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HIV testing

The PrEP ‘care continuum/cascade’: how would it look?

8 Mar, 17 | by Leslie Goode, Blogmaster

We take for granted the value of the care continuum (or ‘cascade’), now increasingly seen as the key measure of health system response to HIV (Cassell (STIs editorial)).   The application of this model to HIV has provided a benchmark for evaluation in contexts as diverse as Moscow (Wirtz & Beyrer (STIs)), South Africa (Schwartz & Baral (STIs)) or the Netherlands (van Veen & van der Sande (STIs)).   But could the same model also offer a means of evaluation in the case of other complex sexual health interventions such as PrEP (Pre-Exposure Prophylaxis)?

An on-line soon-to-be-published paper by Nunn & Chan (N&C), building on an earlier attempt by Kelley & Rosenberg (K&R), does precisely this.  An important difference from the earlier paper seems to be the more concrete definition of a larger number of steps (nine as against five) – especially in the central area of ‘uptake’ and engagement in care.  Here K&R define three stages: ‘need for awareness of PrEP and willingness to use it’, ‘need for good access to healthcare’, and ‘need for a prescription for PrEP.  N&C replace these with a more concrete conceptualization of the process in five stages involving: an occasion where PrEP access is facilitated (4); an appointment arising from that occasion where the assessment is performed (5); the prescription of PrEP, where indicated (6); the actual initiation of PrEP (i.e. when the client starts taking the pills) (7).  Also important is N&C’s substitution of two final steps – adherence (8)) then retention (9) for K&R’s single final step of ‘adherence’.  N&C point out that, whereas, with ART, ‘adherence’ is once-and-for-all and secures the ultimate goal of viral suppression, in the case of PrEP, we can envisage multiple trajectories depending on whether PrEP continues to be indicated (e.g. the client may no longer be exposed to risk).  Finally, K&R’s first step – ‘identifying at risk MSM’ – gives way to three: identifying at risk individuals (1), enhancing HIV awareness (2), enhancing PrEP awareness (3).

Is this nine-stage definition of a PrEP cascade overly “complex” (EECAAC2018)?

Answering such a question requires us to reflect on the function that the ‘cascade model’ is called upon to perform.  If the model divides up the total course of an intervention into a series of staged tasks, this is presumably because the health benefit depends on the completion of the whole intervention, yet the accomplishment of each step is necessary to the achievement of subsequent ones.  The idea of the cascade can provide a fair way of evaluating the progress of an intervention before its potential health benefits have been delivered – and can also identify the precise points at which the intervention is failing (i.e. where clients become ‘disengaged’).

It follows that each step should correspond to a potential outcome that is not inferable from previous or later outcomes but is worthy of independent evaluation.  If everyone who accesses PrEP (4) also attends an appointment at which suitability of PrEP is discussed (5), or everyone who adheres to PrEP (8) is also retained in PrEP (9), then steps (4) and (5), or steps (8) and (9), can be merged.  This is not stated in so many words by the authors of the model.  However, I would assume that it must lie at the basis of their thinking.

Revised UK NICE Guidelines for HIV testing: why local prevalence based targeting by GPs and hospitals makes sense

11 Jan, 17 | by Leslie Goode, Blogmaster

November 2016 saw the publication of revised UK NICE Guidelines for HIV testing (last updated 2011) – only a few weeks before the appearance of the annual Public Health England Report: HIV in the UK/2016.  The latter highlights the estimated level of still undiagnosed HIV in the UK (which, at 13,500/101,000, places us 3% short of the UNAIDS 90:90:90 target) and the proportion of late diagnoses (approx. two/five thousand).  It also draws attention to the ‘diversity’ of the epidemic, and the relatively poor levels of diagnosis amongst the 16,500 infected non-black African heterosexuals (approx. 1/4, as opposed to 1/7 for MSM or 1/8.5 for black African heterosexuals).

