Uptake of home-based voluntary HIV testing in sub-Saharan Africa: a systematic review and meta-analysis

Improving access to HIV testing is a key priority in scaling up HIV treatment and prevention services. Home-based voluntary counselling and testing (HBT) as an approach to delivering wide-scale HIV testing is explored here

Social inequality and HIV-testing

The plan to increase HIV testing is a cornerstone of the international health strategy against the HIV/AIDS epidemic, particularly in sub-Saharan Africa. This paper highlights a problematic aspect of that plan: the reliance on clinic- rather than home-based testing. First, drawing on DHS data from across Africa, we demonstrate the substantial differences in socio-demographic and economic profiles between those who report having ever had an HIV test, and those who report never having had one. Then, using data from a random household survey in rural Malawi, we show that substituting home-based for clinic-based testing may eliminate this source of inequality between those tested and those not tested. This result, which is stable across modeling frameworks, has important implications for accurately and equitably addressing the counseling and treatment programs that comprise the international health strategy against AIDS, and that promise to shape the future trajectory of the epidemic in Africa and beyond.AIDS/HIV, home-based testing, inequality, Malawi

Taking HIV testing to families: designing a family-based intervention to facilitate HIV testing, disclosure and intergenerational communication

Introduction: Facility-based HIV testing does not capture many adults and children who are at risk of HIV in South Africa. This underscores the need to provide targeted, age-appropriate HIV testing for children, adolescents and adults who are not accessing health facilities. While home based counseling and testing has been succesfully delivered in multiple settings, it also often fails to engage adolescents. To date, the full potential for testing entire families and linking them to treatment has not been evaluated. Methods: The steps to expand a successful home-based counseling and testing model to a family-based counseling and testing approach in a high HIV prevalence context in rural South Africa are described. The primary aim of this family-based model is to increase uptake of HIV testing and linkage to care for all family members, through promoting family cohesion and intergenerational communication, increasing HIV disclosure in the family, and improving antiretroviral treatment uptake, adherence and retention. We discuss the three-phased research approach that led to the development of the family-based counseling and testing intervention. Results: The family-based intervention is designed with a maximum of five sessions, depending on the configuration of the family (young, mixed and older families). There is an optional additional session for high-risk or vulnerable family situations. These sessions encourage HIV testing of adults, children and adolescents and disclosure of HIV status. Families with adolescents receive an intensive training session on intergenerational communication, identified as the key causal pathway to improve testing, linkage to care, disclosure and reduced stigma for this group. The rationale for the focus on intergenerational communication is described in relation to our formative work as well as previous literature, and potential challenges with pilot testing the intervention are explored. Conclusion: This paper maps the process for adapting a novel and largely successful home-based counseling and testing intervention for use with families. Expanding the successful home-based counseling and testing model to capture children, adolescents and men could have significant impact if the pilot is successful and scaled-up

Diagnostic Accuracy of Home Sleep Apnea Testing (HSAT) Based on Recording Duration

Introduction: Obstructive Sleep Apnea (OSA) is a chronic sleeping disorder with serious health consequences. Currently, standard diagnosis is through in-lab polysomnography; however, there has been a shift to greater use of Home Sleep Apnea Testing (HSAT) for patients with a high pre-test probability of having OSA. Objective: To investigate the minimum recording time needed during HSAT to accurately diagnose the presence and severity of OSA. Methods: A retrospective review was conducted of HSATs done from January-October 2017. Each study was divided into 1-, 2-,3-,4-,5-, 6-, and 7 hour intervals beginning at the recording start time. The respiratory event index (REI) was determined for each of these time intervals and then compared to the initial REI derived from the total monitoring time (REITMT) by a Fleiss’ κ test, a paired samples t-test, and concordance correlation coefficients (CCC). Results: Significant differences were found between the REITRT and the REI at 60 min (P \u3c 0.0001), 120 min (0.0002), 180 min (\u3c 0.0001) and 240 min (0.0002) with a lack of concordance, signifying these intervals are poor diagnostic correlates for the REITRT. REIs determined at 300, 360, and 420 min were not significantly different from the REITRT and had very significant CCCs, 0.979, 0.990, and 0.996, respectively. The Fleiss’ κ test showed almost perfect agreement between the REITRT and and the REI for 360 and 420 min. Discussion: The results suggest that at least 6 hours of monitoring time during HSAT is needed to accurrately diagnose and determine the severity of OSA

Speaking with Barry Rovner, MD

Q: What Alzheimer’s related studies are you involved in currently at the Farber Institute for Neurosciences? Dr. Rovner: We are evaluating three exciting new disease-modifying drug treatments that may slow down the course of Alzheimer’s disease. I am also a Principal Investigator of Jefferson’s Center for Excellence in Neurodegenerative Diseases funded by the Pennsylvania Department of Health Tobacco Settlement grant. We are testing innovative screening methods to identify dementia in community-based agencies serving older adults, as well as testing in-home skills training services to delay nursing home placement and reduce stress for a racially diverse group of family caregivers. This latter study is being conducted at the Center for Applied Research on Aging and Health, by Principal Investigator Laura N. Gitlin, PhD

“It is better to die”: experiences of traditional health practitioners within the HIV treatment as prevention trial communities in rural South Africa (ANRS 12249 TasP trial)

