Tropical Medicine and International Health doi:10.1111/tmi.

12501

volume 20 no 7 pp 893–902 july 2015

Feasibility and effectiveness of two community-based HIV

testing models in rural Swaziland
Lucy Anne Parker1, Kiran Jobanputra1, Lorraine Rusike2, Sikhathele Mazibuko3, Velephi Okello3,
Bernhard Kerschberger2, Guillaume Jouquet1, Joanne Cyr1 and Roger Teck1
1 Medecins Sans Frontieres, Geneva, Switzerland
2 Medecins Fans Frontieres, Nhlangano, Swaziland
3 Swaziland National AIDS Programme, Mbabane, Swaziland

Abstract objectives To evaluate the feasibility (population reached, costs) and effectiveness (positivity rates,
linkage to care) of two strategies of community-based HIV testing and counselling (HTC) in rural
Swaziland.
methods Strategies used were mobile HTC (MHTC) and home-based HTC (HBHTC). Information
on age, sex, previous testing and HIV results was obtained from routine HTC records. A consecutive
series of individuals testing HIV-positive were followed up for 6 months from the test date to assess
linkage to care.
results A total of 9 060 people were tested: 2 034 through MHTC and 7 026 through HBHTC. A
higher proportion of children and adolescents (<20 years) were tested through HBHTC than MHTC
(57% vs. 17%; P < 0.001). MHTC reached a higher proportion of adult men than HBHTC (42% vs.
39%; P = 0.015). Of 398 HIV-positive individuals, only 135 (34%) were enrolled in HIV care within
6 months. Of 42 individuals eligible for antiretroviral therapy, 22 (52%) started treatment within
6 months. Linkage to care was lowest among people who had tested previously and those aged 20–
40 years. HBHTC was 50% cheaper (US$11 per person tested; $797 per individual enrolled in HIV
care) than MHTC ($24 and $1698, respectively).
conclusion In this high HIV prevalence setting, a community-based testing programme achieved
high uptake of testing and appears to be an effective and affordable way to encourage large numbers
of people to learn their HIV status (particularly underserved populations such as men and young
people). However, for community HTC to impact mortality and incidence, strategies need to be
implemented to ensure people testing HIV-positive in the community are linked to HIV care.

keywords AIDS, HIV testing and counselling, HIV prevention, community-based interventions, HIV
diagnosis and management

counselling (HTC), more than one in three HIV-infected

Introduction
adults in Swaziland are unaware of their status [6].
Despite intense global commitment to fight HIV/AIDS In many generalised epidemics, including Swaziland,
and years of preventative campaigns, there were an esti- HTC coverage is higher among women than men [7].
mated 1.6 million AIDS-related deaths in 2012 (73% of This difference is largely explained by routine HIV testing
which were in sub-Saharan Africa) and 2.3 million new in antenatal care services; in Swaziland, 94% of pregnant
infections [1]. There is a growing body of evidence show- women undergo HIV testing [8]. Furthermore, the rural
ing that a reduction in HIV transmission at population clinics in Swaziland were originally developed as mater-
level can be achieved through high coverage of regular nal and child health services. Although they now provide
HIV testing combined with access to lifelong antiretrovi- primary health care including integrated HIV and tuber-
ral therapy (ART) of all identified HIV-positive individu- culosis care, it is possible that men are reluctant to attend
als [2–5]. Swaziland has the highest HIV prevalence in as that they still perceive them to be ‘female’ spaces.
the world: approximately 31% of 18- to 49-year-olds are Offering HTC in the community represents a crucial
HIV positive, and it is estimated that each year 2.4% of strategy for increasing HTC coverage among individuals
HIV-negative Swazis become HIV positive [6]. Despite who do not use health services regularly such as young
substantial efforts to expand access to HIV testing and men or individuals with work-related barriers [9].

© 2015 The Authors. Tropical Medicine & International Health Published by John Wiley & Sons Ltd. 893
This is an open access article under the terms of the Creative Commons Attribution-NonCommercial-NoDerivs License, which permits use and
distribution in any medium, provided the original work is properly cited, the use is non-commercial and no modifications or adaptations are made.
 13653156, 2015, 7, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/tmi.12501 by Cochrane Saudi Arabia, Wiley Online Library on [23/01/2024]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
Tropical Medicine and International Health volume 20 no 7 pp 893–902 july 2015

