Home- and community-based HIV testing and counselling services can achieve high participation uptake in rural Africa but reach different populations within a community and should be provided depending on the groups that are being targeted, according to new research published in PLOS Medicine by Niklaus Labhardt from the Swiss Tropical and Public Health Institute, and colleagues from SolidarMed, a Swiss non-governmental Organization for Health in Africa.

Annually, about 2.3 million people become newly infected with HIV, the virus that causes AIDS. A key step in receiving treatment for HIV and reducing further transmission of the virus is receiving HIV testing and counselling, but in countries where HIV is prevalent, such as many parts of rural Africa, access to these services can be limited by resources or because people fear stigmatization and discrimination. One option to improve HIV testing and counselling coverage is to provide this service to individuals in a community setting as part of a campaign that provides multiple health services (for example, family planning, TB screening and blood-pressure measurement) instead of relying on individuals visiting health facilities to be tested. However, the evidence base for how to deliver these services to test different populations is poor.

In a cluster randomized controlled trial in rural Lesotho the authors tested two different community approaches for delivering the same HIV testing and counselling services; in one individuals were offered the services in their homes, and in another services were offered at a mobile clinic that was set up at a community gathering. The study included 2563 participants and the authors found that uptake of HIV testing and counselling was higher for those offered home-based services compared to services at the mobile clinic (92.5% and 86.7%, respectively). By analysing this outcome by age the authors noted that there was a large difference in uptake among children <12 years old because the child's caretakers were more likely to agree to HIV-testing in the home-based group. The authors also found that while more individuals tested positive in the mobile clinic setting (6.2% vs 3.6% in the home-based setting), the home-based approach reached more first-time testers (particularly among adolescents) and tended to reach more men.

The authors conclude, "[o]verall, both study groups achieved a high uptake of [HIV testing and counselling], endorsing the use of community-based multi-disease approaches to reach populations that may not access facility-based [HIV testing and counselling]. Based on our results, the choice between [home-based versus mobile clinic approaches] should be guided by the intervention's objective."

However, the authors also noted that improving treatment coverage depends on the testing approaches being combined with effective interventions to improve linkage to care; only one in four individuals who tested positive for HIV in either study group was successfully enrolled in care at local health facilities within 1 month of testing positive for HIV.