The ANRS 12249 Treatment-as-Prevention (TasP) cluster-randomized trial in rural South Africa uses a “test and treat” approach. Home-based testing services and antiretroviral treatment initiation satellite clinics were implemented in every cluster as part of the trial. A social science research agenda was nested within TasP with the aim of understanding the social, economic and contextual factors that affect individuals, households, communities and health systems with respect to TasP. Considering the rural nature of the trial setting, we sought to understand community perceptions and experiences of the TasP Trial interventions as seen through the eyes of traditional health practitioners (THPs). A qualitative study design was adopted using four repeat focus group discussions conducted with nine THPs, combined with community walks and photo-voice techniques, over a period of 18 months. A descriptive, interpretive and explanatory approach to analysis was adopted. Findings indicate that THPs engaged with the home-based testing services and HIV clinics established for TasP. Specifically, home-based testing services were perceived as relatively successful in increasing access to HIV testing. A major gap observed by THPs was linkage to HIV clinics. Most of their clients, and some of the THPs themselves, found it difficult to use HIV clinics due to fear of labelling, stigma and discrimination, and the ensuing personal implications of unsolicited disclosure. On the one hand, a growing number of patients diagnosed with HIV have found sanctuary with THPs as alternatives to clinics. On the other hand, THPs in turn have been struggling to channel patients suspected of HIV into clinics through referrals. Therefore, acceptability of the TasP test and treat approach by THPs is a major boost to the intervention, but further success can be achieved through strengthened ties with communities to combat stigma and effectively link patients into HIV care, including partnerships with THPs themselves

Don\u27t Try This at Home: The FDA\u27s Restrictive Regulation of Home-Testing Devices

Over the past forty years, the Food and Drug Administration (FDA) has successfully restricted consumers\u27 access to home-testing applications based on the notion that it should protect individuals from their own reactions to test results. In the 1970s, the FDA briefly denied women access to home pregnancy tests that were identical to those used in laboratories. In the late 1980s and early 1990s, it relied on concerns about consumer responses to HIV status results to justify a categorical ban on applications for HIV home-testing technology. More recently, it placed burdensome restrictions on direct-to-consumer (DTC) genetic testing companies, such as 23andMe, based on fears that consumers would make irrational medical decisions after receiving genetic variant results. Although the FDA has the statutory authority to ensure the safety and effectiveness of medical devices, it has expansively interpreted the term safety to encompass considerations of how consumers might use test results provided by purely informative devices. This Note argues that courts should not give the FDA deference on its broad interpretation of safety in restricting home-testing devices. It documents the evolution of the expertise-based rationale for judicial deference, noting that courts typically provide scientific agencies, including the FDA, super deference because of the complicated nature of their work. Ultimately, courts should not defer to the FDA’s interpretation of safety because it did not use its scientific expertise when it considered how consumers might react to HIV home-testing and DTC genetic testing results. Further, the FDA should not have the authority to make decisions based on its view of safety because it should not have the power to make value judgments for consumers about whether they should seek their personal medical information

Home sampling for sexually transmitted infections and HIV in men who have sex with men: a prospective observational study

To determine uptake of home sampling kit (HSK) for STI/HIV compared to clinic-based testing, whether the availability of HSK would increase STI testing rates amongst HIV infected MSM, and those attending a community-based HIV testing clinic compared to historical control. Prospective observational study in three facilities providing STI/HIV testing services in Brighton, UK was conducted. Adult MSM attending/contacting a GUM clinic requesting an STI screen (group 1), HIV infected MSM attending routine outpatient clinic (group 2), and MSM attending a community-based rapid HIV testing service (group 3) were eligible. Participants were required to have no symptomatology consistent with STI and known to be immune to hepatitis A and B (group 1). Eligible men were offered a HSK to obtain self-collected specimens as an alternative to routine testing. HSK uptake compared to conventional clinic based STI/HIV testing in group 1, increase in STI testing rates due to availability of HSK compared to historical controls in group 2 and 3, and HSK return rates in all settings were calculated. Among the 128 eligible men in group 1, HSK acceptance was higher (62.5% (95%CI: 53.5–70.9)) compared to GUM clinic-based testing (37.5% (95% CI: 29.1–46.5)), (p = 0.0004). Two thirds of eligible MSM offered an HSK in all three groups accepted it, but HSK return rates varied (highest in group 1, 77.5%, lowest in group 3, 16%). HSK for HIV testing was acceptable to 81%of men in group 1. Compared to historical controls, availability of HSK increased the proportion of MSM testing for STIs in group 2 but not in group 3. HSK for STI/ HIV offers an alternative to conventional clinic-based testing for MSM seeking STI screening. It significantly increases STI testing uptake in HIV infected MSM. HSK could be considered as an adjunct to clinic-based services to further improve STI/HIV testing in MSM

Work Journey Rescheduling – Model Development Analysis.

Using Wakefield as a case study, a method was developed of testing the effects on traffic of several different work journey rescheduling strategies. The method consisted essentially of assigning a series of six 0-D matrices to the Wakefield network, each matrix representing the trips for consecutive 15 minute periods over the morning peak. The six matrices were obtained by firstly disaggregating the l 1/2 hr peak matrix by purpose (into home-based work, commercial vehicle, and other trips) and then disaggregating each of these three matrices by time. This temporal disaggregation was based, for the home based work trips, on employee arrival profiles by zone, and for the CV and other trips on cordon crossing profiles. The different strategies were modelled by making adjustments to the parameters of the employee arrival profiles. Other relevant papers in this series are WP 150 Work Journey Rescheduling : Report of Surveys, and WP 168 Work Journey Reschediuling : Results and conclusions