Kwarisiima  3 , Norton Sang  4 , Vivek Jain  2 , Harsha Thirumurthy  5 , Teri Liegler  2 , Laura B Balzer  6 , Maya L Petersen  7 , Craig R Cohen  8 , Elizabeth A Bukusi  4 , Moses R Kamya  9 , Diane V Havlir  2 , Edwin D Charlebois  10
Affiliations
Observational Study

A hybrid mobile approach for population-wide HIV testing in rural east Africa: an observational study

Gabriel Chamie et al. Lancet HIV. 2016 Mar.

Abstract

Background: Despite large investments in HIV testing, only an estimated 45% of HIV-infected people in sub-Saharan Africa know their HIV status. Optimum methods for maximising population-level testing remain unknown. We sought to show the effectiveness of a hybrid mobile HIV testing approach at achieving population-wide testing coverage.

Methods: We enumerated adult (≥15 years) residents of 32 communities in Uganda (n=20) and Kenya (n=12) using a door-to-door census. Stable residence was defined as living in the community for at least 6 months in the past year. In each community, we did 2 week multiple-disease community health campaigns (CHCs) that included HIV testing, counselling, and referral to care if HIV infected; people who did not participate in the CHCs were approached for home-based testing (HBT) for 1-2 months within the 1-6 months after the CHC. We measured population HIV testing coverage and predictors of testing via HBT rather than CHC and non-testing.

Findings: From April 2, 2013, to June 8, 2014, 168,772 adult residents were enumerated in the door-to-door census. HIV testing was achieved in 131,307 (89%) of 146,906 adults with stable residence. 13,043 of 136,033 (9·6%, 95% CI 9·4-9·8) adults with and without stable residence had HIV; median CD4 count was 514 cells per μL (IQR 355-703). Among 131,307 adults with stable residence tested, 56,106 (43%) reported no previous testing. Among 13,043 HIV-infected adults, 4932 (38%) were unaware of their status. Among 105,170 CHC attendees with stable residence 104,635 (99%) accepted HIV testing. Of 131,307 adults with stable residence tested, 104,635 (80%; range 60-93% across communities) tested via CHCs. In multivariable analyses of adults with stable residence, predictors of non-testing included being male (risk ratio [RR] 1·52, 95% CI 1·48-1·56), single marital status (1·70, 1·66-1·75), age 30-39 years (1·58, 1·52-1·65 vs 15-19 years), residence in Kenya (1·46, 1·41-1·50), and migration out of the community for at least 1 month in the past year (1·60, 1·53-1·68). Compared with unemployed people, testing for HIV was more common among farmers (RR 0·73, 95% CI 0·67-0·79) and students (0·73, 0·69-0·77); and compared with people with no education, testing was more common in those with primary education (0·84, 0·80-0·89).

Interpretation: A hybrid, mobile approach of multiple-disease CHCs followed by HBT allowed for flexibility at the community and individual level to help reach testing coverage goals. Men and mobile populations remain challenges for universal testing.

Funding: National Institutes of Health and President's Emergency Plan for AIDS Relief.

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Conflict of interest statement

Declaration of interests

All authors report grants from National Institutes of Health (NIH) during the conduct of the study. GC, DK, VJ, HT, CC, MP, MK, DH and EC report grants from NIH outside the submitted work. VJ reports grant support from Gilead Sciences outside of the submitted work. DH reports non-financial support from Gilead Sciences, during the conduct of the study. HT reports grants from Bill & Melinda Gates Foundation and the International Initiative for Impact Evaluation outside of the submitted work. CC reports grants from Bill & Melinda Gates Foundation, grants from CIFF, personal fees from Legal consulting about malpractice case, personal fees from Symbiomix Inc., outside the submitted work. None of the authors have been paid by a pharmaceutical company or other agency to write this manuscript.

Figures

Figure 1
Figure 1
East African Map of 32 SEARCH communities in 3 regions: Southwestern Uganda (study community names: 1. Nsiika; 2. Bugamba; 3. Rugazi; 4. Mitooma; 5. Kitwe; 6. Rubaare; 7. Rwashamaire; 8. Ruhoko; 9. Kazo; 10. Nyamuyanja), Eastern Uganda (1. Nsiinze; 2. Nankoma; 3. Kiyunga; 4. Kamuge; 5. Bugono; 6. Muyembe; 7. Merikit; 8. Kiyeyi; 9. Kameke; 10. Kadama) and Western Kenya (1. Nyatoto; 2. Nyamrisra; 3. Ogongo; 4. Kitare; 5. Magunga; 6. Kisegi; 7. Tom Mboya; 8. Sena; 9. Ongo; 10. Othoro; 11. Sibuoche; 12. Bware).
Figure 2
Figure 2. Density of HIV Un-Tested Persons Over Time
Three selected communities (one per region: Nyamuyanja in southwestern Uganda, Nankoma in eastern Uganda, and Nyatoto in western Kenya), with density of stable adult residents who have not participated in HIV testing from the year prior to study start through the end of the hybrid mobile testing approach, viewed at three time points: A) In the one year before implementing the hybrid mobile HIV testing approach, based on self-report; B) Upon completing community health campaign (CHC) implementation; C) After the hybrid mobile testing approach (combined CHC-based and home-based testing). Color intensity ranges from blue (HIV tested) to red (HIV untested), based on density of untested persons (population/square kilometer). Red crosses indicate location of government-run health facilities, and stars indicate locations of CHCs.
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