Focus Area:HTC
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- Home-based HIV Testing and Counseling
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- CDC Handbook for Planning, Implementing, & Monitoring HBHTC
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Home-based HIV Testing and Counseling
Bringing HIV Testing into a Client's Home
Home-based HIV testing and counseling (HBHTC) is a new, innovative HIV testing model that expands HTC into communities and households by offering HTC services in a client’s home. Here, AIDSTAR-One provides HBHTC resources including a selection of literature, HBHTC tools, case studies, and reports for program implementers.
A New HIV Testing and Counseling Strategy
Countries with high HIV prevalence, whether generalized or mixed epidemics, are tasked with increasing coverage and uptake of HIV testing and counseling (HTC), which has the potential to increase enrollment into care and treatment for those who test positive for HIV. Additionally, HTC provides the opportunity for HIV prevention counseling, which can help promote behavior change and provide access to prevention services (e.g., couples testing and prevention of mother-to-child transmission). Despite global advances in expansion of HTC, testing rates remain low. Various HTC models have been utilized for expanding access to testing and access to related services. Home-based HIV testing and counseling (HBHTC), a relatively new model, is a strategy by which HTC services are provided to clients in their homes; this strategy removes barriers (e.g., logistical and stigma) that may be associated with facility-based HTC. HBHTC has been found to be highly acceptable and reach individuals who do not access health facilities.
Home-Based HIV Testing and Counseling Overview
HBHTC has been demonstrated to be an effective component of a national HIV strategy. However, consideration of where and how to implement HBHTC, as well as the target audience, should occur prior to implementation. In many countries, HBHTC programs in both rural and urban contexts have utilized three basic approaches:
- Door-to-door: Counselors visit households in a select geographical area offering HTC to household members
- Index client: Counselors visit households with a known HIV-positive member, targeting other household members
- Integrated: Counselors or community health workers (CHWs) provide HTC, in addition to other health-related services (e.g., tuberculosis screening and family planning).
Potential strengths of the HBHTC model include the following:
- Ensures clients receive HIV test results
- May reach more "first time" testers compared to those using facility-based models
- Can utilize lay counselors or CHWs, reducing the burden on human resources
- Offers HTC to entire families and/or households, and may reach couples and partners
- Limits client transport costs to facilities and lessens stigma associated with visiting HTC facilities
- Reaches populations who may not access HTC in health facilities (e.g., children, rural populations, poorer households).
Areas for HBHTC programmatic inquiry include:
- Identifying populations that would benefit most from HBHTC
- Identifying factors affecting consent (e.g., child testing, in home-based settings)
- Identifying programmatic needs for HBHTC (e.g., counselor training, supply chains, and quality assurance systems)
- Assessing costs of implementation, especially of materials, time, transportation for counselors, and human resources
- Determining HBHTC program goals, effectiveness, and feasibility, and monitoring quality of services.
The potential added value of including an HBHTC strategy appears strong for generalized and perhaps mixed epidemics. If an index approach is used, there is also possible added value for concentrated epidemics. AIDSTAR-One presents a selection of published HBHTC articles, in addition to International AIDS Society (IAS) and Conference on Retroviruses and Opportunistic Infections (CROI) abstracts related to HBHTC. This selection demonstrates acceptability and effectiveness of HBHTC, compares HBHTC with facility-based testing models, and reviews cost-effectiveness studies. The HBHTC literature selection may be used to inform program planners and policymakers in decision making on implementation of HBHTC programs.
Literature review tab
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Expanding Access to Voluntary HIV Counseling and Testing in Sub-Saharan Africa: Alternative Approaches For Improving Uptake, 2001-2007
Matovu, J. K., & Makumbi, F. E. Tropical Medicine & International Health (2007), Vol. 12 No. 11, pp. 1315-1322.
This literature review assesses the range of voluntary counseling and testing (VCT) models, including home-based HIV testing and counseling (HBHTC), in Africa from 2001 to 2007. Advantages of HBHTC include limiting transport costs, increasing uptake for women, and reducing stigma associated with utilization of VCT clinics. Challenges to HBHTC include possible stigma regarding disclosure of status within the household and high costs in terms of time, human resources, and program infrastructure. The applicability of HBHTC in urban areas requires further research.
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Home-Based HIV Voluntary Counseling and Testing (VCT) for Improving Uptake of HIV Testing
Bateganya, M. H., Abdulwadud, O. A., & Keine, S. M. Cochrane Database of Systematic Reviews (2010), No. 7, CD006493. (Updated from 2007 version.)
This systematic Cochrane review discusses home-based HIV testing and counseling (HBHTC) delivery models, including appraising studies on the implementation of HBHTC and determining if HBHTC improved uptake of HIV testing compared to facility-based models. One study met the inclusion criteria (Fylkesnes, K., & Siziya, S. A Randomized Trial on Acceptability of Voluntary HIV Counselling and Testing, Tropical Medicine & International Health [2004], Vol. 9 No. 5, pp. 566-572). This population-based HIV survey examined HIV testing readiness and whether an option location improves acceptability of voluntary counseling and testing in Zambia. Specifically, 849 of 2,445 (approximately 35 percent) persons randomized to be tested at a clinic or “option” location expressed interest in testing. A counselor visited the option location participants, where the clients chose the HIV testing and counseling (HTC) setting (home, clinic, or other location). Results demonstrated higher acceptability with optional testing locations compared to facility-based testing. The majority (84 percent) chose home-based counseling, and HTC was conducted the following day. Participants were nearly five times more likely to accept results in the option location—primarily home-based testing. Participation in both pre- and post-test counseling was greater for HBHTC recipients relative to those tested in a facility. Concerns about privacy, poor perceptions of health services, and access to health facilities may be barriers to facility-based testing and make HBHTC a desirable option. Due to limited evidence, HBHTC cannot be considered a better model of HTC and requires additional research prior to scale-up.
