Home-based HIV voluntary counseling and testing in developing countries

A review of existing research suggests that people in two African countries prefer taking HIV tests at home, with the assistance of counselors, instead of at a clinic.

Still, the review authors say they are not ready to call for developing countries to adopt more home-based HIV testing.

“Given the limited extant literature and the limitations in the existing studies, large-scale implementation of home-based testing models is premature,” said Moses Bateganya, M.D., lead review author and clinical advisor with the University of Washington's affiliated International Training and Education Center on HIV.

It is possible, Bateganya said, that home testing might actually turn out to cost more than testing in clinics. “There is, therefore, an urgent need to design studies to find the most effective HIV-testing strategy,” before spending money on untested systems, Bateganya said.

Despite medical advances and prevention efforts, estimates indicate that HIV — the virus that causes AIDS — afflicts 38 million people worldwide. Sub-Saharan Africa remains an HIV hot spot, accounting for an estimated 24.5 million people with the illness.

Typically, people undergo HIV tests at health clinics, but studies suggest that many do not return for results; only 15 percent of the population of Uganda has done so, said Bateganya, a native of that country. Worldwide, according to the UNAIDS, only an estimated one in 10 people with HIV know they are infected.

In the new review, the authors evaluated studies that examined the use of home-based testing in developing countries.

The review appears in the current issue of The Cochrane Library , a publication of The Cochrane Collaboration, an international organization that evaluates medical research. Systematic reviews draw evidence-based conclusions about medical practice after considering both the content and quality of existing medical trials on a topic.

The review authors initially found 15 studies that looked at home-based HIV testing. However, two are ongoing, and they considered 11 not to meet the criteria for inclusion in the review. That left two studies.

One, published in 2004, looked at 849 people who lived in an urban residential area in Lusaka, Zambia.

Researchers found that residents were 4.6 times more likely to accept HIV testing if they had a choice of where to go — with home-based testing as one of the options — compared to those who had to visit a clinic. They were also more likely to accept counseling prior to tests.

The second study, published in 2005, included 1,868 people who lived in villages in southwestern Uganda. Researchers looked at two years, one in which only clinic-based testing was available and another year in which people could get tests at home.

Those who had the option of receiving results at home were 5.23 times more likely to get them compared to those who participated in the year when results were available only at the clinic.

At this point, it is too early to know if home-based testing is worth pursuing on a wider basis, the review said. According to Bateganya, other options should be evaluated, including routine testing (such as those done during medical procedures), self-testing at home (without a counselor present) or mobile vans.

The World Health Organization discourages mandatory testing, another option, and the review says that many oppose it because of human-rights concerns. There are also worries that forcing people to have tests could make some avoid getting care for other health problems because they do not want to be tested.

For now, Bateganya said, “we will continue to wait for ongoing studies to show whether they will prove that home-based testing is definitely more superior to facility-based HIV testing in getting more people to take the test and accept the results of testing.”

Still, based on the limited evidence that is available, “home-based testing appears to represent a promising option,” said Dr. Carla Makhlouf Obermeyer, a scientist with the World Health Organization's Department of HIV/AIDS who is familiar with the review's findings.

“Home-based testing can be attractive because it overcomes the obstacles of cost, transportation and inconvenience that are associated with other modes of testing,” she said. “It can also contribute to routinizing testing and encouraging open discussion within families, provided of course that consent and confidentiality are protected and this is done at the initiative of the individual.”

The Cochrane Collaboration is an international nonprofit, independent organization that produces and disseminates systematic reviews of health care interventions and promotes the search for evidence in the form of clinical trials and other studies of interventions. Visit http://www.cochrane.org for more information.

Bateganya MH, Abdulwadud OA, Kiene SM. Home-based HIV voluntary counseling and testing in developing countries. Cochrane Database of Systematic Reviews 2007, Issue 4.