In the light of these findings, we can appreciate the move in the NICE Guidelines, regarding opportunistic testing in primary and secondary care, towards an approach that, first, makes absolutely clear its basis in regional prevalence rather than any other factor, and, second, is more specific – and more demanding – about the occasions when testing is recommended.  We find a new distinction of two levels of high local risk: high (0.2-0.5%) and extremely high (>0.5%).  This determines whether testing should be offered on specified occasions, namely, in primary care, at registration and the performance of any blood test, and, in secondary care, at admission and performance of a blood test (‘high’ prevalence areas); or whether there should be universal opportunistic testing (‘extremely high’ prevalence areas).  As compared with the 2011 guidelines, an insistence on local prevalence as the determining factor replaces the specification of multiple high-risk groups (e.g. MSM or black Africans).

The danger with routine HIV testing is well illustrated by a 2011 study of screening in 29 Paris emergency departments: Wilson d’Almeida & Cremieux/STIs/blogs.  This trial seems to have spectacularly failed to pick up any HIV infections that would not have been detected even without the intervention.  By contrast, what is proposed by the NICE Guidelines is routine testing in areas of extremely high prevalence.  Of course, patients may still refuse testing (Dhairyawan & Orking/STIs) – and appear to do so all the more frequently where they belong to groups, like non-African heterosexuals, that the authors of the 2016 guidelines are so anxious to include (Mohammed & Hughes/STIs).  Nevertheless, the 2014 HINTS study (HIv testing in Non-Traditional Settings) of the acceptability of routine HIV testing has demonstrated encouraging levels of uptake (c.65%) in UK Emergency Departments, Acute Care Units, Primary Care Centres, and dermatology outpatients (Rayment & Sullivan; see also Mohammed & Hughes/STIs).  Conversely, there is evidence, where primary care is concerned, that practitioners may be capable of missing opportunities for testing even where their patients present with indicator conditions for HIV infection (Agusti & Casabona/STIs).

Responding to the new NICE guidelines, a GPs’ representative stresses the existing workload of GPs and the sensitivity of sexual health issues, but broadly welcomes the new emphasis.

 

 

 

UNAIDS 2016 Report: How a ‘life-cycle’ approach can help the world ‘get on the fast track’ to HIV prevention

7 Dec, 16 | by Leslie Goode, Blogmaster

‘Get on the Fast Track: a Life-cycle Approach to HIV’ is the latest UNAIDS report, following on from the UN Assembly’s 2016 declaration of commitment to ‘Fast Track’ goals for ending the HIV/AIDS epidemic. The major theme of the ‘life-cycle’ appears to owe much to the findings of the South African CAPRISA study – above all, the idea of a transmission cycle between younger (25 year-old) women and older (>25 year-old) men.  Broadly, phylogenetic analysis reveals that the prevailing pattern of transmission is as follows.  Younger women appear to get infected through casual relationships with considerably older men, who have, in turn, been infected by their longer-term partners; in time, the younger women grow up and form longer-term relationships – and the cycle is repeated.  The former group – younger (≤25 year-old) women – appear to be more vulnerable to infection than men of the equivalent age due to complex social factors, and have recently seen only c. 6% declines in annual incidence; older (>25 year-old) men have incidence rates that have remained obstinately high despite all recent efforts to reduce them.  These are best explained by poor rates of testing, integration into treatment, and viral suppression making them a potential risk to non-HIV-infected partners.

Diagnosing a problem is one thing; framing the solution quite another.  In case of the younger women, the dominant factors appear to be structural and societal – e.g. gender inequalities.  These are difficult to address without major social and political change.  The authors suggest a number of prevention tools, including sexual education in schools, the introduction of pre-exposure prophylaxis (PrEP), and social transfers.  However, recent trials of PrEP in sub-Saharan Africa do not bode well for this intervention (STI/blogs/’Failed PrEP trial’; STI/blogs/‘Another failed PrEP trial’); while the evidence for the effectiveness of sexuality education and ‘social transfers’ is far from conclusive (School-based Sexuality Programmes/STI/blogs; STI/Galarraga & Sosa-Rubi; STI/Minnis & Padian; STI/Khan & Khan).  However, in the case of the other group – i.e. older men – the obstacles to HIV prevention (poor rates of testing and viral suppression) may be less intractable, and the report proposes a number of very practical measures that could help, including: distribution of self-test kits through female partners attending ante-natal clinics (STI/blogs/’Partner-delivered STI testing’); simplifying ART regimens so individuals have to take just one tablet a day; shifting from CD4 count testing to viral load testing.