L. A. Parker et al. HIV testing models in rural Swaziland

Both home-based HTC (HBHCT) and mobile HTC approximately one quarter of the geographical area of
(MHTC) have been successfully implemented in several the country, and has a relatively poor rural population.
sub-Saharan settings, demonstrating high uptake and high The region had an estimated 41 000 people who are
acceptability [10–12]. Relative to facility-based HTC, HIV positive, of whom approximately 15 000 were
community-based strategies have been shown to reach thought to be unaware of their status [6, 7]. There were
HIV-positive populations earlier in the course of their a total of 25 health facilities in Shiselweni during the
HIV infection [12], thereby enabling earlier access to time of the study, three secondary health facilities and
treatment and a reduction in avoidable morbidity, mor- 22 rural clinics. All facilities had integrated HIV and
tality and transmission of the virus. In 2012, M
edecins tuberculosis care and were owned and managed by the
Sans Frontieres (MSF) introduced intensive community- Swaziland Ministry of Health, supported by MSF. For
based HTC in the rural Shiselweni region of the country HTC, the country uses a serial testing algorithm, starting
in collaboration with the Regional Health Department of with the Determine HIV1/2. If positive, the more specific
the Ministry of Health (MoH) of Swaziland. Unigold HIV1/2 test is used for confirmation. If after
While it is clear that community-based HTC increases these two tests, the HIV status remains indeterminate
the number of people who learn their status, it must also (e.g. one positive and one negative), a dry blood spot
be recognised that it may increase the proportion of HIV- (DBS) sample is sent to the National Reference Labora-
infected persons who know their positive status but fail tory for enzyme-linked immunosorbent assay (ELISA)
to enrol in HIV programmes. A study from Malawi testing [19].
showed that of 837 individuals screened HIV-positive, Specific details of the testing strategy used are available
only 209 (27%) completed CD4 staging [13]. In fact, sig- in online Supplementary Information S1. Briefly, two dif-
nificant drop-offs at all steps in the cascade from HIV ferent community-based HTC strategies were evaluated.
testing to treatment have been described, for example The first strategy was mobile HTC (MHTC), introduced
between enrolment and ART initiation or poor adherence on an ongoing basis from September 2012. MSF testing
after initiation [14–16]. Gardner et al [17] showed that teams visited community sites identified by community
even with an ART coverage rate of 75%, this translated leaders, attended mobile ‘outreach’ clinics and set up test-
to only 19% of all persons with HIV being on treatment ing sites at major events. The second strategy was home-
and adherent as shown by a suppressed viral load. It has based HTC (HBHTC), implemented on a campaign basis
been suggested that men, young adults and people with in August 2013. The campaign took place in three remote
work-related barriers are at risk for not accessing care communities that were sensitised ahead of time via radio
[18]. When evaluating HTC strategies, exploring the fac- announcements. During the campaign, the testers moved
tors associated with failed linkage to care is essential, as through the community by foot visiting the households
this can enable development of more focussed interven- door to door.
tions during and after post-test counselling which target In accordance with national HTC guidelines, individu-
those most at risk of not linking to care [15]. als who gave informed consent were considered eligible
Here, we describe the characteristics of the population for HTC provided they were over 12 years of age and
reached and the costs of HBHTC and MHTC in rural deemed by the health worker to be competent to make
Swaziland. We also determine whether the people who this decision; those under 12, or lacking competence to
tested HIV positive subsequently accessed HIV care ser- consent, were tested if a legal guardian provided consent
vices, underwent antiretroviral treatment eligibility deter- on their behalf [19]. No specific algorithm assessing was
mination and, for those who were eligible, started used to determine HIV risk among children and adoles-
treatment. The overall objective of this study was to cents, such that all individuals aged over 18 months were
describe the experience of community-based HTC considered eligible for testing. Children under the age of
approaches in the generalised epidemic context of Swazi- 18 months were referred to the nearest health facility in
land, to inform national and regional HIV programming. accordance with national guidelines, as a positive test
would require virological confirmation which is currently
only provided at health facilities. Individuals who tested
Methods HIV positive or had indeterminate test results were
referred to the health facility of their choice at a date of
Setting
their choice (recommended to be no later than 14 days).
Swaziland is a landlocked lower-middle income country For the purpose of the study, we visited the structures to
in Southern Africa, with a population of 1.2 million. ascertain whether the individuals had attended their refer-
This study was carried out in the Shiselweni region, ral appointment and were subsequently enrolled in the

894 © 2015 The Authors. Tropical Medicine & International Health Published by John Wiley & Sons Ltd.
 13653156, 2015, 7, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/tmi.12501 by Cochrane Saudi Arabia, Wiley Online Library on [23/01/2024]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
Tropical Medicine and International Health volume 20 no 7 pp 893–902 july 2015

