WHAT'S NEW THIS TUESDAY: THREE ON HOME-BASED HIV COUNSELING AND TESTING

Sunday, 15th of July 2012

• THREE ON HOME-BASED HIV COUNSELING AND TESTING

• HOME-BASED HIV COUNSELING AND TESTING AS A GATEWAY TO EARLIER INITIATION OF ANTIRETROVIRAL THERAPY

Edward J. Mills1 and Nathan Ford2,3

Clin Infect Dis. (2012) 54 (2): 282-284. doi: 10.1093/cid/cir812

+ Author Affiliations

1Faculty of Health Sciences, University of Ottawa, Canada

2Médecins Sans Frontières, Geneva, Switzerland

3Centre for Infectious Disease Epidemiology and Research, University of Cape Town, South Africa

Correspondence: Edward J. Mills, PhD, University of Ottawa, 43 Templeton, Ottawa, Ontario, K1N 6X1, Canada 778317 8530 (edward.mills@uottawa.ca).

(See the article by Wachira et al, on pages 275–81.)

Full text, with notes, is at http://cid.oxfordjournals.org/content/54/2/282.full

Timely access to combination antiretroviral therapy (ART) represents the single most effective intervention in reducing 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/mm3, a conservative threshold that had been abandoned in wealthier settings several years earlier [1].

Randomized trial data [2] and cohort evaluations [3] that demonstrate improved 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/mm3. Most developing countries have now adopted or strive for this target threshold. More recent studies have validated this shift by demonstrating the broader benefits of earlier initiation of ART, including reduced incidence of tuberculosis [4], reduced rates of hospitalization [5], reduced likelihood of HIV transmission [6], and increased life expectancy [7].

Changing the threshold for initiation was seen as a daunting task, and a common refrain in discussions about early ART initiation in resource-limited settings 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 patients in sub-Saharan Africa present too late as it is, with an average CD4 T cell count of only 111 cells/mm3 [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] or 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 patients who are not as sick. Earlier treatment 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 reducing demands for more-specialized and inpatient clinical care [5].

Although considerable research attention 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 decrease the likelihood of transmission between 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. Populations such as men, the elderly, and adolescents [14, 15] are regularly excluded from testing campaigns and are thus underrepresented in ART treatment programs, leading to worse overall mortality for these groups [16]. Designers of targeted HBCT that aim to broadly involve either the entire population in a setting or 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 widespread HIV counseling HBCT helps identify 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 implementing long-standing recommendations to test household members of HIV-infected persons [19] and will lend support to the forthcoming World Health Organization recommendations for earlier ART initiation in discordant couples.

The results of this study should provide 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 repeated) of HIV infection and other diseases in a community.

Past criticisms of AIDS exceptionalism have been tempered by effective transitioning of HIV programs from vertical to a more integrated programs, with HIV care delivered as one component of primary care. Such positive synergies could also be extended to HBCT. Home visits by broadly trained health workers could provide a gateway for advice and education regarding other important conditions, 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. Although 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 Médecins Sans Frontières programs in Mozambique already display very positive 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 convincing and as physician shortages mandate 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 approaches for different contexts. Wachira and colleagues rightly note that the cost-effectiveness of HBCT needs to be documented. Given that earlier initiation of ART reduces morbidity and mortality and has been demonstrated to be cost-effective [23], costing studies should take into account 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 settings 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 campaigns could be avoided through adequate planning and training. Operational research 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 initiation rates [26]. This raises the potential for innovative approaches that would integrate 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 infected from the undiagnosed and uninfected” [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.

‘HBCT is effective at getting HIV-infected persons enrolled in HIV care before they become ill.’

• WHAT IS THE IMPACT OF HOME-BASED HIV COUNSELING AND TESTING ON THE CLINICAL STATUS OF NEWLY ENROLLED ADULTS IN A LARGE HIV CARE PROGRAM IN WESTERN KENYA?

Clin Infect Dis. (2012) 54 (2): 275-281.