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Evaluation of a Home-Based Voluntary Counselling and Testing Intervention in Rural Uganda
Wolff, B., Nyanzi, B., Katongole, G., et al. Health Policy Plan (2005), Vol. 20 No.2, pp. 109-116.
This mixed methods study analyzed the results of a pilot intervention offering HIV test results from an annual serosurvey (one year prior) at homes in rural Uganda. Looking at participants who agreed to the serosurvey, providing HIV test results at home increased uptake of results from 10 percent in the year before the intervention to 37 percent during the intervention. Findings from focus groups and in-depth interviews with participants of the pilot intervention indicated that home-based HIV testing and counseling (HBHTC) may reduce barriers to testing uptake (e.g., a variety of personal fears, including stigmatization, emotional vulnerability, and the inconvenience of receiving results at facilities). Findings suggest HBHTC may be more appropriate for some populations than others; yet some populations, such as youth who discussed fears of parents’ reactions to a counselor in the home, may prefer facility-based or other testing options.
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Undiagnosed HIV Infection and Couple HIV Discordance among Household Members of HIV-Infected People Receiving Antiretroviral Therapy in Uganda
Were, W. A., Mermin, J. H., Wamai, N., et al. Journal of Acquired Immune Deficiency Syndromes (2006), Vol. 43 No.1, pp. 91-95.
This intervention aimed to identify household members living with HIV and serodiscordant couples in households of individuals initiating a home-based antiretroviral therapy (ART) program in rural Uganda. Nearly 2,400 household members of 730 index clients were targeted. Almost all household members accepted home-based HIV testing and counseling, a majority of whom had never been tested. HIV prevalence among household members was three times higher than a recent national prevalence survey for households with a patient living with HIV. Of the 120 spouses tested, 43 percent of individuals were found not to be living with HIV. The majority had not been previously tested and did not perceive themselves to be at risk. Home-based testing for homes with people living with HIV initiating ART was acceptable and may detect previously undiagnosed HIV infections and serodiscordant couples.
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Increasing Uptake of HIV Testing and Counseling among the Poorest in Sub-Saharan Countries through Home-Based Service Provision
Helleringer, S., Kohler, H. P., Frimpong, J. A., et al. Journal of Acquired Immune Deficiency Syndromes (2009), Vol. 51 No. 2, pp. 185-193.
Residents in six villages in Malawi were offered home-based HIV testing and counseling (HBHTC), and findings indicated that the poorest households were significantly more likely to test at home and significantly less likely to have utilized facility-based HIV testing and counseling compared to the rest of the study population. Additionally, HBHTC was highest among groups such as women (particularly in the poorest households), individuals reporting sexually transmitted infection symptoms over the past year, and younger respondents. The authors suggest that HBHTC increases uptake for general populations and may also enhance access for poor and vulnerable households and individuals.
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The Costs and Effectiveness of Four HIV Counseling and Testing Strategies in Uganda
Menzies, N., Abang, B., Wanyenze, R., et al. AIDS (2009), Vol. 23 No. 3, pp. 395-401.
This cost-effectiveness analysis compared stand-alone HIV testing and counseling (HTC), hospital HTC, household member HBHTC; where a person living with HIV is identified; also referred to as index client), and door-to-door HBHTC. The analysis was applied to a retrospective cohort of approximately 84,000 individuals who received HTC at one of the four programs. HBHTC strategies, including door-to-door and index client, demonstrated a lower per client cost and reached the largest proportion of previously untested individuals and people living with HIV with higher CD4 cell counts. Discordant couples were only a small percentage of all participants; however, offering testing to households where a person living with HIV resided identified the highest percentage of discordant couples. The authors suggest that employing multiple HTC strategies with different costs and efficiencies can be used to expand access.
The results of the cost-effectiveness comparisons are reproduced in the following table. Costs are reported as 2007 U.S. dollars. HIV prevalence in the client groups were higher for stand-alone HTC and hospital-based HTC: approximately 19 percent (n = 9579) and 27 percent (n = 22482), respectively. However, HIV prevalence was lower in household-member HBHTC (6 percent) and door-to-door HBHTC (5 percent).
Stand-alone HTC Hospital-based HTC Household-member HBHTC/index client Door-to-door HBHTC Cost per HTC client 19.26 11.68 13.85 8.29 Cost per new HTC client 29.70 14.73 14.54 9.21 Cost per individual living with HIV identified 100.59 43.10 231.65 163.93 -
Feasibility, Acceptability and Cost of Home-Based HIV Testing in Rural Kenya
Negin, J., Wariero, J., Mutuo, P., et al. Tropical Medicine & International Health (2009), Vol. 14 No. 8, pp. 849-855.
A home-based HIV testing and counseling (HBHTC) program in a rural, high HIV-prevalence village in Kenya was assessed to determine the feasibility, acceptability, and cost of HBHTC, and to examine its applicability to high-prevalence areas. Qualitative and quantitative data were collected. Of 3,180 individuals, aged 15 to 49, almost 64 percent (2,033 adults) consented to an HIV counseling visit; the majority of this group (approximately 98 percent [1,984 adults]) consented to HIV testing. After parental or guardian consent, an additional 399 people, aged 15 or younger, were tested, in addition to 606 persons aged 50 or older who were tested. Interviews with counselors and supervisors during recruitment suggest the following reasons for test refusal: religious beliefs, fears about stigma, and already knowing HIV status/previous testing. A total of 2,989 people were tested, with overall HIV prevalence at 7 percent. The cost of testing was approximately U.S.$6 per person and the cost per case detected was U.S.$84. Counselors reported they felt welcomed in homes and that community members were accepting of the program. The study suggests that HBHTC is feasible, yields high testing uptake, and is an economical strategy for which scale-up should be considered in similar settings.
