HIV testing rates in rural areas of resource-limited
countries can be substantially increased using an intervention that involves
community-based testing, mobilising targeted communities, and the provision of
post-testing support, investigators report in The Lancet Infectious Diseases.
The intervention was associated with testing rates that were
up to nine times higher than those achieved by standard voluntary counselling
and testing (VCT) services, and led to the diagnosis of more cases of HIV.
“Bringing VCT directly to communities and linking VCT with
mobilisation efforts and support services after HIV testing results in
substantially greater uptake of both HIV testing and case detection than does
standard voluntary counselling and testing,” write the investigators.
The study – called Project Accept – was undertaken because
of the high rates of undiagnosed HIV infection in many resource-limited
Investigators wanted to see if community-based HIV testing
combined with community mobilisation and good post-testing support increased
the number of individuals coming forward for screening.
They therefore designed a study involving communities in
Tanzania (ten communities in Kisarawe District), Thailand (14 communities in
Chiang Mai Province), and Zimbabwe (eight communities in the Mutoko District).
Communities in each of these regions were randomised to
receive the community-based intervention or standard VCT services, based at a
clinic or health centre. The study was conducted between 2006-09.
Investigators wished to see if the intervention was
associated with higher rates of testing, the diagnosis of more cases of HIV,
and an increased likelihood of repeat testing. Their current analysis was
limited to individuals aged 16 and 32 years. This was because of this age group’s
high risk of HIV and low testing rates.
In each of the regions, the proportion of individuals
receiving their first HIV test was higher in the districts that received the
community-based intervention than those using standard VCT (Tanzania: 37% vs.
9%; Thailand: 69% vs. 23%; Zimbabwe 51% vs. 5% - all p < 0.001).
“We believe that the CBVCT [community based VCT] strategy
achieved HIV testing in an average of 55% of community residents aged 16-32
years across the three sites because of the multicomponent, comprehensive, and
integrated nature of the intervention,” comment the investigators.
They add: “Ease of access for HIV testing services has a
major effect on uptake” and suggest “both community mobilisation and social
networking dynamics promoted uptake of HIV testing in CBVCT communities.”
However, testing rates for couples were higher at standard
VCT centres. The investigators suggest that this is because of their linkage
with antenatal services.
HIV prevalence rates were lower at the community-based sites
(Tanzania 4% vs. 7%; Thailand: 2% vs. 3%; Zimbabwe 13% vs. 22% - all p <
0.001). Nevertheless, because of the community sites tested more people, they
detected more HIV infections than the standard VCT sites (952 vs. 264, p =
Rates of repeat HIV testing at the community-based sites
were high and increased during the study reaching 28%.
The investigators believe that the benefits of
community-based VCT extend beyond increasing the number of tested individuals
and HIV cases diagnosed, and could help combat the stigma the surrounds HIV.
“As increasing numbers of people learn their serostatus, an
untested person is more likely to personally know someone who has tested,
instilling trust in the safety and benefits of learning their serostatus.”
Furthermore, high rates of repeat testing at community
services could benefit HIV prevention.
“As a CBVCT programme matures, the epidemiological
benefits…also evolve from case detection towards behavioural reinforcement and
They conclude: “Within a short period, Project Accept
mobilised large proportions of the study population 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