HIV Prevention Knowledge Base
Biomedical Interventions: HIV Testing and Counseling as Prevention
No “Magic Bullet”: Exploring Community Mobilization Strategies Used in a Multi-Site Community Based Randomized Controlled Trial: Project Accept
The Project Accept randomized controlled trial tested the hypothesis that voluntary HIV counseling and testing together with community mobilization would shift community norms and reduce HIV incidence. This paper is a qualitative examination of the seven community mobilization strategies used in the trial. Using semistructured interviews, the study found that no single strategy (out of stakeholder commitment, community coalition formation, community engagement, participation or awareness raising, involvement of leaders and partnership building) was used alone. The study identified three elements that are crucial to the success of community mobilization efforts. First, strategies evolved over time and were adapted during the process of community involvement. It also took time for acceptance to develop in communities. In addition, each intervention site had unique characteristics requiring tailored community mobilization efforts. Involving lay community members was crucial, the study found.
Community-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
This paper presents interim analysis of randomized controlled trial, Project Accept. The trial compared the impact on HIV incidence of clinic-based HIV testing and counseling (HTC) versus community-based HTC. The study covered 32 communities, 10 in Tanzania, 8 in Zimbabwe, and 14 in Thailand with the intervention running over three years from 2006 to 2009. Those in the community-based HTC areas had a mean 40 percent higher likelihood of undergoing their first HIV test, compared to those in the community-based HTC areas. Uptake increased 4-fold in Tanzania, 10-fold in Zimbabwe, and 3-fold in Thailand. Almost four times more cases of HIV were detected in the community-based HTC areas, even though HIV prevalence was higher in the clinic-based HTC areas. The study’s ability to mobilize large numbers of people to get tested has important implications for future HIV programming, the authors conclude.
Project Accept (HPTN 043): A Community-Based Intervention to Reduce HIV Incidence in Populations at Risk for HIV in Sub-Saharan Africa and Thailand
This paper reports the first year results of a unique study: an international, multisite, community randomized control trial of a multilevel HIV structural prevention intervention. This community-level approach had three strategies: (1) community mobilization to increase HIV testing and counseling (HTC); (2) community-based mobile HTC; and (3) comprehensive post-test services. The study assesses whether, compared to people living in communities with standard HTC, those living in communities where community-based HTC is offered will have lower incidence of HIV and experience less stigma, fewer risk behaviors, higher rates of HIV testing, and more accepting social norms related to HIV. It also assessed the cost-effectiveness of the intervention. In the first year of the intervention, about three times more members living in intervention communities in Tanzania and Thailand sought out HIV testing; in Zimbabwe, the increase was 10-fold. First-year data suggest that this community-level intervention can create changes in social norms about HIV, and because of its low cost, can be replicated in resource-poor settings.
Home-based HIV Voluntary Counselling and Testing in Developing Countries
This review looked for randomized and nonrandomized (e.g., cohort and pre-/post-test) controlled trials of home-based voluntary HIV testing and counseling (HTC) in the published literature; the authors found only two studies from developing countries, and none from developed countries, that met inclusion criteria. The randomized controlled trial compared optional location-based and clinic-based HTC, and found that uptake was substantially higher in the optional location group. The pre-/post-test study found similar results: uptake of home HTC was higher than facility-based HTC. The authors conclude that given the lack of methodologically sound evidence, more studies are needed to determine the efficacy and cost-effectiveness of clinic-based testing versus testing on other sites, including the home. The review gives a useful summary of the different modes of HTC, including mandatory, voluntary, opt-out, and home-based testing and counseling.
Promotion of Couples’ Voluntary HIV Counseling and Testing
The Rwanda Zambia Research Group at Emory University has several research projects underway to understand factors related to HIV transmission. This webpage summarizes a five-year project to promote HIV testing and counseling among cohabitating couples in Kigali, Rwanda, and Lusaka, Zambia. The group planned two community-oriented interventions to increase couples HIV testing and counseling, and also studied psychosocial and structural factors influencing condom use, regular follow-up, and biological outcomes of unprotected sex in serodiscordant couples, including couple communication, alcohol use, intimacy, and gender roles. Links to the project’s progress reports can also be found from this page.
Scaling up HIV Testing and Counseling in the WHO European Region as an Essential Component of Efforts to Achieve Universal Access to HIV Prevention, Treatment, Care and Support: Policy Framework
This document lays out a policy framework for countries to increase access to HIV testing and counseling (HTC), a key element of attaining the goal of universal access to HIV care. The target audience includes policymakers, national AIDS program planners, health care providers, and nongovernmental organizations in the HIV field in Europe. It is built around 10 principles, such as the position that scaling up of HTC is not only a public health priority but must also be a part of broader HIV prevention, treatment, care, and support efforts, and that HTC must take diverse settings and populations into account. It spells out the need to increase uptake of HTC among most-at-risk populations, the importance of informed consent, confidentiality, and elimination of coercive testing. The document also makes detailed recommendations to World Health Organization member states for each of the principles covered.
Guidance on Testing and Counselling for HIV in Settings Attended by People Who Inject Drugs: Improving Access to Treatment, Care and Prevention
This document provides policymakers, HIV program planners, care providers, nongovernmental organizations, and civil society groups with information on how health care providers can initiate HIV testing and counseling among people who inject drugs. Developed specifically for the Asia-Pacific context, it can be used to help most-at-risk populations know their HIV status and access treatment and care. The document balances medical ethics and clinical, public health, and human rights objectives for reaching this special population. The primary components of this guidance include recommendations for testing and counseling people who inject drugs; process and elements of HIV testing and counseling; and programmatic considerations.