The report also has much to say about other phases of the life-cycle, as well as about ‘key populations’ (estimated 45% of new infections).  Regarding the latter, the authors report the stability, or even rise, in new infections amongst sex-workers, drug-users and MSM. They emphasize the negative impact of criminalization of key populations and same-sex relations (73 countries) (see STI/blog/’HIV criminalization’/; STI/blog/’Health workers violate human rights’), the very low levels of domestic funding (on average, only 12% of total spending on MSM prevention), and the relatively young age of many in the ‘key populations’.  The authors recommend ‘comprehensive’ programmes for these populations incorporating access to a range of health care programmes, such as the Red Umbrella programme for sex workers in South African, and the ‘Targeted Strategy Plan’ for the transgender population in Lima, Peru.

 

Partner-delivered HIV self-testing through antenatal clinics: the way ahead for partner notification in low-resource settings?

23 Nov, 16 | by Leslie Goode, Blogmaster

A recently published, Kenya-based, randomized controlled study (Masters & Thirumurthy/STIs) (M&T) evaluates a novel intervention that appears to combine in a fresh way elements of various innovative interventions for HIV prevention.  Recently published studies (e.g. Kissinger/STIs; Estcourt & Cassell/STIs) have explored the potential of ‘expedited’, or ‘accelerated’ partner therapy – where the partner of an index STI-infected individual is offered therapy through the infected individual directly, without a clinic attendance, or with only a telephone interview. They have also evaluated the benefits of ‘self-testing’ for HIV (e.g. Pai & Dheda/STIs).  The intervention trialled by M&T – partner delivered HIV self-testing – combines elements of these two types of interventions.  A third crucial element is that it takes advantage of the unique opportunity offered by antenatal and postpartum clinics in low resource settings (see Azeze & Haile/STIs; Sombie & Dabis/STIs; Ganiyu & Mason/STIs) to make contact with HIV-infected individuals who might otherwise have little access to health services.

In M&T’s study, participants attending antenatal and postpartum clinics (ANC) who were assigned to the intervention arm of the study (n=284/570) were offered two oral-fluid-based HIVselfing kits, one for themselves, one for their partner.  Discussion about HIV, self-testing, couple testing, and awareness of partner’s result were subsequently reported by index patients at monthly follow-up meetings over a three-month period.  This ANC-based, partner-delivered HIV self-testing intervention was evaluated against a control group (n=286/570) who were given an invitation card for conventional clinic-based HIV testing and encouraged to distribute the card to partners.

The primary outcome was reported partner HIV testing which was 91% for the intervention as against 52% for the control.  The intervention looked at couple testing (42% difference between intervention group and control), and awareness of partner’s HIV status (difference=39%).  0% participants in either group reported intimate partner violence (IPV) as a consequence of HIV testing.

Concerns around interventions of this kind tend to centre upon two things.  First, the absence of any direct contact between partner and health services, and consequent loss of an opportunity to test for the full range of STIs and help ensure integration into treatment (Estcourt & Cassell/STIs).  Second, worries as to the likelihood of IPV related to testing.  On the first, concern may be less where the self-test is for HIV, and the partner misses out on testing for the other STIs (Kissinger/STIs), than it would be where, as in many non-African settings, the self-test would generally be for Chlamydia or gonorrhoea and HIV could remain undiagnosed.  Regarding IPV, the authors note its lack of association with testing in the study (despite base-line reported rates of 27%).  They also point to the large proportion of eligible declining to participate (715/1,315).  This – taken together with zero cases of IPV – they interpret as a possible indication of the ‘agency’ of these women, and their capacity to make their own judgments regarding the possible impact of participation on their relationships.  The problem of ensuring engagement with care among those self-tested for HIV, however, is one that the authors acknowledge as still needing to be resolved.

As for the study itself, a primary limitation is self-reporting.  But here the authors note that misreporting is hardly likely to account for the differences between intervention and control arm – which is the evidence that the authors principally emphasize.

 

How Mobile Technology Can Lead to Improved Care of STIs – by Julie Potyraj

16 Aug, 16 | by Leslie Goode, Blogmaster

Blog by Julie Potyraj, Community Manager, Milken Institute School of Public Health at The George Washington University

e: jpotyraj@publichealthonline.gwu.edu

As we move into an era where our phones do everything from lowering the temperature in our homes to arranging a ride, it comes as no surprise that these devices also offer a new way to meet and engage with potential sexual partners. Along with the rise in popularity of dating apps, there has been an increase the incidence of sexually transmitted infections. In 2014 the CDC received the highest number of reports in history for chlamydia, syphilis, and gonorrhea in the United States. The challenge is to figure out a way to use technology to safeguard our sexual health in addition to meeting new partners.