L. A. Parker et al. HIV testing models in rural Swaziland

National HIV programme. Tracing individuals who referrals to preventative services for clients that tested
missed their appointment followed national protocol and HIV negative.
was led by the nurses and expert client counsellors in the
health centres (see Supplementary Information S1; refer-
Costing
ral process). Antiretroviral treatment eligibility assessment
through point-of-care (PoC) CD4 testing or WHO staging The cost of MHTC and HBHTC was estimated from a
was not provided at the community testing events. service provider perspective using an ingredient costing
approach [20], whereby the total costs of each testing
strategy was estimated and divided by the total number
Population and data collection of tests performed, individuals newly identified as HIV
To determine the characteristics of the population under- positive, and HIV-positive individuals linked to HIV care
going HTC in the community, individual level data were within 6 months. Further details of the costing analysis
obtained from paper testing records of two consecutive can be found in Supplementary Information S2.
samples (subgroups 1 & 2: Individuals tested from 01/08/
2013 to 30/08/2013 for HBHTC; and individuals tested Data analysis
from 15/03/2013 to 17/0572013 for MHTC). For
MHTC, detailed information was also collected regarding To estimate testing coverage through HBHTC, we
the type of event, and categorised as: obtained estimates regarding the number of homesteads
• Testing at comprehensive outreach: mobile ‘outreach’ and total population from the local councils. For MHTC,
clinics organised in collaboration with Ministry of we did not estimate coverage or uptake due to the lack of
Health (MOH) facilities. MOH staff were present a realistic target population (denominator) and the diffi-
offering primary healthcare services, while MSF pro- culty in determining who was really offered the test and
vided logistical support and offered HTC. who refused the test due to having a known HIV-positive
• MSF-led mobile testing. MSF testing teams set up status. With regard to the demographic characteristics of
tents and offered HTC at community sites identified the population reached, statistical comparisons between
by community leaders or workplaces. the two strategies were made with regard to the main
• Testing at major events such as football matches or indicators (gender, previous testing and HIV positivity)
world AIDS day. among adults only (≥20 years) using a Pearson’s chi-
• If more than one site was visited in 1 day, the infor- squared test. Linkage to care was defined as attendance at
mation regarding each site was collected accordingly, the referral facility and registration in the pre-ART regis-
and they were considered as two separate testing ter within 6 months of the test date. Linkage status was
events. established for all individuals who tested HIV positive,
irrespective of their expressed motivation to seek treat-
To determine the proportion of HIV-positive patients ment and care, unless they intended to access care outside
who were successfully linked to HIV care (registered in Shiselweni (and thus could not be followed up). To ana-
the HIV programme at their chosen facility within lyse factors associated with linkage to care, odds ratios
6 months), a consecutive sample of community-based (OR) and 95% confidence intervals (95% CI) were calcu-
testing participants who tested HIV positive (or had an lated using unconditional logistic regression. Variables
indeterminate HIV result) was followed up for 6 months that were associated with linkage in univariable analysis
from the test date (subgroup 3: Individuals testing HIV with a P -value of <0.10 were included in the multivari-
positive from 11/02/2013 to 29/08/2013). MSF data able model. Data entry was carried out using Epidata
clerks visited each of the health facilities in the region to (The EpiData Association, Odense, Denmark) data analy-
trace referrals using the Swaziland HTC client record. sis used Stata/SE Version 12 (StataCorp, Texas, USA).
This triplicate form has a unique form number allowing
the data clerks to identify individuals who had attended
Ethics
their appointment. Given that some individuals may have
sought care without using the referral form, the data This study used routine programme data without patient
clerks also performed a manual search of clinic HIV care identifiers. The study was approved by the Swaziland Sci-
records (paper ART and pre-ART registers) using name, entific and Ethics Committee and met the criteria for
age, village and date. Clients who were referred to a exemption from full ethics review from the international
health facility outside Shiselweni region were excluded MSF ERB. Both institutional review boards waived the
from the analysis of linkage to care. We did not follow need for written informed consent.

© 2015 The Authors. Tropical Medicine & International Health Published by John Wiley & Sons Ltd. 895
 13653156, 2015, 7, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/tmi.12501 by Cochrane Saudi Arabia, Wiley Online Library on [23/01/2024]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
Tropical Medicine and International Health volume 20 no 7 pp 893–902 july 2015

L. A. Parker et al. HIV testing models in rural Swaziland

(P < 0.001). A total of 110 (5.4%) of those tested

Results
through MHTC were under the age of 10, 245 (12%)
Testing coverage and uptake were adolescents (10–19 years old) and 1 679 (83%)
were adults (20 years or older). By contrast, 2086 (30%)
We analysed a consecutive sample of 2 043 people tested
of those tested by HBHTC were children under the age
through MHTC (Figure 1, subgroup 1.) There were a
of 10, 1924 (27%) were adolescents and 3016 (43%)
total of 135 events, of which 37 (27%) were comprehen-
were adults. Given the equal gender distribution among
sive outreach events (run by clinics), 83 (62%) were MSF
children and the fact that children and adolescents were
run mobile testing events and 15 (11%) were organised
more likely to be first-time testers, comparisons between
around a major event. In the month of August, 7 026
HBHTC and MHTC in terms of gender and previous
individuals were tested through an intensive HBHTC
testing were made among the adult population only.
campaign in the three rural constituencies (Figure 1, sub-
Details of the gender and previous testing characteristics
group 2). 2 005 (26%) of 7 681 homesteads were tested.
among the children and adolescents can be found in
The main reason for homesteads not being reached was
Table 1.
lack of time; each constituency was tested over seven
Among adults, a higher proportion of men were tested
consecutive days, and this was not sufficient to reach all
by MHTC than HBHTC (702, 42% vs. 1163, 39%,
homesteads in this rural setting.
P = 0.020). The proportion of males tested was higher
According to local council records, a total of 12 269
among the subgroup of MHTC that was categorised as
people lived in the 2 005 households that were visited
major events, where 243 of 426 people tested were male
during the HBHTC campaign. 8 768 (71%) were present
(57%, data not shown in tables).
the day of testing. 673 (8%) of those present had a
Of the adults tested through HBHTC, 1 013 (34%)
known HIV-positive status and 395 (5%) reported that
were testing for the first time. This was significantly
they knew their status as they had tested negative in the
higher than for MHTC (359, 22%, P < 0.001). Similarly,
previous 2 months. Of the remaining 7 484 individuals,
the proportion of adults who had not tested within the
6 452 (86%) were tested. A further 597 individuals were
last 12 months was higher among those tested by
tested outside the households.
HBHTC compared to MHTC (Table 1, P > 0.001).

