Bakanda

Cohen

Corbett

Cullinan

De Cock

Decroo

Edward J. Mills

Faal

Ford

Grinsztejn

Human Rights Watch

Koenig

Kranzer

Kuwane

Maher

Miller

Mills

Muula

Nathan Ford

Phillips

Rosen

Severe

Sterne

Tumwesigye

Wachira

Were

Zachariah

English

Crossref

Clinical Infectious Diseases

Home-Based HIV Counseling and Testing as a Gateway to Earlier Initiation of Antiretroviral Therapy

Mills, Edward J

Ford, Nathan

MSF Field Research

EDITORIAL COMMENTARY
Home-Based HIV Counseling and Testing as a Gateway to
Earlier Initiation of Antiretroviral Therapy
Edward J. Mills1 and Nathan Ford2,3
1Faculty of Health Sciences, University of Ottawa, Canada; 2Me ´decins Sans Frontie `res, Geneva, Switzerland; and 3Centre for Infectious Disease Epidemiology and
Research, University of Cape Town, South Africa
(See the article by Wachira et al, on pages 275–81.)
Timely access to combination anti-
retroviral therapy (ART) represents the
single most effective intervention in re-
ducing mortality and morbidity among
patients with human immunodeﬁciency
virus (HIV) infection or AIDS. Until
recently, the threshold for initiating ART
in resource-limited settings was set
at a CD4 T-cell count #200 cells/mm
3,
a conservative threshold that had been
abandoned in wealthier settings several
years earlier [1].
Randomized trial data [2] and cohort
evaluations [3] that demonstrate impro-
ved survival when ART is initiated earlier
provided convincing evidence for the
World Health Organization to revise
guidance for resource-limited settings to
initiate ART at a CD4 T-cell count #350
cells/mm
3.M o s td e v e l o p i n gc o u n t r i e s
have now adopted or strive for this target
threshold. More recent studies have val-
idated this shift by demonstrating the
broader beneﬁts of earlier initiation of
ART, including reduced incidence of
tuberculosis [4], reduced rates of hospi-
talization [5], reduced likelihood of HIV
transmission [6], and increased life ex-
pectancy [7].
Changing the threshold for initiation
was seen as a daunting task, and a com-
mon refrain in discussions about early
ART initiation in resource-limited set-
tings was that raising the threshold
would overwhelm healthcare systems by
increasing the number of new patients
requiring a clinician’s time [8]. It has
often been pointed out that most pa-
tients in sub-Saharan Africa present too
late as it is, with an average CD4 T cell
count of only 111 cells/mm
3 [9]. For the
most part, however, the reasons that
patients present late to care have nothing
to do with initiation thresholds at the
clinic. Rather, they are related to a lack
of awareness of their HIV status [10]o r
disincentives to accessing care, such as
high costs [11] or distances from clinics
[12]. There is no convincing evidence
that individuals arrive late to care because
they have been ‘‘crowded out’’ by pa-
tients who are not as sick. Earlier treat-
ment means that patients do not become
as sick and thus need less-complex care.
Evidence from programs to date suggests
that earlier initiation supports access to
care by promoting delivery of ART by
nurse-led primary care clinics and re-
ducing demands for more-specialized
and inpatient clinical care [5].
Although considerable research atten-
tion has been paid to demonstrating the
relative merits of earlier ART initiation,
the question of how to encourage persons
to seek treatment earlier has to date been
almost entirely neglected. Recently, the
need for better retention in care between
testing and initiation of treatment for
eligible patients has been recognized [13].
An important prior concern is to identify
patients as early as possible, both to de-
crease the likelihood of transmission be-
tween partners and to provide an early
opportunity to engage patients into care.
Home-based counseling and testing
(HBCT) represent an important strategy
for identifying patients before their CD4
T cells are severely depleted. It is also
a strategy to engage underrepresented
populations in HIV/AIDS testing. Pop-
ulations such as men, the elderly, and
adolescents [14, 15] are regularly excluded
from testing campaigns and are thus un-
derrepresented in ART treatment pro-
grams, leading to worse overall mortality
for these groups [16]. Designers of tar-
geted HBCT that aim to broadly involve
e i t h e rt h ee n t i r ep o p u l a t i o ni nas e t t i n go r
an accurate sample of it need to consider
whether these groups are likely to be
identiﬁed through HBCT or more likely
to be located outside the home [17].
The study by Wachira and colleagues
provides compelling evidence that widesp-
read HIV counseling HBCT helps identify
Received 21 September 2011; accepted 26 September
2011.
Correspondence: Edward J. Mills, PhD, University of
Ottawa, 43 Templeton, Ottawa, Ontario, K1N 6X1, Canada
778317 8530 (edward.mills@uottawa.ca).
Clinical Infectious Diseases 2012;54(2):282–4
 The Author 2011. Published by Oxford University Press on
behalf of the Infectious Diseases Society of America. All rights
reserved. For Permissions, please e-mail: journals.permissions@
oup.com.
DOI: 10.1093/cid/cir812
282 d CID 2012:54 (15 January) d EDITORIAL COMMENTARY
 