In an effort to encourage online daters to get tested, a study published in Sexual Health posted advertisements for free HIV test kits on the dating website Grindr. In exchange for providing personal information about their health status and behaviors, participants received a free test kit. Not only did this intervention encourage HIV testing, but the study also showed an increase in the number of young men seeking treatment. Even a few of the volunteers who helped with the study became aware of their statuses.

The Grindr study shows that the privacy and comforts of home testing can be a desirable alternative to visiting a doctors’ office. Providing this alternative could potentially increase the number of people seeking testing for STIs. Improved testing technology used in tandem with the convenience and range of a mobile device introduces the opportunity to connect huge numbers of people with diagnostic interventions. The more people who get tested, the more data there is available. If this trend continues, we can anticipate an incredible expansion in electronic reporting, STI surveillance, and the use of this data in health informatics.

Mobile technology contributes to the collection of big data, which is defined as complex data sets that are so large that they cannot be evaluated by traditional data management tools. With better surveillance of STIs, medical providers can reach and identify commonly overlooked demographics by tracking trends to improve diagnostic care, interventions, patient outcomes, and cost of care.

More widely available data about STI outbreaks and incidence rates could help health care providers to make more informed medical decisions. For example, a care provider who identifies chlamydia from a patient’s urine could use big data to inform her decision about what type of antibiotic to prescribe. She may find there is an increasing incidence of azithromycin-resistant chlamydia in her city or state. Her awareness of this emerging trend would lead her to prescribe her patient with doxycycline instead; providing better medical care through informed treatment decisions.

The use of mobile technology can broaden epidemiologic surveillance and trend analysis of STI infections, offering knowledge to care providers that is otherwise unobtainable. More people using STI diagnostic interventions leads to the more people being tested and in turn better access to STI statistics. Mobile technologies, and health interventions that make use of them, can contribute to the collection of timely, relevant data. The analysis and interpretation of this data offers the possibility of improving health care quality and outcomes for patients.

Julie Potyraj

Is the UK meeting its national guidelines for HIV testing of MSM?

9 May, 16 | by Leslie Goode, Blogmaster

The potential role of frequent HIV testing in curbing the HIV epidemic among the MSM population has long been recognized. The introduction of the strategy of ‘opt-out’ testing in the UK (2007), as in other countries at around the same time, brought a steep rise in testing, followed by stabilization (McDaid & Hart (STIs); Saxton & Hughes (STIs) (for New Zealand); Heijman & Prins (STIs)  (Netherlands)), and may now ‘have reached its limit in maximizing routine uptake’ (McDaid & Flowers).  Nonetheless, amongst UK MSM at least, HIV incidence is not declining.  UK guidelines currently recommend annual HIV testing for MSM, and three-monthly testing for those ‘at higher risk’.  But how far are these goals being met?  An audit conducted in UK GUM clinics (Desai & Suillivan/STIs) was reassuring;  but a recent (2013) cross-sectional survey of gay bars in Glasgow reports levels of HIV testing over the previous six months of only 37%, and a relatively high proportion of ‘high-risk’ takers figuring among those who had never tested (OR: 0.51)( McDaid & Flowers (STIs)).

Last month saw the publication of study (McDaid & Flowers (M&F)) based on data from three cross-sectional surveys – Glasgow/Edinburgh gay commercial venues; an internet-based Scotland-wide survey; London gay social venues – and including 2409 MSM in total.  Frequency of testing was reckoned over a two-year period, and classified as ‘one or less’, ‘two or three times’, or ‘four or more times’.  On this basis, the study estimates the proportion testing annually at only 54.9%  – and the proportion of those reporting higher risk unprotected anal intercourse (UAI) (=37.8% of the total) who tested four or more times at only 26.7%.  So neither in respect to MSM in general, nor in respect to those ‘at high risk’ are the UK national guidelines being met.  Moreover, involvement in higher risk UAI – unlike number of sexual partners and AI partners – turns out not to be significantly correlated with the highest rates of testing; while more of those reporting higher risk activities claimed to have tested as a result of a perceived risk event, rather than as part of a regular check-up.  The authors conjecture the episodes of higher risk UAI may have been less frequent events (albeit reported by a third of participants) after which the participants, being risk-aware, took appropriate preventative action.  This seems a plausible interpretation.