Demographics and previous testing among the population

reached by MHTC and HBHTC HIV positivity rate
A higher proportion of children and adolescents were Overall, the HIV positivity rate was highest among those
tested during the HBHTC campaign than by MHTC tested though MHTC where 96 individuals (4.7%) tested

September, 2012 Médicins sans Frontières begins implementation of community-

based HTC activities in rural Swaziland
Routine data shows 18,207 individuals were tested from 01/09/12 to 30/08/13

Subgroup 3:
Subgroup 1: Subgroup 2:
Consecutive sample of individuals who tested
Consecutive sample of individuals tested by Consecutive sample of individuals tested by
HIV positive by either MHTC or HBHTC from
HBHTC from 01/08/13 to 30/08/13 MHTC from 15/03/13 to 17/05/13
11/02/13 - 29/08/13
N = 7026 N = 2043
N = 439

41 individuals excluded due to

being referred to a facility
outside the region
N = 398

Figure 1 Participants of MSF supported community-based HTC activities from in rural Swaziland from 01/09/12 to 30/30/13. Indivi-
duals testing prior to 11/02/13 were not included because the L&R SOPs had not been fully implemented at this time.

896 © 2015 The Authors. Tropical Medicine & International Health Published by John Wiley & Sons Ltd.
 Table 1 Characteristics of the participants tested through community-based HTC in rural Swaziland

MHTC HBHTC

Adolescent Adolescent
Tropical Medicine and International Health

Children (10–19 Adult Children (10–19 Adult

(1–9 years) years) (≥20 years) Total* (1–9 years) years) (≥20 years) Total*

n % n % N % n % n % n % N % n % P†

Total 110 – 245 – 1679 – 2034 – 2086 – 1924 – 3016 – 7026 –

Gender
L. A. Parker et al. HIV testing models in rural Swaziland

Male 50 46 142 58 703 42 895 44 1025 49 918 48 1163 39 3106 44 0.020

Female 58 54 103 42 969 58 1130 56 1058 51 1005 52 1851 61 3914 56
Previous HIV test
Never 91 83 153 63 359 22 603 30 1899 92 1576 83 1013 34 4488 64 <0.001
Within last 12 months 9 8 56 23 715 43 780 39 57 3 113 6 781 26 951 14
Over a year ago 9 8 35 14 592 35 636 32 114 6 219 11 1181 40 1514 22

© 2015 The Authors. Tropical Medicine & International Health Published by John Wiley & Sons Ltd.
HIV test result
Negative 109 100 240 98 1578 95 1927 94 2058 99 1884 98 2806 94 6748 96 0.285
Positive 0 – 5 2 91 5 96 6 21 1 32 2 189 6 242 4
Indeterminate 0 – 0 – 0 0 0 0 0 – 3 0 2 0 5 0

*32 individuals had missing information on age and do not appear in this table. Furthermore, the sum of the subtotals does not add up to the total because 1 (0.01%)
individual had missing information on gender, 75 (0.83%) had missing info for previous HIV testing and 42 (0.5%) had a missing HIV test result.
†P value from Pearson’s chi-squared test comparing proportions among adults only.

897
volume 20 no 7 pp 893–902 july 2015

13653156, 2015, 7, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/tmi.12501 by Cochrane Saudi Arabia, Wiley Online Library on [23/01/2024]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
 13653156, 2015, 7, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/tmi.12501 by Cochrane Saudi Arabia, Wiley Online Library on [23/01/2024]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
Tropical Medicine and International Health volume 20 no 7 pp 893–902 july 2015

L. A. Parker et al. HIV testing models in rural Swaziland

HIV positive vs. 243 (3.5%) of those tested by HBHTC of the test date (figure 2). Of these, 103 (76%) had a
(P = 0.009). The number needed to screen to identify one CD4 count taken and completed ART eligibility assess-
HIV-positive individual was 21 (95% CI: 17–26) for ment (equivalent to 26% of those tested HIV positive).
MHTC and 29 (95% CI: 26–33) for HBHTC. Among Forty-two (41%) were eligible for combined ART accord-
adults only, there was no difference in the HIV positivity ing to national guidelines (CD4 < 350 and/or WHO clini-
rates between the two strategies (Table 1, P = 0.285), cal stages III or IV), of whom 22 (52%) initiated
with 5-6% found to be HIV positive through either strat- treatment. The median time from HIV testing to pre-
egy. The number of adults needed to screen to identify ART enrolment was 12 days (IQR 6–29 days), and the
one HIV-positive individual was 18 (95% CI: 15–23) for median time from HIV test to ART initiation was
MHTC and 16 (95% CI: 14–18) for HBHTC. Of the 34 days (IQR 20–60).
4 010 children and adolescents tested during the HBHTC There was no difference in linkage to care between the
campaign, 53 (1.3%) tested HIV positive and a further two testing strategies or between men and women
three had indeterminate test results. (Table 2). Linkage to care was highest among children
and older individuals (approximately half of the children
aged 18 months to 9 years or adults aged over 50 were
Linkage to HIV care
linked to care, Table 2). Particularly, low rates of linkage
We analysed a consecutive sample of 439 individuals that to care were observed for individuals aged 20–29 and
tested HIV positive at a MHTC event or during the 30–39 years old (Table 2). Enrolment in HIV care was
HBHTC campaign (Figure 1, subgroup 3). Of the 398 highest among first-time testers (44% compared to 28%
HIV-positive individuals referred within Shiselweni, 135 of those who had tested previously, P = 0.004). Single
(34%) were registered in pre-ART care within 6 months people were less likely seek HIV care than individuals

