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.