Studies of HIV testing in other countries published in STI Journal seem to show a broadly comparable situation, with testing levels for MSM and high-risk MSM consistently falling short of respective national guidelines.  Thus Saxton & Hughes (STIs) in location based surveys in Auckland report levels of MSM annual testing rising slowly to 50% in 2011; while Guy & Hellard (STIs) surveying testing in Australian GP clinics give figures for annual testing by MSM, and high-risk MSM, of 35% and 15% respectively as of 2010.  As for the US, Katz & Stekler (STIs) report levels of annual testing of 77%, but, as the location of this survey was GP clinics, an appropriate UK comparator would be the study reported by Desai & Suillivan/STIs, which reports levels of 92%.

In their recommendations M&F stress the importance of reducing the known barriers to HIV testing, and also draw our attention to the key role that testing will have in facilitating the effectiveness of future PrEP interventions, given the need for participants in PrEP to have an accurate knowledge of their HIV status.

 

 

Responding appropriately to differentials in HIV care outcomes – are local answers needed?

12 May, 14 | by Leslie Goode, Blogmaster

The recent discovery of the preventative potential of anti-retroviral therapy (ART) (STIs/blog/modelling ART impact)  throws into sharp relief the challenge represented for the US by the very inadequate proportion of its 1.2 million HIV+ citizens (<30%) who are virally suppressed.  Nunn & Mayer  use new geographical mapping tools to bring home forcibly the epidemiological dimension of the problem by visualizing the association which HIV+ incidence/mortality show with social status and ethnicity as reflected in residence.  The picture that emerges is of an enormous concentration of the problem in certain very circumscribed neighbourhoods.  To give just one example of what is best conveyed in the diagrams (figures 1 & 2), age-adjusted death rates rise from <11.2 per 1000 people living with AIDS (PLWHA) to 19.4-32.5 per 1000 PLWHA as one passes from a predominantly white neighbourhood with large gay population and high rates of HIV/AIDS (≥2142 per 100,000 population) to the predominantly Afro-Caribbean neighbourhood of Harlem.

For Nunn & Mayer (N&M), these visualizations raise the question whether either (1.) the allocation of resources to metropolitan areas, or (2.) the nature of the strategies employed by public health interventions, reflects the very geographically focussed nature of the problem of HIV/AIDS incidence and mortality.  Their response to the epidemiological dimension of the problem revealed by their mapping tools is to urge the importance of implementation research as a vital component of HIV initiatives.

N&M’s emphasis on viraemia suppression, rather than just HIV incidence, accords well with their insistence of the epidemiological importance of the local dimension.  Retention in care is a factor that is presumably amenable to initiatives at local level – whereas HIV incidence may owe much to transmission through sexual contacts external to the community (STI/blog/Grabowski & Gray).

Their message is in line with increasing public health interest over recent years in “program impact evaluation methods that take account of the complex interactions among interventions and between intervention packages and the context into which they are introduced” (STIs/Aral & Blanchard).  There is surely a strong argument in favour of designing interventions to take place within an evaluative framework allowing a reflection on the kind of program mix likely to be most effective in a given context.  On the other hand, N&M may be in danger of undervaluing the potential of interventions of a non-localized character that act on the socio-economic determinants of the HIV problem, and especially non-retention in care – for example, the wider provision of medical insurance (STI/blogs/ObamaCare).  It would be interesting to see how far a geographical mapping of the incidence of other health problems in New York or Philadelpia coincided with N&M’s mapping of HIV/AIDS mortality.  How far is the effect of “micro-epidemics”, conjured up by epidemiological language, just a reflection of socio-economic determinants that produce identical results wherever they happen to be present?

 

 

Peer group education through social media: turning the tide of the MSM HIV epidemic?

