A new approach to reach people who don’t know their HIV status in sub-Saharan Africa

Knowledge of HIV status is the starting point for prevention, care and treatment and the first step toward reaching UNAIDS 90-90-90 targets. However, few programs have an accurate way to determine how many people are eligible for testing. Most HIV testing approaches are relying on proxies for understanding what percentage of people know their status. Kenya is one of 4 African countries considered to have a high HIV burden, with approximately 1.5 million people living with HIV. It’s estimated that there are over 70,000 new infections each year among adults and 6,500 among children. In an effort to increase HIV testing coverage, ensure linkage to treatment and increase antiretroviral therapy (ART) coverage, Family AIDS Care and Education Services (FACES) started a community-based hybrid HIV testing services program in Homa Bay County, one of the counties with the highest HIV burden.

Over 3 months in 2016, FACES launched a campaign using community mapping and household census to locate people for testing. They mobilized people to attend community health campaigns (CHCs) that offered testing and referrals for multiple diseases, including HIV. Residents from the census who didn’t attend a CHC were followed up with for home-based testing. People who were diagnosed with HIV at the CHCs were offered same-day linkage to start antiretroviral therapy.

The campaign successfully identified people living with HIV who were previously unaware of their status, including many first-time testers. More than half of those were men, a group that has been challenging to engage for testing. HIV yield and the percentage of people living with HIV who were previously unidentified were higher at the CHCs than through the follow-up for home-based testing. That may reflect that people who perceive themselves of having higher risk for HIV actively sought out testing.

Although overall yield was 1.2%, the fact that 7.2% of people living with HIV had not been previously identified—and 13.3% among youth—are important given that individuals unaware of their infection status pose greater risk of transmission. This approach of identifying people unaware of their HIV positive status in combination with the percentage of people living with HIV who hadn’t previously been identified has potential to help target HIV testing approaches to reduce the number of people unaware of their HIV status.

The lessons learned from this approach can inform community-based HIV-testing approaches in sub-Saharan Africa. It showed that offering testing at CHCs in combination with home visits is an effective strategy for reaching first-time testers, especially men and adolescents. Innovative approaches that make HIV testing more acceptable and accessible for the community, like HIV testing as part of a package of health services, may be critical to reach populations that may otherwise be hesitant to use facility-based testing services. As countries adopt universal health care, CHCs may be a useful approach to identify people previously unaware of their HIV positive status while also screening for other common illnesses with referrals for treatment.

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