398 HIV+ tested in by MHTC or HBHTC from

11th Feb – 29th Aug 2013 (subgroup 3)

135 (34%) linked to HIV care 263(66%) not linked to HIV care
facility within 6 months facility 6 months after HIV+ test

103 (76%) treatment 32 (24%) no information regarding

eligibility(1) assessed CD4 or WHO staging

42 (41%) CD4<350 and/or 61 (59%) CD4>350 and

WHO stage III/IV WHO stage I or II

22(52%) intiated
combined ART

20 (48%) had not initiated

ART 6 months after HIV
test

Figure 2 Linkage-to-care, assessment of ART eligibility and treatment initiation among individuals testing HIV+ through community
testing in Shiselweni, Swaziland. (1)Treatment eligibility was defined as any client with CD4 < 350 and/or WHO III/IV stage.

898 © 2015 The Authors. Tropical Medicine & International Health Published by John Wiley & Sons Ltd.
 13653156, 2015, 7, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/tmi.12501 by Cochrane Saudi Arabia, Wiley Online Library on [23/01/2024]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
Tropical Medicine and International Health volume 20 no 7 pp 893–902 july 2015

L. A. Parker et al. HIV testing models in rural Swaziland

Table 2 Factors associated with linkage to care among individuals testing HIV positive or with indeterminate test results in commu-
nity-based testing events

Linked to HIV care facility Crude odds ratio Adjusted odds ratio
N within 6 months (%) P (95% CI) (95% CI)

Total 398 135 (34)

Strategy type
MHTC 228 60 (35) 0.617 1 –
HBHTC 170 75 (33) 1.1 (0.7–1.7) –
Age
Children (1–9 years) 14 7 (50) 0.001 3.4 (1.1–10.6) 3.1 (0.9–10.1)
Adolescents (10–19 years) 33 14 (42) 2.5 (1.1–5.7) 2.5 (1.0–6.0)
Adults (20–29 years) 120 27 (23) 1 1
Adults (30–39 years) 104 28 (27) 1.3 (0.7–2.3) 1.1 (0.6–2.1)
Adults (40–49 years) 62 27 (44) 2.7 (1.4–5.1) 2.2 (1.1–4.5)
Adults (≥50 years) 60 30 (50) 3.4 (1.7–6.7) 2.3 (1.1–5.0)
Gender
Female 242 84 (35) 1 –
Male 155 51 (33) 0.711 0.9 (0.6–1.4) –
Previous HIV test
Never 161 71 (44) 0.004 1 1
Within last 12 months 70 19 (27) 0.4 (0.3–0.9) 0.5 (0.3–1.0)
Over a year ago 160 45 (28) 0.5 (0.3–0.8) 0.6 (0.3–0.9)
Marital status
Single/separated 153 44 (29) 0.044 1 1
Married/cohabitation 194 67 (36) 1.3 (0.8–2.1) 1.5 (0.9–2.7)
Widowed 38 19 (50) 2.5 (1.2–5.1) 2.1 (0.9–5.2)

NB: 5 (1.3%) had missing information on age, 1 (0.3%) on sex, 7 (1.8%) on previous testing and 19 (4.7%) on marital status.

who reported being married or living in stable partner- Table 3 Cost of community-based HIV testing strategies led by
ship although this association lost statistical significance MSF in Shiselweni, Swaziland, 2013
after controlling for age and previous testing (Table 2).
Of four individuals who had indeterminate test results MHTC HBHTC
and were referred to a facility within Shiselweni, none Cost per person reached 24 USD 11 USD
were linked to care within 6 months, and hence, none Cost per HIV positive identified 543 USD 343 USD
were retested. Cost per HIV positive 1698 USD 797 USD
identified and linked to care
Break-up of costs (%)
Cost of MHTC and HBHTC campaign Transport 25 6
Human resources 52 26
From service provider perspective, HBHTC was signifi- Testing equipment 16 30
cantly cheaper ($11 per person tested, $343 per HIV- Infection control 2 1
positive individual identified, and $797 per HIV-positive Information, education and 1 3
individual linked to care) than MHTC ($24, $543 and counselling
$1 698, respectively, Table 3). The main cost driver for Other* 3 33
HBHTC was accommodation and food for staff during
*Other costs included trailers, tents, furniture for MHTC;
the campaign, accounting for nearly one-third of the total accommodation, food, airtime for HBHTC.
costs (Table 3). The main cost drivers for MHTC were
human resources, followed by transport costs. people and hence have the potential to increase the num-
ber of people who know their HIV status, in this rural,
low-resourced, high-prevalence setting of Swaziland.
Discussion
Rates of sero-positivity were similar between strategies,
We found mobile- and home-based HTC to be feasible but HBHTC cost 50% less than the mobile strategies,
and affordable ways to reach a substantial number of and was a more effective strategy for reaching first-time