Juddy Wachira1,4, Sylvester Kimaiyo4,5, Samson Ndege4,6, Joseph Mamlin2,4,5, and  Paula Braitstein2,3,4,5,7

+ Author Affiliations

1School of Health Physical Education and Recreation

2School of Medicine, Indiana University, Bloomington

3Regenstrief Institute, Indianapolis

4USAID-AMPATH (US Agency for International Development–Academic Model Providing Access to Healthcare) Partnership

5Moi University School of Medicine

6Moi University School of Public Health, Eldoret, Kenya

7Dalla Lana School of Public Health, University of Toronto, Canada

Correspondence: Paula Braitstein, PhD, Indiana University School of Medicine, 1001 W 10th St, OPW-M200, Indianapolis, IN 46202 (pbraitstein@yahoo.com).

 Abstract below; full text is at http://cid.oxfordjournals.org/content/54/2/275.full.pdf+html

(See the Editorial Commentary by Mills and Ford, on pages 282–4.)

Background. This article describes the effect point of entry into the human immunodeficiency virus (HIV) care program had on the clinical status of adults presenting for the first time to USAID-AMPATH (US Agency for International Development–Academic Model Providing Access to Healthcare) Partnership clinics for HIV care.

Methods. All patients aged ≥14 years enrolled between August 2008 and April 2010 were included. Points of entry to USAID-AMPATH clinics were home-based counseling and testing (HBCT), provider-initiated testing and counseling (PITC), HIV testing in the tuberculosis clinic, and voluntary counseling and testing (VCT). Tests for trend were calculated, and multivariable logistic regression was used to compare the effect of HBCT versus other points of entry on primary outcomes controlling for age and sex.

Results. There were 19 552 eligible individuals. Of these, 946 tested in HBCT, 10 261 in VCT, 8073 in PITC, and 272 in the tuberculosis clinic. The median (interquartile range) enrollment CD4 cell counts among those who tested HIV positive was 323 (194–491), 217 (87–404), 190 (70–371), and 136 cells/mm3 (59–266) for HBCT, VCT, PITC, and the tuberculosis clinic, respectively (P < .001). Compared with those patients whose HIV infection was diagnosed in the tuberculosis clinic, those who tested positive in HBCT were, controlling for age and sex, less likely to have to have World Health Organization stage III or IV HIV infection at enrollment (adjusted odds ratio [AOR], 0.04; 95% confidence interval [CI], .03–.06), less likely to enroll with a CD4 cell count of <200 cells/mm3 (AOR, 0.20; 95% CI, .14–.28), and less likely to enroll into care with a chief complaint (AOR, 0.08; 95% CI, .05–.12).

Conclusions. HBCT is effective at getting HIV-infected persons enrolled in HIV care before they become ill.

• ACCESS TO UNIVERSAL HIV CARE AND PREVENTION SERVICES: LIGHT AT THE END OF A LONG TUNNEL?

Frederick K. Sawe

Clin Infect Dis. (2012) 54 (1): 119-120. doi: 10.1093/cid/cir796 First

+ Author Affiliations

HIV Program, Kenya Medical Research Institute/Walter Reed Project, Kericho

Correspondence: Fredrick Sawe, MBChB, MMED, Kenya Medical Research Institute/Walter Reed Project, Hospital Rd, PO Box 1357-20200, Kericho, Kenya (fsawe@wrp-kch.org).

Also at http://cid.oxfordjournals.org/content/54/1/119.full

(See the article by Jarrin et al, on pages 111–8.)

There has been a rapid scaling-up of human immunodeficiency virus (HIV) prevention and care services globally in the last 10 years, with falling rates of new HIV infections and >6.6 million of the 15 million people who need antiretroviral therapy (ART) currently receiving it [1]. Recent studies have demonstrated the efficacy of antiretrovirals when used for prevention [2], and the promising results of the RV144 HIV vaccine trial [3] have boosted HIV prevention efforts. However, much still remains to be done: More efficacious HIV infection prevention interventions; therapeutic drugs that are less toxic, durable, and easier to take; and improved models of healthcare delivery are urgently needed. The challenges going forward remain enormous: Approximately 33.3 million people were living with HIV at the end of 2009, with 1.8 million new HIV infections and 2.6 million deaths due to HIV in that year, most of them in resource-limited settings (RLSs) [4]. With a shortage of approximately 10 billion dollars in HIV/AIDS funding in an era when funding is either declining or has flat-lined, HIV/AIDS programs in RLSs would have to choose priorities [1]. HIV/AIDS morbidities and mortalities are high in RLSs because of late presentations of patients for care, coupled with weak and fragile healthcare systems. Without aggressive and effective universal HIV infection prevention programs, HIV/AIDS treatment as it is currently implemented in RLSs is not sustainable.

