title: 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.
abstract: OBJECTIVE
  Antiretroviral therapy (ART) significantly decreases HIV-associated morbidity, mortality, and HIV transmission through HIV viral load suppression. In high HIV prevalence settings, outreach strategies are needed to find asymptomatic HIV positive persons, link them to HIV care and ART, and achieve viral suppression.
  
  
  METHODS
  We conducted a prospective intervention study in two rural communities in KwaZulu-Natal, South Africa, and Mbabara district, Uganda. The intervention included home HIV testing and counseling (HTC), point-of-care CD4 count testing for HIV positive persons, referral to care, and one month then quarterly lay counselor follow-up visits. The outcomes at 12 months were linkage to care, and ART initiation and viral suppression among HIV positive persons eligible for ART (CD4≤350 cells/μL).
  
  
  RESULTS
  3,393 adults were tested for HIV (96% coverage), of whom 635 (19%) were HIV positive. At baseline, 36% of HIV positive persons were newly identified (64% were previously known to be HIV positive) and 40% were taking ART. By month 12, 619 (97%) of HIV positive persons visited an HIV clinic, and of 123 ART eligible participants, 94 (76%) initiated ART by 12 months. Of the 77 participants on ART by month 9, 59 (77%) achieved viral suppression by month 12. Among all HIV positive persons, the proportion with viral suppression (<1,000 copies/mL) increased from 50% to 65% (p=<0.001) at 12 months.
  
  
  CONCLUSIONS
  Community-based HTC in rural South Africa and Uganda achieved high testing coverage and linkage to care. Among those eligible for ART, a high proportion initiated ART and achieved viral suppression, indicating high adherence. Implementation of this HTC approach by existing community health workers in Africa should be evaluated to determine effectiveness and costs.
authors.affiliation: Departments of Global Health and Medicine, University of Washington, Seattle, WA ; Vaccine and Infectious Diseases Division, Fred Hutchinson Cancer Research Center, Seattle, WA.
authors.forename: Ruanne V
authors.initials: RV
authors.lastname: Barnabas
authors.affiliation: Human Sciences Research Council, Sweetwaters, KwaZulu-Natal, South Africa.
authors.forename: Heidi
authors.initials: H
authors.lastname: van Rooyen
authors.affiliation: Integrated Community-Based Initiatives, Kabwohe, Uganda.
authors.forename: Elioda
authors.initials: E
authors.lastname: Tumwesigye
authors.affiliation: Departments of Global Health and Medicine, University of Washington, Seattle, WA.
authors.forename: Pamela M
authors.initials: PM
authors.lastname: Murnane
authors.affiliation: Departments of Global Health and Medicine, University of Washington, Seattle, WA ; Department of Epidemiology, University of Washington, Seattle, WA.
authors.forename: Jared M
authors.initials: JM
authors.lastname: Baeten
authors.affiliation: Human Sciences Research Council, Sweetwaters, KwaZulu-Natal, South Africa.
authors.forename: Hilton
authors.initials: H
authors.lastname: Humphries
authors.affiliation: Integrated Community-Based Initiatives, Kabwohe, Uganda.
authors.forename: Bosco
authors.initials: B
authors.lastname: Turyamureeba
authors.affiliation: Human Sciences Research Council, Sweetwaters, KwaZulu-Natal, South Africa.
authors.forename: Philip
authors.initials: P
authors.lastname: Joseph
authors.affiliation: Departments of Global Health and Medicine, University of Washington, Seattle, WA.
authors.forename: Meighan
authors.initials: M
authors.lastname: Krows
authors.affiliation: Vaccine and Infectious Diseases Division, Fred Hutchinson Cancer Research Center, Seattle, WA ; Department of Biostatistics, University of Washington, Seattle, WA, USA.
authors.forename: James P
authors.initials: JP
authors.lastname: Hughes
authors.affiliation: Departments of Global Health and Medicine, University of Washington, Seattle, WA ; Department of Epidemiology, University of Washington, Seattle, WA.
authors.forename: Connie
authors.initials: C
authors.lastname: Celum
keywords: Community-based HIV testing and counseling (HTC); HIV infectiousness; HIV prevention and care; community viral load; home HTC; linkage to care; point-of-care CD4