HIV Testing and Counselling in Prisons and Other Closed Settings
This technical paper systematically reviews the literature to identify best practices and recommendations on HIV testing and counseling (HTC) in prisons and other closed settings. Due to a lack of documentation of this issue in many low-resource settings, the literature review was augmented by findings from a discussion among experts. In addition to providing the findings of the literature review, this document provides 11 recommendations on providing HTC to this population. Recommendations include scaling up HTC, key principles of informed consent, code of conduct for health personnel in prison systems, and continuity of care once prisoners are released back into the community.
Guidance on Provider-Initiated HIV Testing and Counselling in Health Facilities
In support of multiple approaches to help people find out about their HIV status, the World Health Organization has published guidance on implementing provider-initiated HIV testing and counseling in health facilities. The guidance is divided by category of HIV epidemic: generalized, concentrated, or low level. It discusses to whom providers should recommend HIV testing and counseling as standard of care. Furthermore, the document covers the enabling environment needed for such a program and provides guidance on post-test counseling, frequency of testing, HIV testing technologies, programmatic considerations, and monitoring and evaluation. Any level audience, from policymaker to health care provider, can find useful information in this document.
Home-based HIV Testing and Counseling in Rural and Urban Kenyan Communities
A home-based HIV testing and counseling (HBHTC) intervention was implemented in two sites in Kenya to determine the up-take of testing as well as to assess HIV prevalence and referral success rates. Individuals were offered voluntary counseling and testing through counselors and, if they consented, data was collected on any previous testing and access to care and treatment services. All adults received HIV test results in their homes as well as risk reduction counseling. Those who tested positive were counseled and provided information on HIV services, offered a free CD4 count test, referred to the nearest facility for free care and treatment, and visited by a counselor one month after the test. There was an 81.7 percent acceptance rate of HBHTC in the participating communities (19,966 accepted out of 24,450 offered). The motivation for testing by the majority (84.9 percent) of acceptors was their desire to plan for the future. HIV prevalence was 16.3 percent among the participants, and the majority of those found to be HIV-positive were first time testers. About a third (38 percent) of those reporting to be in a couple were counseled and tested together, and 84.3 percent were HIV-concordant negative. Half of those who tested positive were visited one month after their tests. About a half reported attending a patient support center. In conclusion, the intervention was successful in contacting individuals who had never been tested and in identifying newly diagnosed HIV-positive individuals and linking them to care and treatment services.
NIMH Project Accept (HPTN 043) HIV/AIDS Community Mobilization to Promote Mobile HIV Voluntary Counseling and Testing in Rural Communities in Northern Thailand: Modifications by Experience
The intervention strove to increase the up-take of HIV testing through its mobile voluntary counseling and testing (MVCT) centers by implementing community mobilization (CM) activities. The intervention was implemented in communities in rural Thailand from 2006 to 2009. Communities were randomly selected as control or intervention sites and were similar on measures including ethnicity, livelihoods, and health care services. Community Working Groups were established at each intervention site to increase involvement and facilitate activities. For intervention rounds one to three in the intervention communities, the CM teams went door-to-door and conducted small meetings to educate individuals about HIV and inform them about the MVCT centers. The MVCT services followed a few days later. Since the number of participants accessing MVCT was decreasing, the project’s strategy was modified to implement larger-scale events, coupled with MVCT, during the last rounds of the project. It was found that about 17,000 individuals were tested, with the majority first time testers (61.1 percent). The project identified 136 individuals who were HIV-positive, and the majority did not have any signs or symptoms of AIDS. Participation did increase during the last rounds of the project based on the change of the CM strategy. Participants were younger in the later phases as well. It was found that CM can help educate communities about HIV and reduce stigma. When coupled with MVCT, up-take of testing can increase the identification of new HIV cases.
An Incentivized HIV Counseling and Testing Program Targeting Hard-to-Reach Unemployed Men in Cape Town, South Africa
Men access HIV counseling and testing (HCT) services less than women do. Innovative strategies are sought to increase the uptake of HCT services by men. Past studies have demonstrated success in attracting men when HCT services were coupled with a conditional case transfer program. The retrospective observational study combined the use of incentives with a mobile HCT clinic. It then compared the enhanced intervention to a non-incentivized mobile HCT site and a stationary non-incentivized HCT site to explore which service was most accessed by men. All services were operating in poor underserved peri-urban sites. The stationary site included all men who came for testing on their own initiative. The mobile non-incentive site did not advertise or actively recruit clients. The mobile incentive-based HCT partnered with a local organization that worked with unemployed or under-employed men to encourage them to access the services. The incentive to accessing HCT was receiving a food voucher worth about US$10.00. Only men were included in the data analysis. All women, young men under age 15, and those of known HIV status were excluded from the data analysis. A total of 9,416 first-time testers accessed one of the three HCT services, with a higher proportion of self-reported first-time testers using the incentivized site compared to the non-incentivized mobile site. It was found that HIV prevalence among testers was the highest among those who received testing from the incentivized site (16.5 percent) compared to the stationary clinic (10.2 percent) and the non-incentivized site (5.5 percent). The incentive-based mobile HCT was successful in reaching higher-risk men who have never tested for HIV.