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Social Inequality and HIV Testing: Comparing Home- and Clinic-based Testing in Rural Malawi
Weinreb, A., & Stechlov, G. Demographic Research (2009), Vol. 21 No. 21, pp. 627-649.
Data was analyzed from a Demographic and Health Survey in Malawi demonstrating differences in home-based HIV testing and counseling (HBHTC) versus clinic-based testing; the analysis highlighted differences in socioeconomic characteristics among those who tested for HIV and those who did not. With the sample used for this analysis, 912 (83 percent) women had a home test. Eighty-one percent of these women were first-time testers, compared to only 203 (18 percent) who reported ever having had a clinic-based HIV test. HBHTC was effective in increasing HIV testing rates. Also, HBHTC was shown to reduce the inequalities found among facility-based testers: among women who consented to HBHTC, there were no observed differences in education level, economic status, or marital status. The authors recommend HBHTC for countries experiencing high HIV prevalence.
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Comparison of Home- and Clinic-based HIV Testing among Household Members of Persons Taking Antiretroviral Therapy in Uganda: Results from a Randomized Trial
Lugada, E., Levin, J., Abang, B., et al. Journal of Acquired Immune Deficiency Syndromes (2010), Vol. 55 No. 2, pp. 245-252.
A study in Uganda compared HIV testing uptake of household members of individuals living with HIV who were randomized to receive antiretroviral therapy (ART) at home or in a clinic. Results demonstrated higher testing uptake among household members in the home group, and a greater number received test results compared to the clinic group. HIV prevalence was higher in household members of the clinic-based ART group. Children living with HIV were more likely to be identified in the home-based ART group.
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Home-based Voluntary HIV Counselling and Testing Found Highly Acceptable and to Reduce Inequalities
Mutale, W., Michelo, C., Jürgensen, M., et al. BMC Public Health (2010), Vol. 10, p. 347.
This study examined acceptability of home-based HIV testing and counseling (HBHTC) in rural and urban areas, intention of clients to be tested, and the extent to which HBHTC services affected inequalities in HIV testing in adult Zambian participants of a population-based survey. High uptake of HIV testing through HBHTC was observed, particularly in rural areas and with youth and less educated groups. An increase in clients who had not tested previously for HIV was demonstrated from 18 percent before HBHTC provision to 38 percent after. More men than women expressed intention to get an HIV test. Results seemed to reduce existing inequalities in access to HIV testing.
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Acceptance of HIV Testing for Children Ages 18 Months to 13 Years Identified through Voluntary, Home-based HIV Counseling and Testing in Western Kenya
Vreeman, R. C., Nyandiko, W. M., Braitstein, P., et al. Journal of Acquired Immune Deficiency Syndromes (2010), Vol. 55 No. 2, pp. e3-10.
This study analyzes uptake of pediatric HIV testing, characteristics of testers, and HIV prevalence among at-risk children aged 18 months to 13 years in a home-based HIV testing and counseling (HBHTC) program in Kenya. Of approximately 2,300 children offered testing, consenting adults accepted HIV testing for 57 percent of the children. Consenting household members were adults (defined as aged 13 years or older). Children younger than 13 were considered eligible for testing if they met one of the following: mother known to be deceased; mother’s living status uncertain; mother known to be HIV-positive; or mother’s HIV status uncertain. Parents/guardians could choose to have a child tested even if the child did not meet the eligibility criteria. Factors that affected acceptance of HIV testing included the relationship of the child to the head of household, if the child’s mother was living with HIV, and if parents were not home. However, caregivers refused HIV testing for nearly half of these children at high risk of HIV, suggesting pediatric home-based testing may need enhancement. HBHTC offers an opportunity to test high-risk children early in disease progression; however, further understanding of refusal and barriers to consenting for testing of children is needed.
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Community-based Interventions 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
Sweat, M., Morin, S., Celentano, D., et al. The Lancet Infectious Diseases (2011), Vol. 11, pp. 525-532.
This article reviews interim results for Project Accept, a randomized controlled HIV prevention trial taking place in Africa and Thailand comparing community-based HIV testing and counseling (HTC) plus clinic-based voluntary counseling and testing (VCT) to clinic-based VCT alone. The number of first-time testers during the study was higher in community-based VCT than in standard VCT in Tanzania, Zimbabwe, and Thailand. HIV prevalence was higher in standard VCT across all sites. However, community-based VCT detected approximately four times the number of HIV cases than did clinic-based VCT. Authors suggest community-based VCT should be considered as an HTC strategy, especially in areas with limited access to facility-based testing.
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No “Magic Bullet”: Exploring Community Mobilization Strategies Used in a Multi-site Community Based Randomized Controlled Trial: Project Accept (HPTN 043)
Tedrow, V., Zelaya, C., Kennedy, C., et al. AIDS Behavior (2011). Epub ahead of print.
This article discusses results on community mobilization Project Accept, a randomized controlled HIV prevention trial taking place in Africa and Thailand comparing community-based HIV testing and counseling plus clinic-based voluntary counseling and testing (VCT) to clinic-based VCT alone. Results from a qualitative study based on key informant interviews with Project Accept staff from the study sites in Africa and Thailand identified seven community mobilization strategies used by the project. The key strategies included stakeholder commitment, community coalitions, community engagement, community participation, raising awareness, community leader involvement, and partnership creation. The success of the strategies was dependent on their evolution, the process of acceptance and trust, and tailoring mobilization strategies to the different communities.
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Home-Based HIV Testing and Counselling in a Survey Context in Uganda
Yoder, S. P., Katahoire, A. R., Kyaddondo, D., et al. Calverton, MD: ORC Macro (2006).