© 2015 The Authors. Tropical Medicine & International Health Published by John Wiley & Sons Ltd. 899
 13653156, 2015, 7, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/tmi.12501 by Cochrane Saudi Arabia, Wiley Online Library on [23/01/2024]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
Tropical Medicine and International Health volume 20 no 7 pp 893–902 july 2015

L. A. Parker et al. HIV testing models in rural Swaziland

testers. MHTC appeared more effective for reaching spe- when testing numbers are low the number of HIV-posi-
cific target groups (such as men), and thus, both testing tive individuals identified will increase and the cost per
strategies may have a complementary role to play, HIV-positive individual identified will be reduced.
depending on the specific objectives of the testing pro- A key challenge highlighted in our study was the low
gramme. Only one-third of those testing HIV positive rate of linkage to HIV care among individuals who tested
were subsequently enrolled in pre-ART care and hence HIV-positive. If linkage to HIV care for HIV-positive
ensuring that people who test HIV positive in the com- individuals were the sole objective of HTC, the commu-
munity access HIV prevention and care services remains nity-based strategies as described here could not be
a significant challenge in this setting. deemed effective. Two-thirds of the HIV-positive individ-
In high-prevalence generalised HIV epidemics, as is the uals identified were not registered in HIV care within
case in Swaziland, increasing the proportion of people 6 months of the test. While high levels of attrition after
who know their HIV status is an important public health HIV testing have been observed in numerous studies [14–
goal, and both strategies evaluated contributed to this 16, 23, 24], some studies have shown relatively high lev-
process (almost half of those testing in the Shiselweni els of linkage [10, 12]. In the light of our findings, and
region in this evaluation period were tested by this small reviewing the details of the different studies, it appears
community team). A significant number of children were that PoC ART eligibility determination could be a valu-
tested by HBHTC; 54 tested HIV positive, of whom 22 able addition to HBHTC and MHTC programmes, for
were under the age of 10, which demonstrates the poten- the purposes of increasing linkage of HIV-positive people
tial of HBHTC for reaching HIV-positive children missed to HIV care. Nevertheless, determination of ART eligibil-
by the PMTCT programme and child welfare services. ity does not guarantee that an individual initiates ART.
Community testing offering HIV testing to all individuals One study showed that one in five people did not
over 18 months of age can therefore complement the undergo CD4 staging even with PoC CD4 available [18],
detection of HIV-positive children for linkage into HIV and of those that did a further 27% did not receive their
care and treatment. Other studies have also identified results. Furthermore, even when CD4 staging is close to
home-based testing to be a good strategy to target chil- 100%, treatment initiation can be as low as 50%[25]. In
dren [21, 22]. Furthermore, we showed that HBHTC was our study, we found that one in four people attending
a more effective strategy for reaching people who are the clinic did not have CD4 staging recorded, and only
overdue for retesting (national HTC guidelines recom- half of the individuals eligible for ART after CD4 testing
mend that HIV-negative adults undergo yearly testing) and WHO staging initiated ART within 6 months of the
[19]. In a high-incidence setting, increasing rates of HIV test.
annual retesting is of particular relevance, as identifying Linkage to care was especially poor among individuals
people with HIV infection, who believe they are still HIV who had tested in the past. It is possible that these indi-
negative, may be an important element of transmission viduals are more reluctant to believe and act upon the
reduction. test results, given they had had a negative test in the past.
The costs reported here for both HBHTC and MHTC Furthermore, we showed linkage was low among people
here were comparable to those summarised in a recent aged 20–40, which may reflect occupational barriers pre-
systematic review [12]. It is worth noting that HBHTC in venting these individuals from attending the clinic for
this study was carried out in the form of an intensive HIV care. However, it is alarming that linkage to care
door-to-door campaign with supplementary working was not higher than 50% for any of the subgroups con-
hours for the testing teams, and as such incurred some sidered. Strategies to improve linkage to care and to
additional costs (staff accommodation and food) that reduce attrition between testing and treatment initiation
could be avoided to make the activity more economical. are urgently needed [23]. Providing incentives has been
However, it is difficult to calculate what impact this suggested to have positive impact on linkage rates [26],
would have on costs as the number of people tested dur- as has incorporating POC CD4 counts and follow-up vis-
ing the campaign is likely to be higher than the number its by a lay counsellor [27]. Reducing the number of
tested if door-to-door testing were to be undertaken as a health facility visits has also been suggested as a key
routine activity. Relative to HBHTC, MHTC was signifi- facilitator for improving access [26]. Indeed, one study in
cantly more expensive which can be explained by the fact Malawi has shown that offering home initiation after
that some mobile events had very low attendance levels home self-testing significantly increased the proportion of
(e.g. remote communities), yet HR and transport costs adults initiating ART [28].
remained constant. If MHTC is directed at high-risk During the HBHTC campaign, nearly a third of the
groups with poor access to HTC, it is possible that even reported households members were not present the day