In this issue Jarrin and colleagues describe their findings from the Concerted Action on SeroConversion to AIDS and Death in Europe (CASCADE) study. The CASCADE study examined the uptake of combination antiretroviral therapy (cART) and HIV disease progression to AIDS, initiation of ART, and death according to geographical origin in subjects with known dates of seroconversion after they had migrated to or were originally from the West (European Union, United States, Canada, Australia, and New Zealand). The study showed that in settings where there is universal access to healthcare, migrants living in the West when they seroconverted, who were originally from North Africa and the Middle East, sub-Saharan Africa, Latin America, and Asia had similar outcomes in the risk of AIDS and death compared to those living or originally from the West. However, seroconverters from North Africa, the Middle East, and sub-Saharan Africa appeared to have lower mortality risks than those from the West. The seroconverters from sub-Saharan Africa were also more likely to initiate cART than those from the West.

The above findings by Jarrin and colleagues are very encouraging for the public health approach to scaling up HIV/AIDS continuum of prevention and care in RLSs in support of the World Health Organization/Joint United Nations Programme on HIV/AIDS plan for universal access to HIV prevention and care services. This calls for innovation and adaptations of such results to local settings through a radical shift in emphasis to simplification, innovation in drug design, diagnostics, cost savings, adapted healthcare delivery systems, renewed commitment, and resources that will be crucial in reaching universal and sustainable coverage of HIV prevention and treatment services. Other interventions to expand HIV services include the scaling up of HIV testing to identify all who are in need of HIV prevention and treatment; early and timely initiation of ART; and improvement of the healthcare infrastructure to include decentralization, networking, and integration of HIV/AIDS services with other existing healthcare programs [5].

Jarrin and colleagues analyzed a cohort of HIV-infected patients with known times of seroconversion while living in the West. The role of acute/early HIV infections in the transmission of HIV infection and understanding the pathogenesis of acute/early HIV (and hence important data for HIV prevention trials including vaccines) is crucial [5]. Given that patients with acute infections are at highest risk of HIV transmission and may be responsible for up to 50% of all new infections, this information is critical [6–8]. Not much has been done to deal with this problem in current HIV programs in RLSs; further research in RLSs is needed.

Research and experience from RLSs has shown a high loss to follow-up (LTFU) rate between HIV diagnosis, pre- and post-ART care enrollment, and follow-up, leading to rapid disease progression, late presentation at initiation of ART, high opportunistic disease burden, and accompanying high morbidity and mortality [9]. Although LTFU was generally high for all groups in the CASCADE study, it is encouraging that the study shows significantly lower LTFU by subjects who were originally from sub-Saharan Africa. Innovative strategies are needed to address these challenges of LTFU and high mortality at initiation of ART in RLSs. These include earlier HIV diagnosis and ART initiation, screening and prophylaxis for opportunistic infections, optimized diagnosis and management of specific diseases and treatment of complications, and program strengthening. Access to HIV prevention and care services by those who need HIV treatment in RLSs is faced with many challenges and barriers, including availability of the services, fear of stigma and discrimination, transportation costs, user fees, and access to food [10].

In summary, scaling up of programs to diagnose and treat HIV infection early to improve quality of life as part of a comprehensive care package of combination HIV infection prevention based on proven, well-tested clinical trials can reduce HIV/AIDS-related morbidities and deaths and control the epidemic, especially in RLSs, until an affordable, safe, and globally effective HIV vaccine is found.