This report examines the impact of offering home-based HIV testing and counseling (HBHTC) in conjunction with a population-based survey and found an increase in the proportion of respondents who learned their HIV status. Respondents reported major difficulties with facility-based testing, such as cost in time and money to travel and the risk of being seen at a clinic, were removed by HBHTC. Several drawbacks to HBHTC were discussed, including expense in materials, time, and personnel; transportation for counselors; and lack of linkage to treatment and care services for those who tested positive for HIV. Authors recommend that the HBHTC strategy not be applied in HIV testing survey research in Uganda.
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Know Your Status Campaign Review Report
Lesotho Ministry of Social Health and Welfare. March 13–April 4, 2008.
Know Your Status (KYS) was a campaign implemented in Lesotho in 2007 offering community-based HIV testing and counseling (HTC). Approximately 3,800 trained community health workers (CHWs) offered HTC in designated local areas or homes. Twenty-three percent of the tests were conducted in community-based settings; the uptake of services varied, ranging from 7 to 39 percent. Challenges included providing incentives for CHWs, lack of clarity in the scope of work and KYS, and human resource shortages. The Ministry of Social Health and Welfare recommends enhanced quality assurance mechanisms for community-based HTC, ongoing training for CHWs, increased recruitment, and conducting an in-depth cost-effectiveness analysis of HTC models to better direct resources.
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A Testing Challenge: The Experience of Lesotho’s Universal HIV Counseling and Testing Campaign
Human Rights Watch (United States) and AIDS & Rights Alliance for Southern Africa. (November 2008).
This article analyzes the Operational Plan of the Know Your Status campaign in Lesotho in terms of a “rights-based” approach of HIV testing and counseling versus a “public health” approach. The following areas were explored: informed consent and counseling; confidentiality; linkages between HIV testing and prevention, care, and treatment services; accountability mechanisms; and the adequacy of the policy and legal framework for protecting the rights of people living with HIV. There was no evidence of involuntary testing and few reports of confidentiality breaches. Several efforts were made to provide linkages between testing and treatment services. However, there was a failure to ensure that defined human rights safeguards were properly put into practice.
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Scaling up HIV Counseling, Testing and Care Services through Community Camping: An Innovation for Rural Populations in Uganda
Tumwebaze, H. Mayanja Memorial Hospital Foundation. IAS Abstract MOPE0413 (2010).
The Mayanja Memorial Hospital Foundation in Uganda implemented a community health services outreach program in rural Uganda that offered HIV testing and counseling (HTC) services, including comprehensive home-based HTC services though “community camping.” Trained counselors resided in rural communities for short periods of time, providing door-to-door HTC and care (including referral and psychosocial support). From 2007 to 2010, 120 “camp” visits were conducted, with a total of 54,073 persons tested and received results. Of those tested, 934 were HIV-positive, given a care package, and referred into care. The approach increased access to hard-to-reach populations and mitigated access and utilization gaps.
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Results of a Randomized Controlled Trial of Home-based versus TB Clinic-based HIV Voluntary Counseling and Testing for Family and Household Members of TB Evaluation Patients in Uganda
Charlebois, E., Nanteza-Walusimbi, M., Okwera, A., et al. IAS Abstract MOPE0439 (2010).
A randomized controlled intervention in Kampala, Uganda, is evaluated on whether barriers to HIV testing for family members of tuberculosis (TB) patients were reduced through home-based HIV testing and counseling (HBHTC). Households of approximately 300 TB patients were randomized within HIV status to either HBHTC or TB clinic-based HIV voluntary counseling and testing. More than 1,000 individual household members were included. HBHTC had significantly higher proportions of household members tested compared with clinic-based testing (74 percent and 40 percent, respectively). While the study is still underway, preliminary findings suggest only 19 percent of patients tested HIV positive. Approximately 63 percent of individuals newly diagnosed were spouses of HIV-positive TB index patients. The authors suggest that HBHTC is a more effective approach to increasing testing of household members than clinic-based HIV testing and counseling. However, challenges to HBHTC remain, such as privacy, and men and children are often unavailable during the day.
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Increasing Access to PMTCT Services in a Rural Setting in Western Kenya: The Role of Home-based Counseling and Testing (HBCT)
Ndege, S., Kioko, R., Kimwattan, S., et al. IAS Abstract TUPE0294 (2010).
The AMPATH Partnership implemented a home-based HIV testing and counseling (HBHTC) program to assist prevention of mother-to-child transmission (PMTCT) in its clinics’ catchment population in western Kenya. This retrospective study collected data on women identified in two clinics from 2008 to 2010 and analyzed uptake of HIV testing and counseling. Of those eligible, 3,934 were tested, yielding a HIV prevalence rate of approximately 4 percent. Of those tested, 54 percent were attending antenatal care (39 were HIV-positive, and 31 enrolled into PMTCT). Approximately 50 percent were not attending antenatal care, and 103 were HIV-positive. A significantly higher proportion of pregnant HIV-positive women who attended antenatal care enrolled into the PMTCT program, compared with those who did not attend antenatal care. Results suggest HBHTC increased the proportion of women knowing their HIV serostatus, which in turn increased access to PMTCT.
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Factors Associated with Early Uptake of HIV Care and Treatment Services after Testing HIV-Positive during Home Based Testing and Counseling (HBTC) in Rural Western Kenya
Amolloh, M., Medley, A., Owuor, P., et al. CROI Paper #1077 (2011).
