Date Published: May 2, 2019
Publisher: Public Library of Science
Author(s): Haddi Jatou Cham, Duncan MacKellar, Haruka Maruyama, Oscar Ernest Rwabiyago, Omari Msumi, Claire Steiner, Gerald Kundi, Rachel Weber, Johnita Byrd, Chutima Suraratdecha, Tewodaj Mengistu, Eliufoo Churi, Sherri Pals, Caitlin Madevu-Matson, Geofrey Alexander, Sarah Porter, Kokuhumbya Kazaura, Deogratius Mbilinyi, Fernando Morales, Thomas Rutachunzibwa, Jessica Justman, Anath Rwebembera, Evelyn Byrd Quinlivan.
To diagnose ≥90% HIV-infected residents (diagnostic coverage), the Bukoba Combination Prevention Evaluation (BCPE) implemented provider-initiated (PITC), home- (HBHTC), and venue-based (VBHTC) HIV testing and counseling (HTC) intervention in Bukoba Municipal Council, a mixed urban and rural lake zone community of 150,000 residents in Tanzania. This paper describes the methods, outcomes, and incremental costs of these HTC interventions. PITC was implemented in outpatient department clinics in all eight public and three faith-based health facilities. In clinics, lay counselors routinely screened and referred eligible patients for HIV testing conducted by HTC-dedicated healthcare workers. In all 14 wards, community teams offered HTC to eligible persons encountered at 31,293 home visits and at 79 male- and youth-frequented venues. HTC was recommended for persons who were not in HIV care or had not tested in the prior 90 days. BCPE conducted 133,695 HIV tests during the 2.5 year intervention (PITC: 88,813, 66%; HBHTC: 27,407, 21%; VBHTC: 17,475, 13%). Compared with other strategies, PITC conducted proportionally more tests among females (65%), and VBHTC conducted proportionally more tests among males (69%) and young-adults aged 15–24 years (42%). Of 5,550 (4.2% of all tests) HIV-positive tests, 4,143 (75%) clients were newly HIV diagnosed, including 1,583 males and 881 young adults aged 15–24 years. Of HIV tests conducted 3.7%, 1.8%, and 2.1% of PITC, HBHTC, and VBHTC clients, respectively, were newly HIV diagnosed; PITC accounted for 79% of all new diagnoses. Cost per test (per new diagnosis) was $4.55 ($123.66), $6.45 ($354.44), and $7.98 ($372.67) for PITC, HBHTC, and VBHTC, respectively. In a task-shifting analysis in which lay counselors replaced healthcare workers, estimated costs per test (per new diagnosis) would have been $3.06 ($83.15), $ 4.81 ($264.04), and $5.45 ($254.52), for PITC, HBHTC, and VBHTC, respectively. BCPE models reached different target groups, including men and young adults, two groups with consistently low coverage. Implementation of multiple models is likely necessary to achieve ≥90% diagnostic coverage.
The Joint United Nations Programme on HIV/AIDS (UNAIDS) 90-90-90 targets proposes that epidemic control will be achieved by 2030 if 90% of all people living with HIV (PLHIV) are diagnosed (diagnostic coverage), 90% of diagnosed PLHIV receive sustained antiretroviral therapy (ART), and 90% of PLHIV on ART are virally suppressed by 2020 . Diagnosis of HIV infection is thus necessary for timely ART, which substantially reduces HIV-related mortality and HIV transmission risk to partners and offspring [2, 3].
Over a 2.5 year intervention period, BCPE comprehensively implemented facility- and community-based HTC throughout Bukoba Municipal Council in accordance with Tanzania national testing guidelines using a standard screening method, eligibility criteria, and testing algorithm. In 11 health facilities, during 31,000 home visits, and at 79 venues, BCPE conducted over 133,000 tests and newly diagnosed 4,143 PLHIV, of whom 1,583 and 881 were males and young adults aged 15–24 years, two groups with consistently low diagnostic coverage . An additional 588 PLHIV who had been previously diagnosed but were currently out-of-care were also identified. Compared to the two CBHTC strategies, facility-based PITC in OPD clinics had the lowest cost per test and new diagnosis. PITC also achieved a higher absolute number and yield of new HIV diagnoses overall, and for nearly all demographic groups. Notably, among males aged >24 years, facility-based PITC had approximately twice the yield of new HIV diagnoses compared with community-based strategies. Home- and venue-based strategies, however, tested proportionally more males and young adults aged 15–24 years, and HBHTC tested proportionally more rural residents.