900 © 2015 The Authors. Tropical Medicine & International Health Published by John Wiley & Sons Ltd.
 13653156, 2015, 7, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/tmi.12501 by Cochrane Saudi Arabia, Wiley Online Library on [23/01/2024]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
Tropical Medicine and International Health volume 20 no 7 pp 893–902 july 2015

L. A. Parker et al. HIV testing models in rural Swaziland

of testing, perhaps due to work commitments. Improving Swaziland for their support and constructive comments
HBHTC testing coverage by visiting the homesteads in the and throughout the design and implementation and/or
evenings may be a useful strategy to reduce health inequali- drafting the manuscript. This work was funded by M
edec-
ties caused by work-related barriers. HBHTC was intro- ins sans Frontieres (MSF), Geneva, Switzerland. Some of
duced as a campaign, and it is not clear if uptake the authors are/were employed by MSF during the study
(acceptance) would be similarly high if HBHTC were to be implementation, analysis and write-up. The funding body
carried out on a routine basis or if recurrent campaigns also organised a steering committee comprised of staff
were to take place. Furthermore, it is important to respect and academics from different international organisations
the opt-in nature of HBHTC as concerns have been raised to guide operational research in Swaziland, thereby influ-
about HBHTC and the possibility of household members encing study design, data collection and analysis. They
participating in HTC under coercion. In our analysis of had no role in decision to publish or preparation of the
factors associated with linkage to care, one key limitation manuscript. The opinions and statements in this article
was the lack of availability of CD4 or WHO staging to are those of the authors and do not necessarily represent
determine eligibility for ART. It is possible that individuals the official policy, endorsement or views of MSF.
who feel healthy are less likely to attend the clinic, poten-
tially acting as a confounder in our risk factor analysis.
Finally, we must recognise as a limitation that our costing References
analysis is limited to the service provider’s perspective. 1. Joint United Nations Programme on HIV/AIDS (UNAIDS).
However, if we had considered the patient perspective, Global Report: UNAIDS Report on the Global AIDS Epi-
both community-based HTC strategies are likely to be even demic 2013. UNAIDS: Geneva, Switzerland, 2013.
more cost-effective because from a patient perspective the 2. Granich RM, Gilks CF, Dye C, De Cock KM, Williams BG.
main costs are transport costs (to go to a site offering Universal voluntary HIV testing with immediate antiretrovi-
HTC) and opportunity cost (loss of time travelling to the ral therapy as a strategy for elimination of HIV transmis-
sion: a mathematical model. Lancet 2009: 373: 48–57.
HTC site and waiting for ones turn to test).
3. Jones A, Cremin I, Abdullah F et al. Transformation of HIV
In conclusion, community-based testing appears to be
from pandemic to low-endemic levels: a public health
an effective and affordable way to improve HTC cover- approach to combination prevention. Lancet 2014: 384:
age in high-prevalence settings. We found that HBHTC 272–279.
cost less than MHTC and was more effective at reaching 4. Coates TJ, Kulich M, Celentano DD et al. Effect of commu-
first-time testers and people who had not tested in the nity-based voluntary counselling and testing on HIV inci-
past 12 months. Furthermore, in a setting with high ante- dence and social and behavioural outcomes (NIMH Project
natal HIV prevalence and low coverage of infant testing Accept; HPTN 043): a cluster-randomised trial. Lancet
throughout breastfeeding, HBHTC enabled identification Glob. Heal. 2014: 2: e267–e277.
of HIV-positive children missed by the PMTCT pro- 5. Cohen MS, Chen YQ, McCauley M et al. Prevention of
HIV-1 infection with early antiretroviral therapy. N Engl J
gramme and child welfare services. MHTC, although
Med 2011: 365: 493–505.
more expensive, can still be a useful strategy to reach
6. Swaziland Ministry of Health. Swaziland HIV Incidence
specific target groups with poor access to HTC (e.g. Measurement Survey (SHIMS). First Findings Report. Swazi-
young men or people with work-related barriers). Com- land Ministry of Health: Mbabane, Swaziland, 2012.
munity-based testing can thus contribute to increasing the 7. Central Statistical Office and UNICEF. Swaziland Multiple
number of people who know their HIV status. However, Indicator Cluster Survey 2010. Final Report. Swaziland
for it to have impact on HIV morbidity, mortality and Ministry of Health: Mbabane, Swaziland, 2011.
incidence, it should include not only PoC treatment eligi- 8. Strategic information Department SM of H. PMTCT Pro-
bility determination but also other ‘directive’ linkage gramme Annual Report 2012. Swaziland Ministry of
strategies to help guide people testing HIV positive in the Health: Mbabane, Swaziland, 2013.
community into HIV care and treatment. 9. WHO. Consolidated guidelines on the use of antiretroviral
drugs for treating and preventing HIV infection. World
Health Organization, Geneva, Swaziland, 2013.
Acknowledgements 10. Van Rooyen H, Barnabas RV, Baeten JM et al. High HIV
testing uptake and linkage to care in a novel program of
Tengetile Hlophe, the MSF community testing teams in home-based HIV counseling and testing with facilitated
Shiselweni and the MSF operational research data clerks referral in KwaZulu-Natal, South Africa. J Acquir Immune
without whom the study would have not been possible. Defic Syndr 2013: 64: e1–e8.
Annick Antierens, Johnny Lujan, Elias Pavlopoulos and 11. Mutale W, Michelo C, J€ urgensen M, Fylkesnes K. Home-
the MSF steering committee on operational research in based voluntary HIV counselling and testing found highly