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 infected individuals earlier in their disease
progression [18]. HBCT also identiﬁed
more discordant couples compared with
more common, clinic-based entry points
to HIV testing, indicating the potential for
HBCT to contribute to a reduction in HIV
transmission. In this regard, HBCT should
become an important strategy for imple-
menting long-standing recommendations
to test household members of HIV-
infected persons [19] and will lend sup-
port to the forthcoming World Health
Organization recommendations for earlier
ART initiation in discordant couples.
The results of this study should pro-
vide an urgently needed impetus for ART
providers to look beyond the clinic and
explore how best to provide expanded
access to testing. Home- and community-
based approaches can help increase access
to testing and care, identify discordant
couples, and ensure that testing can be
linked with knowledge of HIV infection,
general health, and possibly unrelated
health issues that are of importance to
families. HBCT represents an important
opportunity to accurately document the
prevalence (and incidence when re-
peated) of HIV infection and other dis-
eases in a community.
Past criticisms of AIDS exceptionalism
have been tempered by effective tran-
sitioning of HIV programs from vertical
to a more integrated programs, with HIV
care delivered as one component of pri-
mary care. Such positive synergies could
also be extended to HBCT. Home visits by
broadly trained health workers could
provide a gateway for advice and educa-
tion regarding other important condi-
tions, such as active case ﬁnding for
tuberculosis [20] and screening for risk
factors for diabetes and cardiovascular
diseases [21].
It is possible that interventions such as
HBCT will create a leapfrogging effect for
health systems in sub-Saharan Africa. Al-
though home-based care is uncommon in
wealthier settings, it is an important entry
point for care in resource-limited areas,
particularly in rural settings. Evidence
from Me ´decins Sans Frontie `res programs
in Mozambique already display very pos-
itive outcomes from village and home-
based HIV treatment, led by village
member volunteers, with very low rates of
mortality (2%) and attrition from ART
(0.2%) [22]. It seems likely that such
initiatives will become more common
as the evidence for community- and
home-based care becomes more con-
vincing and as physician shortages man-
date the shifting of tasks from skilled to
less-skilled individuals.
The broader implementation of HBCT
should be accompanied by operational
research to ﬁne-tune implementation ap-
proaches for different contexts. Wachira
and colleagues rightly note that the cost-
effectiveness of HBCT needs to be docu-
mented. Given that earlier initiation of
ART reduces morbidity and mortality and
has been demonstrated to be cost-effective
[23], costing studies should take into ac-
count the costs associated with lower rates
of survival and subsequent life expectancy
for patients accessing ART with low CD4
T cell counts. Ethical concerns will also
doubtless be raised, particularly for set-
tings where stigma concerning HIV/AIDS
continues to be a major concern. Previous
efforts to expand HIV testing through
household and community programs have
been criticized as violating human rights
[24]. Reassuringly, in this study, HBCT
had a high rate of acceptance, a ﬁnding
consistent with those of other studies [25];
many criticisms raised about past cam-
paigns could be avoided through adequate
planning and training. Operational re-
search will be important in determining
how to ensure broad acceptance of HBCT.
Finally, recent research has shown that the
provision of a patient’s CD4 T cell count
at the time of testing increases ART initi-
ation rates [26]. This raises the potential
for innovative approaches that would in-
tegrate point-of-care CD4 T cell counts
into HBCT programs [27].
Ten years ago it was suggested that
‘‘[t]he quest for secrecy promotes rather
than breaks the destructive silence around
HIV/AIDS, and divides the known in-
fected from the undiagnosed and un-
infected’’ [28]. We now also know that
limiting access to testing also limits timely
access to care, to the harm of both HIV-
positive and HIV-negative individuals.
Program implementers are compelled by
the latest evidence and guidelines to enroll
persons into care earlier but have been
given few guidelines as to how to go about
it. HBCT appears to be a feasible and
acceptable approach that can further both
HIV treatment and prevention objectives
and potentially support broader health
objectives.
Note
Potential conﬂicts of interest. All authors:
No reported conﬂicts.
All authors have submitted the ICMJE Form
for Disclosure of Potential Conﬂicts of Interest.
Conﬂicts that the editors consider relevant to the
content of the manuscript have been disclosed.
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A testing challenge: the experience of Lesotho’s universal HIV counseling and testing campaign.

