HIV Home Care Increases Antiretroviral Use

Having the option of home-based antiretroviral therapy after self-testing for HIV led to a 3-fold increase in the uptake of treatment, according to a first-of-its-kind study.

Of the estimated 34 million people living with AIDS, just 8 million are actually receiving treatment, Peter MacPherson, MD, from the Malawi–Liverpool Wellcome Trust Clinical Research Programme in Blantyre, told Medscape Medical News.

When home treatment was offered, people with HIV-positive test results were more willing to report their infection to counselors and access home care, said Dr. MacPherson, who presented the study results at the 20th Conference on Retroviruses and Opportunistic Infections in Atlanta, Georgia.

"HIV testing is the entry point to treatment and prevention," he noted. "Our study is the first to show that a comprehensive strategy improving all steps — from testing to antiretroviral initiation — can be successful."

For the study, trained local volunteers offered HIV self-testing and counseling to 16,660 adults in 14 poor urban neighborhoods in Malawi. Half of the neighborhoods were randomized to receive optional home-based HIV care; the other half was offered clinic-based care.

For home care, nurses visited on a motorbike and completed the preantiretroviral steps and treatment initiation in the home.

Our study is the first to show that a comprehensive strategy improving all steps...can be successful.

Dr. MacPherson pointed out that previous work in Blantyre has shown that patients tend to struggle to complete the large number of assessment steps required before treatment can be started, "and people living with AIDs frequently drop out of care before starting treatment."

Home care is "more convenient for patients, and all of steps were completed at 2 short home visits," he reported.

The researchers found that more adults in the home-based group reported positive self-test results than in the clinic-based group (6% vs 3%; risk ratio [RR], 1.86; 95% confidence interval [CI], 1.16 - 2.97). Antiretroviral uptake was also higher in the home-based group (2.2% vs 0.7%; RR, 2.94, 95% CI, 2.10 - 4.12). The difference between the 2 group was still increasing at 6 months.

Global Significance

The researchers believe that these results can be generalized to other countries in the region.

"Around the world, we know that large increases in the number of people testing [positive] for HIV and starting treatment soon after diagnosis will be crucial to begin turning back the tide of new infections," Dr. MacPherson said. "All regions have struggled with how best to achieve this."

He noted that this study provides the first evidence that a relatively simple intervention after self-testing can have a big impact on treatment rates. "This or similar approaches could be effective in countries introducing self-testing," he said.

Asked by Medscape Medical News to comment on the findings, meeting delegate Margaret McNairy, MD, from Columbia University in New York City, said that increased coverage of HIV testing, improved linkage of HIV-positive individuals to care programs, and prompt initiation of antiretrovirals are essential to HIV program effectiveness. "This is true in terms of both optimization of individual health outcomes and the prevention of HIV transmission at the population level," she said.

Dr. McNairy emphasized the importance of the findings for different regions around the world. "Across resource-rich and resource-limited settings, testing coverage rates, linkage to care, and antiretroviral initiation are far from optimal. Many studies conclude that less than one third of individuals who test HIV-positive remain in care until antiretroviral initiation."

She said the global community eagerly awaits results on rates of retention in care after antiretroviral initiation and cost effectiveness. "If these secondary outcomes are found to be positive, many are hopeful that this study will introduce a new model for implementing HIV services across settings and hard-to-reach populations."

Julie Myers, MD, from the Bureau of HIV/AIDS Prevention and Control in New York City, said the convenience, privacy, and anonymity of rapid HIV self-testing make it a promising new option to improve diagnosis and facilitate both treatment and prevention.

It is expected that with the recent approval by the US Food and Drug Administration of over-the-counter self-testing kits, testing will become more common.

However, Dr. Myers points to concerns that have been raised about whether individuals will ultimately seek medical care after their positive test result.

This study shows that overall uptake of self-testing was very high, underscoring the acceptability of HIV self-testing in this setting, Dr. Myers said. "While this study was conducted in a high-prevalence, resource-limited setting, the possibility of adaptation of the intervention to other contexts warrants exploration," she added.

Dr. MacPherson and his team have extended home-based HIV care to all study neighborhoods involved in self-testing. They are also exploring whether this approach could help reduce new cases of tuberculosis.

Patients with HIV are at the highest risk of developing tuberculosis. Prompt initiation of antiretrovirals could curb new lung infections.

Dr. MacPherson reports receiving funding from the Wellcome Trust Clinical PhD Programme at the Liverpool School of Tropical Medicine in the United Kingdom. Dr. McNaily and Dr. Myers have disclosed no relevant financial relationships.

20th Conference on Retroviruses and Opportunistic Infections (CROI): Abstract 95LB. Presented March 5, 2013.