A home-based HIV testing and counseling (HBHTC) intervention in rural Kenya was evaluated on coverage, acceptance, and HIV prevalence, and on how it identified the characteristics of people who enrolled into HIV care after testing. Following the HBHTC intervention, peer educators visited households to gather data on enrollment into care and perception of health status. Peer educators also offered to assist with linkage to care for those not currently in care. Characteristics of those who tested HIV-positive and were receiving care (42 percent) included being female, perceived health status as fair or poor, having received couple or family testing, and living in a household with another individual receiving HIV care. The most common reasons for not seeking care for those not enrolled included feeling in good health and disbelief of test results. Authors recommend use of peer educators to reach youth, men, and people who are asymptomatic, and to facilitate enrollment into HIV care.
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Can We Reach “Universal Screening” through Repeated Door-to-Door HIV Testing and Counseling Campaigns in Sub-Saharan Settings? A Case Study on Likoma Island, Malawi
Helleringer, S., Reniers, G., Mkandawire, J., et al. CROI Paper #1012 (2011).
A quantitative assessment of repeated HIV testing and counseling (HTC) uptake in two consecutive home-based HTC campaigns in Malawi, as part of an effort to implement a “test and treat” approach, found that HTC uptake during the campaigns improved overtime, from 70 percent (597 of 852) in the first campaign to greater than 80 percent (1,717 of 2,035) in the second campaign. Of 801 individuals, 56 percent repeatedly accepted testing. Yet, a large portion of “never testers,” 12 percent, was found, particularly among men and older persons, and many of these persons had not previously tested at a health facility either. Therefore, populations with undetected HIV infection exist, and future research must identify alternative strategies to target these individuals.
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What is the Impact of Home-Based HIV Counseling and Testing on the Clinical Status of Newly Enrolled Adults in a Large HIV Care Program in Western Kenya?
Wachira, J., Kimaiyo, S., Ndege, S., et al. Clinical Infectious Diseases (2012), Vol. 54 No. 2, pp. 275-281.
This study compares the clinical status of 19,500 participants who entered HIV care via one of four points of entry in western Kenya: home-based HIV testing and counseling (HBHTC), provider-initiated testing and counseling, HIV testing in a tuberculosis clinic, and voluntary counseling and testing at clinical facilities or mobile units. HBHTC was compared with the other three methods; the study showed that patients admitted to HIV care via HBHTC were less likely to have World Health Organization Stage III or IV infection. HBHTC was also effective for identifying pregnant women in the community. Men were proportionately less well represented. The study shows that HBHTC effectively enrolls HIV-positive people at a much earlier stage of disease compared with the other HIV testing models, and if “treatment as prevention” is effectively scaled up, HBHTC could play an active role in identifying HIV-positive community members and linking them to care and treatment. However, cost-effectiveness studies are urgently needed.
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Facility and Home Based HIV Counseling and Testing: A Comparative Analysis of Uptake of Services by Rural Communities in Southwestern Uganda
Mulogo, E. M., Abdulaziz, A. S., Guerra, R., et al. BMC Health Services Research (2011), Vol. 11 No. 54.
This paper presents findings from baseline data of a longitudinal, cross-sectional study in a rural area of Uganda. The study compared uptake predictors among 1,000 participants for voluntary counseling and testing offered in homes using lay counselors and community health workers. The facility-based testing participants were less likely to come from rural areas as opposed to trading centers. Home-based participants were less likely to report symptoms of a sexually transmitted infection and were more concerned about being shunned by friends, family, and their community if they contracted HIV. The authors conclude that both types of HIV testing and counseling should be offered so that individuals can choose the method that best suits them. The authors note that a woman with sexually transmitted infection symptoms, for example, may feel reluctant to disclose them in a home setting where her husband might hear. Giving participants a choice of testing location, according to factors such as residence, educational level, and marital status, could improve both service coverage and uptake rates.
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High Acceptance of Home-Based HIV Counseling and Testing in an Urban Community Setting in Uganda
Sekandi, J. N., Sempeera, H., List, J., et al. BMC Public Health (2011), Vol. 11 No. 730.
This cross-sectional survey of 588 participants in an urban setting in Uganda examined the factors associated with uptake of home-based HIV testing and counseling (HBHTC). Males aged 25 to 34, persons who had previously been married, and persons who had previously undergone HIV testing were all significantly more likely to accept HBHTC. Taking testing into the home reached HIV-positive people who had not previously been tested, identifying 30 HIV-positive individuals among the 408 who underwent testing. The authors note that HIV seroprevalence may have been underestimated because the number of HIV-positive individuals among the group that declined testing is unknown. On the other hand, selection bias may have overestimated HIV seroprevalence because three-quarters of the participants were women.
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Perceived Acceptability of Home-Based Couples Voluntary HIV Counseling and Testing in Northern Tanzania
Njua, B., Watt, M. H., Ostermann, J., et al. AIDS Care (2011).
This study, based on interviews and focus group discussions, focused on the acceptability of home-based couples counseling and testing. The participants included married men and women, people living with HIV, health care workers, home-care providers, HIV counselors, and community leaders. The participants identified the following advantages to this HIV testing and counseling model: improved access, normalization of testing, confidentiality, and benefits to a couple’s relationship. Drawbacks included stigma, physical abuse, divorce, and blame. Unequal gender relations are a significant barrier that needs to be overcome. For such an intervention to be successful, it must incorporate making appointments for home visits, establishing a trusting relationship between clients and counselors, and instituting measures to address potential negative consequences. The next step should be a randomized controlled trial at pilot sites as well as cost-effectiveness analysis to compare home-based couples counseling and testing with other testing modalities.
Case Study: Getting in the Door—Home-based HIV Testing and Counseling in Kenya
Home-based HIV testing and counseling (HBHTC) has emerged as a promising approach to meet the Kenyan government’s challenge—that 80 percent of all Kenyans to know their HIV status by the end of 2013. By using rapid tests, HIV programs are able to offer HTC services to individuals and families within the privacy and convenience of their own homes. Furthermore, HBHTC provides an entry point at the community level for referrals and integration of other health messages, such as family planning, tuberculosis screening, and malaria prevention. This case study provides program planners, implementers, and decision makers with examples of strategies and approaches for ensuring quality in HBHTC.
