Initiation of antiretroviral therapy and viral suppression after home HIV testing and counselling in KwaZulu-Natal, South Africa, and Mbarara district, Uganda: a prospective, observational intervention study

Background Antiretroviral therapy significantly decreases HIV-associated morbidity, mortality, and HIV transmission through HIV viral load suppression. In settings of high prevalence, outreach strategies are needed to find asymptomatic HIV-positive people, to link them to HIV care, to initiate antiretroviral therapy, and to achieve viral suppression. We aimed to assess the effect of a community-based strategy of HIV testing and counselling (HTC) and linkage to care in households. Methods We did an uncontrolled prospective intervention study in 1600 households in two rural communities in KwaZulu-Natal, South Africa, and Mbabara district, Uganda, between Sept 27, 2011, and May 6, 2013. The intervention consisted of home HTC and, for HIV-positive people, point-of-care CD4 count testing, referral to care, and follow-up visits by lay counsellors, including the off er of couples HTC. Eligible participants were resident adults who were able to consent to HIV testing. The outcomes at 12 months were linkage to care, antiretroviral therapy initiation among HIV-positive people eligible for therapy (CD4 count <= 350 cells per mu L), and viral suppression. Findings We identified 3545 adults in 1549 households in the two communities. 3393 adults (96%) were enrolled and tested for HIV, of whom 635 (19%) were HIV positive. At baseline, 229 (36%) HIV-positive people were newly identified, 406 (64%) were previously known to be HIV positive, and 254 (40%) were taking antiretroviral therapy. By month 12, 619 (97%) HIV-positive people had visited an HIV clinic, and of 123 participants eligible for antiretroviral therapy, 94 (76%) had initiated antiretroviral therapy by 12 months. Of the 77 participants on antiretroviral therapy by month 9, 59 (77%) achieved viral suppression by month 12. Among all HIV-positive people, the number with viral suppression (<1000 copies per mL) increased from 287 (50%) to 370 (65%; p < 0.0001) at 12 months. There were no reported cases of study-related social harm during the study. Interpretation Community-based HTC in rural South Africa and Uganda achieved high coverage of testing and linkage to care. Among people eligible for antiretroviral therapy, a high proportion initiated antiretroviral therapy and achieved viral suppression, suggesting high adherence. Our results could be generalisable to other southern African countries with a high burden of HIV, but pilot studies would be useful in other settings before initiation of clinical trials to estimate the effectiveness and cost-effectiveness of the intervention.