4 Oct, 13 | by Leslie Goode, Blogmaster

The link between social networking technology and risk-taking sexual behaviour appears to be a complex one.  On the one hand, there is a strong likelihood that social networking increases MSM at risk by involving them in sexual networks.  For example, according to the European MSM Internet Survey, 58% of MSM reporting a non-steady partner over the last twelve months also report having met that partner on the Internet.  On the other hand, there is also evidence of risk-reducing behaviours like increased communication before sexual encounters may become more pronounced (sti.bmj/STI&AidsConferenceVienna/2013/marcus&schmidt).  So how about using the technologies, that spread MSM HIV transmission, to prevent that transmission? (sti.bmj/STI&AIDSConferenceVienna2013/Young)

This intriguing possibility has recently been explored in a small randomized control trial (Young & Coates) that uses facebook to deliver the peer education (Young&Coates).  The use of peer education is one of a number of interventions that has been considered as a means to influence MSM sexual behaviour, and has been trialled in a handful of studies with varied results (sti.bmj/Lorenc&Lindsay). Other studies have evaluated the effectiveness of educational tools made available to the MSM community on the internet – such as the ISEAN Hivos program in SE Asia (sti.bmj/Nasution) and a recent program in Peru (sti.bmj/Blas&Kurth). The novelty of Y&C’s study is to bring the two kinds of intervention together, using the social networking to deliver the peer education.  The rationale for this is the apparent popularity of social networking among the ethnic populations, and LGBT populations, that are precisely those most at risk from HIV.

The participants were 112 MSM, 85% Afro-American or Latino, recruited from the Internet and social websites: the peer educators, 16 Afro-American or Latino MSM, recruited from community organizations, screened online, then given three 3-hour training sessions at UCLA.  28 participants and four peer educators were randomly assigned to each one of four closed groups on facebook – two intervention and two control.  The intervention group peer educators were encouraged to initiate and maintain engagement of their participants on HIV prevention: those in the control groups, were to do so on general health issues.

The principal quantifiable outcome of the 12 week trial was the request, return and follow-up of home HIV testing kits which participants were told they could obtain at the end of each four week section of the 12 week trial.  In the intervention arm 25/57 kits (41%) were requested, 9/25 kits (36%) returned, and 8 followed up for test results – as against 11/55 (20%) requested, 2/11 returned (18%) and 0 followed up for test results in the control arm. The peer educators were paid a total of $120 US each for participation over the whole twelve-week period.

While these are promising findings, and warrant further research,  this kind of intervention, like other peer education interventions reviewed by Lorenc & Lindsay are certainly “resource intensive and challenging to implement” (sti.bmj/Lorenc&Lindsay).

US HIV screening guidance shifts to a population-based approach

29 May, 13 | by Leslie Goode, Blogmaster

The updating of important US guidelines on HIV testing by the US Planning Services Task Force (USPSTF) (http://annals.org/article.aspx?articleid=1682314) confirms a shift from a risk-based to a population-based approach to HIV testing.   The USPSTF guidelines are now in line with the most recent (2006) guidelines of the Communicable Diseases Centre (CDC)  http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5514a1.htm).  The option for risk-based screening has now been superseded in the guidance of both bodies by a policy of population-based testing for 15–65 (USPSTF)/13-64 (CDC) year olds.  The USPSTF advocates screening on an “opt-out” basis, while the CDC guidelines have relaxed earlier requirements for written consent and pre-/post- test counselling.  Universal screening of pregnant women was already a recommendation in both sets of guidelines.

The new consensus follows important trends in policy with regard to HIV testing that can be observed both in the US and internationally.  Earlier guidance reflected concerns around the toxicity of antiretroviral drugs and the possibility of psychological harm from testing.  However, current antiretroviral therapies have proved safe and effective, and are perceived to allow HIV infected individuals to enjoy a normal life expectancy.  Any harm to the asymptomatic individual from adverse side effects of the therapy is far outweighed by the potential health benefits of early diagnosis and treatment, as well as reducing the risk of further transmission, while the “psychological” implications of testing are less apparent, now HIV is perceived to be a “chronic” and potentially treatable condition (http://annals.org/article.aspx?articleid=1682313).  Yet, for all this positive change in perception of the benefits of testing, an estimated 20% of the infected population in the US remain undiagnosed, and beyond the reach of what is now recognized to be life-extending treatment (http://sti.bmj.com/content/87/Suppl_1/A98.3.abstract?sid=345955f4-7eb8-4ea4-be62-89230052756a).