CDC Handbook for Planning, Implementing, and Monitoring, Home-Based HIV Testing and Counselling
HBHTC refers to HIV testing and counselling (HTC) services conducted by trained HTC service providers in someone’s home. The main purpose of HBHTC is to bring HTC services to households, overcoming some of the barriers of access to testing services and providing testing to individuals who might not otherwise seek services. The purpose of this handbook is to provide practical guidance on ways to address these challenges and to outline some of the key considerations when planning, implementing, and monitoring HBHTC.
South-to-South Technical Assistance: Swaziland
July 2010 - At the request of PEPFAR's Technical Working Group and USAID, AIDSTAR-One facilitated its first south-to-south (S2S) exchange of technical assistance (TA) in support of Swaziland's pilot of home-based HIV testing and counseling (HBHTC). Expert trainers well-versed in HBHTC from The AIDS Support Organization in Uganda (TASO) conducted HBHTC training and provided technical guidance. As a result, Swaziland launched a six-month HBHTC pilot project to determine feasibility and acceptability for potential national scale-up.
Technical Consultation: Home-based HIV Testing and Counseling: Program Components and Approaches
AIDSTAR-One, in collaboration with the President’s Emergency Plan for AIDS Relief (PEPFAR) Technical Working Group on Counseling and Testing, the U.S. Agency for International Development (USAID), and the U.S. Centers for Disease Control and Prevention (CDC), convened a technical consultation on HBHTC from November 3 to 5, 2009, in Nairobi, Kenya. The meeting’s 40 participants were primarily PEPFAR HBHTC program implementers in Kenya and Uganda. The report summarizes implementers’ experiences and expertise, identifying key features of their HBHTC programs, the challenges and strategic approaches, the lessons learned, and suggestions for new and ongoing HBHTC programs.
Download the HBHTC: Program Approaches and Components Technical Consultation Report (PDF, 254 KB)
AIDSTAR-One collected HBHTC tools from Kenyan and Ugandan implementers at the 2009 HBHTC technical consultation in Kenya. Click here for the full report of this meeting.
The tools are available for use as examples to inform persons involved in planning and implementing HBHTC programs. (Note that these tools are not endorsed by PEPFAR/USAID).
| About the Tools | |
|---|---|
| Designed to assist HIV counselors in providing HIV testing and counseling (including rapid testing) to different audiences by including the important messages and steps of the process. | |
| Used for training counselors on home-based HIV testing and counseling techniques. Examples of the training tools include: training assessments, HBHTC protocol, data collection form for training participants, and rapid HIV testing training modules. | |
| Designed to highlight key points that should be addressed in HBHTC program design, such as community characteristics, local support services, security concerns, and potential barriers to HBHTC. | |
| Used to refer clients to various health and support services and to track HIV positive clients identified during an HBHTC visit. | |
| Designed to collect information on HBHTC for program purposes. These tools include daily, weekly, and monthly reporting forms, in addition to a HIV rapid test reporting form and a supply request form. | |
| Designed for HBHTC program supervisors to record HBHTC activities and evaluate counselors' performance. | |
| Designed to collect specific demographic and health information from HBHTC clients at the household level. | |
Cue Cards
| Title | Country | Summary | Contact Information |
|---|---|---|---|
| Home-based HIV Counseling & Testing: Adult Cue Cards (PDF, 206KB) |
Uganda |
Cue cards for counselors providing HIV counseling to adults. Cue cards explain how to perform the following types of counseling: individual test counseling, couples test counseling, positive HIV results, negative HIV results, couple concordant positive results, couple HIV discordant results, counseling on risk reduction. |
Ministry of Health (MOH-STD/ACP Department) SCOT Uganda |
| Home-based HIV Counseling & Testing: Child Counseling Cue Cards (PDF, 257KB) |
Uganda |
Cue cards for counselors providing HIV counseling to children and to parents/guardians of those children. Cue cards explain how to provide the following types of counseling: child test decision counseling, positive and negative HIV results to a parent/guardian, counseling to non-sexually active children, counseling to sexually active children, and counseling to parents/guardians of children with positive and negative HIV status. Cue cards cater to children of the following ages: < 18 months, children under 12 years, and adolescents 12–18 years. Cards also cover counseling for children who have a mother of unknown HIV status. |
Ministry of Health (MOH-STD/ACP Department) SCOT Uganda |
| Home-based HIV Counseling & Testing: Rapid Testing Cue Cards (PDF, 237KB) |
Uganda |
Cue cards for conducting HIV rapid testing. Cue cards explain: HIV sequential testing algorithm, conducting a variety of rapid HIV tests and interpreting results, and how to prepare a dried blood spot in the field. |
Ministry of Health (MOH-STD/ACP Department) SCOT Uganda |
Training Tools
| Title | Country | Summary | Contact Information |
|---|---|---|---|
| Home-based HIV Counseling & Testing-Training Assessment Tool (Pre-test) (PDF, 80KB) |
Kenya |
A pre test for HBHTC training participants assessing knowledge of HIV transmission, treatment and counseling, and testing. Should be given prior to training so the trainer is able to identify the trainees' levels of HIV and counseling and testing knowledge. Answer sheet for trainers included. |