© 2015 The Authors. Tropical Medicine & International Health Published by John Wiley & Sons Ltd. 901
 13653156, 2015, 7, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/tmi.12501 by Cochrane Saudi Arabia, Wiley Online Library on [23/01/2024]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
Tropical Medicine and International Health volume 20 no 7 pp 893–902 july 2015

L. A. Parker et al. HIV testing models in rural Swaziland

acceptable and to reduce inequalities. BMC Public Health International Conference on AIDS and STIs in Africa: Cape
2010: 10: 347. Town; 2013:1.
12. Suthar AB, Ford N, Bachanas PJ et al. Towards universal 22. Ahmed S, Kim MH, Sugandhi N et al. Beyond early infant
voluntary HIV testing and counselling: a systematic review diagnosis: case finding strategies for identification of HIV-
and meta-analysis of community-based approaches. PLoS infected infants and children. AIDS 2013: 27(Suppl 2):
Med 2013: 10: e1001496. S235–S245.
13. Wringe A, Floyd S, Kazooba P et al. Antiretroviral therapy 23. MacPherson P, Corbett EL, Makombe SD et al. Determi-
uptake and coverage in four HIV community cohort studies nants and consequences of failure of linkage to antiretroviral
in sub-Saharan Africa. Trop Med Int Health 2012: 17: e38– therapy at primary care level in Blantyre, Malawi: a pro-
e48. spective cohort study. PLoS ONE 2012: 7: e44794.
14. Rosen S, Fox MP. Retention in HIV care between testing 24. Kranzer K, Zeinecker J, Ginsberg P et al. Linkage to HIV
and treatment in sub-Saharan Africa: a systematic review. care and antiretroviral therapy in Cape Town, South Africa.
PLoS Med 2011: 8: e1001056. PLoS ONE 2010: 5: e13801.
15. El-Sadr WM, Gamble TR, Cohen MS. Linkage from HIV 25. Shapiro AE, Variava E, Rakgokong MH et al. Community-
testing to care: a positive test often leads nowhere. Sex based targeted case finding for tuberculosis and HIV in
Transm Dis 2013: 40: 26–27. household contacts of patients with tuberculosis in South
16. McNairy ML, El-Sadr WM. The HIV care continuum: no Africa. Am J Respir Crit Care Med 2012: 185: 1110–1116.
partial credit given. AIDS 2012: 26: 1735–1738. 26. Govindasamy D, Meghij J, Kebede Negussi E, Clare Bagga-
17. Gardner EM, McLees MP, Steiner JF, Del Rio C, Burman ley R, Ford N & Kranzer K. Interventions to improve or
WJ. The spectrum of engagement in HIV care and its rele- facilitate linkage to or retention in pre-ART (HIV) care and
vance to test-and-treat strategies for prevention of HIV initiation of ART in low- and middle-income settings–a sys-
infection. Clin Infect Dis 2011: 52: 793–800. tematic review. J Int AIDS Soc 2014;17:19032. (Available
18. Govindasamy D, Ford N, Kranzer K. Risk factors, from: http://www.pubmedcentral.nih.gov/articlerender.fcgi?
barriers and facilitators for linkage to antiretroviral ther- artid=4122816&tool=pmcentrez&rendertype=abstract.)
apy care: a systematic review. AIDS 2012: 26: Accessed November 2, 2014.
2059–2067. 27. Barnabas RV, van Rooyen H, Tumwesigye E et al. Initiation
19. Kingdom of Swaziland Ministry of Health. Swaziland of antiretroviral therapy and viral suppression after home
National HIV Testing and Counselling Guidelines, August HIV testing and counselling in KwaZulu-Natal, South
2010. Swaziland Ministry of Health: Mbabane, Swaziland, Africa, and Mbarara district, Uganda: a prospective, obser-
2010. vational intervention study. Lancet. HIV 2014;1:e68–e76.
20. Levin HM, McEwan PJ. Cost-Effectiveness Analysis: Meth- 28. MacPherson P, Lalloo DG, Webb EL et al. Effect of
ods and Applications (2nd edn), Sage: Thousand Oaks, CA, optional home initiation of HIV care following HIV self-
2001. testing on antiretroviral therapy initiation among adults in
21. Labhardt ND. comparison of home-based versus community Malawi: a randomized clinical trial. JAMA 2014: 312: 372–
gathering approach in providing HIV counselling and testing 379.
in Lesotho: a cluster randomized trial. In: ICASA

Corresponding Author Lucy Anne Parker, M
edecins Sans Frontieres, 78 rue de Lausanne, Geneva, Switzerland.
Tel.: +41 22 849 84 84, Fax +41 22 849 84 88, E-mail: [email protected]

902 © 2015 The Authors. Tropical Medicine & International Health Published by John Wiley & Sons Ltd.