Acceptance of anti-retroviral therapy among patients infected with HIV and tuberculosis in rural Malawi is low and associated with cost of transport. PLoS One

Association of aging and survival in a large HIV-infected cohort on antiretroviral therapy. AIDS

Comparison of two active case-finding strategies for community-based diagnosis of symptomatic smear-positive tuberculosis and control of infectious tuberculosis in Harare, Zimbabwe (DETECTB): a clusterrandomised trial. Lancet

Costeffectiveness of early versus standard antiretroviral therapy in HIV-infected adults in Haiti.

Distribution of antiretroviral treatment through selfforming groups of patients in Tete province,

Distribution of hyperglycaemia and related cardiovascular disease risk factors in low-income countries: a cross-sectional population-based survey in rural Uganda.

Early initiation of antiretroviral therapy and associated reduction in mortality, morbidity and defaulting in a nurse-managed, community cohort in Lesotho. AIDS

Early versus standard antiretroviral therapy for HIV-infected adults in Haiti.

Effects of early versus delayed initiation of antiretroviral therapy (ART) on HIV clinical outcomes: results from the HPTN 052 randomized clinical trial [abstract

Expanding HIV care in Africa: making men matter in Johannesburg. Lancet

Gender distribution of adult patients on highly active antiretroviral therapy (HAART) in Southern Africa: a systematic review. BMC Public Health

High prevalence of self-reported undiagnosed HIV despite high coverage of HIV testing: a cross-sectional population based sero-survey in South Africa. PLos One

High uptake of home-based, district-wide, HIV counseling and testing in Uganda.

Life expectancy of persons receiving combination antiretroviral therapy

Prevention of HIV-1 infection with early antiretroviral therapy.

Prognosis of patients with HIV-1 infection starting antiretroviral therapy in sub-Saharan Africa: a collaborative analysis of scale-up programmes. Lancet

Providing immediate CD4 count results at HIV testing improves ART initiation.

Retention in HIV care between testing and treatment in sub-Saharan Africa: a systematic review. PLoS Med

Shadow on the continent: public health and HIV/AIDS

Survival of HIV-infected adolescents on antiretroviral therapy in Uganda: findings from a nationally representative cohort in Uganda. PLoS One

Timing of initiation of antiretroviral therapy in AIDS-free HIV-1-infected patients: a collaborative analysis of 18 HIV cohort studies. Lancet

Undiagnosed HIV infection and couple HIV discordance among household members of HIV-infected people receiving antiretroviral therapy in Uganda. J Acquir Immune Defic Syndr

Viewpoint: why do we need a point-of-care CD4 test for low-income countries? Trop Med Int Health

What is the impact of homebased HIV counseling and testing (HBCT) on the clinical status of newly enrolled adults in a large HIV care program in western Kenya? Clin Infect Dis

What’s good for the individual might crash the system. Health-E News.

When should antiretroviral therapy for HIV be started? BMJ

Why are antiretroviral treatment patients lost to follow-up? A qualitative study from South Africa. Trop Med Int Health

Home-based HIV counseling and testing as a gateway to earlier initiation of antiretroviral therapy

Home-based HIV counseling and testing as a gateway to earlier initiation of antiretroviral therapy

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