International Medical Corps (IMC) Kenya |
| Home-based HIV Counseling & Testing Training Course- Participant's Manual (PDF, 3MB) |
Uganda |
Home-based HIV Counseling & Testing Training Participant's Manual. By the end of the training, participants should be able to: educate households and communities on HBHTC benefits; conduct pre-test counseling sessions with individuals, couples, and children; conduct a rapid HIV test using the finger stick method; provide HIV test results to individuals, couples, and children; support individuals and couples to develop a risk reduction plan. |
Ministry of Health (MOH-STD/ACP Department) SCOT Uganda |
| Home-based HIV Counseling & Testing Training Course-Facilitator's Manual (PDF, 1.97MB) |
Uganda |
Home-based HIV Counseling & Testing Training Facilitator's Manual. Manual consists of 10 modules: 1) course overview, 2) community mobilization, 3) key concepts, 4) household education, 5) individual counseling and risk assessment, 6) providing results, 7) rapid HIV testing using the finger stick technique, 8) voluntary HIV counseling for children, 9) field planning and management, and 10) quality assurance and control. |
Ministry of Health (MOH-STD/ACP Department) SCOT Uganda |
| Home-based HIV Counseling & Testing Training: Manual for Resident Parish Mobilisers (DOC, 1.28MB) |
Uganda |
A Home-based HIV Counseling & Testing Training Manual for Resident Parish Mobilizers that includes: community mobilizing, nutrition and HIV, stigma and psychosocial support, and communication skills. |
Integrated Community Based Initiatives (ICOBI) Head Office Plot 37 Lumumba Ave, Nakasero PO Box 16331, Kampala. PH: 256414250413 |
| Home-based HIV Counseling & Testing Protocol: 35 minutes (DOC, 45KB) |
Kenya |
A brief protocol explaining how to conduct HBHTC and provides "talking points" on the following: risk assessment, test preparation, testing, post-test intervention, and risk reduction plan. |
Kenya Medical Research Institute PO Box 54840 Nairobi, Kenya 00200 PH: 2542722541 |
| Participant Information Sheet (for HBCT training) (PDF, 54KB) |
Kenya |
Information sheet for HBHTC Training Participants that collects the following information: name and contact information, organization, position, whether the individual was previous trained in HIV counseling, and highest level of education attained. |
International Medical Corps (IMC) Kenya |
| Daily Evaluation Form (Training) (PDF, 28KB) |
Kenya |
A form that allows participants to evaluate HBHTC training on a daily basis. Allows for feedback on specific sessions and asks participants for suggestions to improve training. |
International Medical Corps (IMC) Kenya |
| Trainee Monitoring Form (PDF, 38KB) |
Uganda |
A monitoring form used to collect a training participants data, performance on pre- & post-tests, participation, and approval for certification. |
TASO/SCOT Plot 138 Upper Mawanda Rd. PO Box 33604 Kampala, UG PH: 25641347694. |
| Guide for Writing a Training Activity Report (PDF, 22KB) |
Uganda |
A guide for how to write a report on a training activity. |
TASO/SCOT Plot 138 Upper Mawanda Rd. PO Box 33604 Kampala, UG PH: 25641347694. |
| Training Event Summary Form (PDF, 60KB) |
Uganda |
A form that summarizes information about a completed training activity. |
TASO/SCOT Plot 138 Upper Mawanda Rd. PO Box 33604 Kampala, UG PH: 25641347694. |
| Assuring the Quality of HIV Rapid Testing- Training Module (PDF, 1.2MB) |
Uganda |
A training module designed for HBHTC trainees to learn to identify all of the supplies required for HIV rapid testing and the components of test kits for HIV rapid testing |
TASO/SCOT Plot 138 Upper Mawanda Rd. PO Box 33604 Kampala, UG PH: 25641347694. |
| Blood Collection - Finger Prick - Training Module (PDF, 739KB) |
Uganda |
A training module designed for HBHTC trainees to learn to explain the preparation tasks required for rapid tests; put a client at ease while collecting blood; and collect blood from a finger prick accurately and confidently. |
TASO/SCOT Plot 138 Upper Mawanda Rd. PO Box 33604 Kampala, UG PH: 25641347694. |
| Blood Collection & Handling of DBS - Training Module (PDF, 1.76MB) |
Uganda |
A training module designed for HBHTC trainees to learn how to collect dried blood spots (DBS); package and store DSB properly to maintain specimen integrity; maintain DBS records; and distinguish between valid and invalid DBS. |
TASO/SCOT Plot 138 Upper Mawanda Rd. PO Box 33604 Kampala, UG PH: 25641347694. |
| Introduction & Performing HIV Rapid Tests - Training Module (PDF, 2.53MB) |
Uganda |
A training module designed for HBHTC trainees to learn to explain the different types of HIV tests; discuss the testing algorithm; explain the infection control measures and post-exposure prophylaxis (PEP) procedures HIV Clinical settings; conduct the finger-stick blood collection technique; accurately interpret HIV test results; and describe quality assurance in HIV testing. |
TASO/SCOT Plot 138 Upper Mawanda Rd. PO Box 33604 Kampala, UG PH: 25641347694. |
| Quality Control for HIV Testing - Training Module (PDF, 1.2MB) |
Uganda |
A training module designed for HBHTC trainees to learn about quality control (QC); benefits of QC in rapid testing; internal versus external QC; troubleshooting invalid results; and QC records. |
TASO/SCOT Plot 138 Upper Mawanda Rd. PO Box 33604 Kampala, UG PH: 25641347694. |
Program Tools
| Title | Country | Summary | Contact Information |
|---|---|---|---|
| Home-based HIV Counseling & Testing Protocol Summary (PPT, 17.5KB) |
Kenya |
Provides a summary of key points to address during HBHTC household mobilization visits and program logistics. |
