Study examines community-based HIV testing programs in Africa, Southeast Asia

If you want to improve HIV testing rates in remote rural areas, get the community involved, says UCLA's Thomas Coates, who has directed a new study examining HIV testing programs in communities in Africa and Southeast Asia.

The research, published online in The Lancet Infectious Diseases, shows that when community mobilization activities and post-test psychosocial support services were added to easily accessible HIV counseling and testing programs, rates of initial and repeat testing in these communities improved significantly, compared with areas that were offered only clinic-based voluntary counseling and testing.

The study presents interim findings from Project Accept, a National Institute of Mental Health-funded effort that has been tracing 10 rural communities in Tanzania, eight in Zimbabwe and 14 in Thailand. Coates, co-director of the UC Global Health Institute and an associate director of the UCLA AIDS Institute, chairs the steering committee overseeing the 10-year project.

"Project Accept is an important demonstration that effective strategies, such as we developed and implemented, can encourage HIV testing and identification of persons with HIV and referral into care," Coates said. "This is an important part of HIV prevention and care."

Coates noted that HIV testing is important because it has been demonstrated to reduce risky behavior and is the first step in identifying people with HIV infection and getting them into treatment.

"Many individuals in the United States with HIV infection do not know if they have it, and strategies like this might be used in cities and neighborhoods with high densities of HIV infection," he said. In the study, researchers paired demographically similar communities in each setting; one of each pair was then randomized to receive either clinic-based voluntary counseling and testing alone or a combination of that and community-based testing. The community-based testing included mobile HIV testing along with the community mobilization and post-test psychosocial support services.

Mobilization activities, designed to make individuals aware of HIV and HIV testing, varied by community, but often consisted of forums and discussion groups, house-to-house visits to discuss the project, community entertainment like dances and concerts, and the engagement of civil, traditional and religious leaders.

The researchers found that the proportion of people receiving their first HIV test was significantly higher in areas getting community-based testing than in those receiving stand-alone testing, in each country: Tanzania (37 percent vs. 9 percent), Zimbabwe (51 percent vs. 5 percent) and Thailand (69 percent vs. 23 percent).

HIV prevalence was higher among those testing for HIV in the clinic-based testing areas than in the community-based areas. But due to the larger number of people tested in community-based areas, these programs detected almost four times as many HIV cases as the clinic-only programs across the three study sites (952 vs. 264).

Repeat HIV testing in community-based program areas increased in all sites by the end of the three-year intervention period, reaching 28 percent of all those who were initially tested.

"Communities can be mobilized to learn their HIV infection status, including in remote rural communities with little infrastructure across different regions, epidemic settings and cultures," the researchers wrote. "Within a short period, Project Accept mobilized large proportions of the study populations to go through the difficult process of learning their HIV infection status, proving that local communities respond to HIV epidemics when comprehensive, user-friendly services are provided."

Of note, the authors found an association between gender and HIV testing across study groups in Tanzania and Thailand, with a larger proportion of men testing for HIV in community-based areas than in stand-alone areas. Few individuals tested for HIV infection as couples in Tanzania and Zimbabwe, and the proportion was lower in community-based areas than in stand-alone areas. By contrast, the proportion of those testing as couples in Thailand was much higher than in other sites, especially in the areas receiving stand-alone testing.