Guidelines for HIV testing issued by national authorities will clearly reflect local factors, such as the size and character of the untreated HIV-infected populations, and what is cost-effective in a particular setting.  A large recent study of untargeted HIV screening in Paris hospital emergency departments, for example, reached largely negative conclusions as to its effectiveness as a strategy (http://blogs.bmj.com/sti/2011/11/28/non-targeted-hiv-testing-in-health-settings-worthwhile/?preview=true&preview_id=536&preview_nonce=d2ce801784 ).  Public Health England advocates that population-based routine testing should be commissioned in areas where prevalence is ≥2 per 1000 of 15-59 year olds http://www.hpa.org.uk/web/HPAweb&Page&HPAwebAutoListName/Page/1272032270566). Yet the updating of the US guidelines reminds us there remain certain factors – such as the development of safe and efficacious anti-retroviral therapy and the recent demonstration of its potential contribution to HIV prevention – that are relevant to the value of HIV-testing in any setting.  These more general factors will doubtless influence public health opinion in the direction of a less hesitant and more pro-active attitude to screening, increasingly liable to favour routinization.

Home-based HIV testing: an acceptable intervention for sub-Saharan Africans?

3 Jan, 13 | by Leslie Goode, Blogmaster

HIV testing is the gateway to accessing care – but can involve issues of stigma.  So improving accessibility to testing – by, amongst other things, overcoming the associated stigma – is a major concern for developed and underdeveloped countries alike, and has led to initiatives for testing in “non-traditional settings” (e.g. the UK based HINTS study: http://sti.bmj.com/content/88/8/601.abstract?sid=30e86f02-5f14-47ea-a52f-890e265e9295).  In many low-income countries, where need is particularly great, and medical infra-structure poor (e.g. many nations of sub-Saharan African), these “non-traditional settings” have included non-medical ones, including the home (see Obare & Kohler (2009): http://sti.bmj.com/content/85/2/139.abstract?sid=ec2937f2-fabf-4e25-bcf2-3d8d1c6fc021).

Yet, serious concerns have recently been raised about the implications of implementing such an approach in low-resource settings.  It is argued that the consequences of stigma may be very serious for those affected (Turan & Cohen: http://link.springer.com/article/10.1007/s10461-010-9798-5/fulltext.html) , and that, where there is a drive to implement testing by untrained and ill-qualified staff, considerations of acceptability can easily be over-ridden (e.g.  Human Rights Watch: http://www.hrw.org/sites/default/files/reports/lesotho1108.pdf).

So a recent meta-analysis of Sabathy & Ford in PLoS-Medicine seeking to cast a light on the acceptability of home-testing  in sub-Saharan Africa is very welcome (http://www.plosmedicine.org/article/info%3Adoi%2F10.1371%2Fjournal.pmed.1001351).

21 studies reported in 19 papers are selected as meeting the criteria, and derive from six sub-Saharan African countries.  The overall results are a strong endorsement of the acceptability of home-based testing (HBT).  Of those offered the test 77% accepted and received a result; furthermore, among those testing positive between 40% and 79% turned out not to have tested previously.  There were two particularly encouraging findings.  First, in the eight studies that separated data on the basis of gender, 47% of those offered the test were men.  This is important, given the often very low rates of male attendance (as low as 9%) for facility-based testing.  Second, in the two studies that report CD4 counts,  only 68% and 69% respectively of those testing positive had a CD4 count >200.  The authors conclude that HBT may be a useful approach for earlier detection.

The study identifies as its key finding the potential of HBT to reach wide sections of the community who would not otherwise have sought testing.  It also indicates a number of directions for further research.  These include, most obviously, the feasibility and acceptability of repeat HBT for ongoing knowledge of HIV status.  On this the study of Obare & Kohler 2009 has produced some encouraging results (http://sti.bmj.com/content/85/2/139.abstract?sid=ec2937f2-fabf-4e25-bcf2-3d8d1c6fc021).  The option of self-testing with support from HBT staff is also something to be explored.  Finally, the whole issue of the cost-effectiveness of HBT relative to other interventions requires further research in order to guide policy-makers operating in resource-poor settings.

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