Kenya Medical Research Institute PO Box 54840 Nairobi, Kenya 00200 PH: 2542722541 |
| Home-based HIV Counseling & Testing Feasibility Guide/Tool (DOC, 43KB) |
Kenya |
This tool collects critical information that can tailor planning of HBHTC services for a specific geographical area. Specific data collected includes population characteristics, community occupational and social dynamics, infrastructure, climatic conditions, security concerns, potential barriers to service, and current HIV/AIDS services offered in the area. |
Liverpool VCT, Care, and Treatment Head Office, Argwings Kodhek Road PO Box 19835-00202, KNH, Nairobi. PH: 254202714590. |
Referral Tools
| Title | Country | Summary | Contact Information |
|---|---|---|---|
| Community Client Referral Form (PDF, 171KB) |
Kenya |
A referral form for HBHTC (Note: triplicate form). |
IRDO Tuungane Youth Project Mito Jura Road, Tom Mboya Estate, PO Box 9171 Kisumu, Kenya. PH: 0572020585 |
| Home-based HIV Counseling & Testing Referral Tracking - Follow-up Form (DOC, 47KB) |
Kenya |
This tool can be used to track all HIV positive clients every month after HBHTC. The form tracks the person who tested HIV positive, the number of people in his/her household, the date he/she was tested and where, and the type of care the client is enrolled in. Furthermore, it contains questions asking the client what made him/her seek treatment services at a specific health facility and asks about client's satisfaction with services. |
International Medical Corps (IMC) Kenya |
Reporting Tools
| Title | Country | Summary | Contact Information |
|---|---|---|---|
| Home-based HIV Counseling & Testing Summary Tool (DOC, 273KB) |
Kenya |
Tool for HBHTC counselors to summarize information from households visited. |
USAID/APHIA II Rift Valley |
| Home-based HIV Counseling & Testing Index Client Reporting Form (XLS, 236KB) |
Kenya |
Form used by HBHTC counselors to record individual HBHTC client information for index client visits. |
USAID/APHIA II Rift Valley |
| Central Districts: Home-based HIV Counseling & Testing Counselor's Weekly/Monthly Report form (XLS, 33KB) |
Uganda |
Weekly or monthly reporting form used by HBHTC counselors to record household visit information. |
Integrated Community Based Initiatives (ICOBI) Head Office Plot 37 Lumumba Ave, Nakasero PO Box 16331, Kampala. PH: 256414250413 |
| Home-based Counseling & Testing Daily Activity Report Form (DOC, 30KB) |
Uganda |
Daily reporting form for HBHTC counselors. |
Integrated Community Based Initiatives (ICOBI) Head Office Plot 37 Lumumba Ave, Nakasero PO Box 16331, Kampala. PH: 256414250413 |
| Central District Home-based HIV Counseling & Testing Requisition Form (DOC, 114KB) |
Uganda |
Form to request needed supplies/tools for HBHTC. |
Integrated Community Based Initiatives (ICOBI) Head Office Plot 37 Lumumba Ave, Nakasero PO Box 16331, Kampala. PH: 256414250413 |
| HIV Rapid Testing Logbook (PDF, 241KB) |
Kenya |
Logbook to record rapid testing information which tracks test results, specimen, and test kit information. |
Kenya Medical Research Institute PO Box 54840 Nairobi, Kenya 00200 PH: 2542722541 |
Supervision Tools
| Title | Country | Summary | Contact Information |
|---|---|---|---|
| Home-based HIV Counseling & Testing In-charge Weekly Summary Sheet (DOC, 44KB) |
Kenya |
Weekly reporting form for supervisors to summarize HBHTC activity information. |
Liverpool VCT, Care, and Treatment Head Office, Argwings Kodhek Road PO Box 19835-00202, KNH, Nairobi. PH: 254202714590. |
| HBCT Session Quality Assurance Guide for Supervisors (Counselors Assessment Tool) (DOC, 104KB) |
Kenya |
A quality assurance checklist for a supervisor to assess an employee's ability to conduct HBHTC and allows the supervisor to give feedback. Employees are rated on the ability to provide the following: pre-test counseling, risk assessment, rapid HIV testing, test results counseling, support disclosure, risk reduction plans, sources of support/referrals, and overall counseling skills. Employees are rated on a 1–5 scale with 1 listed as "very poor" and 5 as "excellently done." The checklist also allows the supervisor to give general observation comments. |
Kenya Medical Research Institute PO Box 54840 Nairobi, Kenya 00200 PH: 2542722541 |
Household and Client Information Tools
| Title | Country | Summary | Contact Information |
|---|---|---|---|
| Census Form per Household (DOC, 66KB) |
Kenya |
HBHTC household census form to collect demographic information and eligibility for HBHTC. |
IRDO Tuungane Youth Project Mito Jura Road, Tom Mboya Estate, PO Box 9171 Kisumu, Kenya. PH: 0572020585 |
| Individual Household Member Card (Client Profile) (PDF, 124KB) |
Kenya |
A form that collects the following information from an individual who underwent HBHTC: basic demographic information, sexual behavior, testing history, counseling summary, laboratory results, reason for taking HIV test, and whether or not the individual is willing to be revisited. |
International Medical Corps (IMC) Kenya |
| Home-based Counseling and HIV Testing Form (non-IEIP) (PDF, 130) |
Kenya |
A comprehensive form for HBHTC participants that collects the following information: whether he/she knows HIV status, marriage status, education, sexual behavior, family planning, reasons for getting tested, results, tuberculosis (TB) status, and referrals for services. |
Kenya Medical Research Institute PO Box 54840 Nairobi, Kenya 00200 PH: 2542722541 |
| HBCT Booking Cards (DOC, 57KB) |
Kenya |
An appointment card for HBHTC. |
Liverpool VCT, Care, and Treatment Head Office, Argwings Kodhek Road PO Box 19835-00202, KNH, Nairobi. PH: 254202714590. |