title: A hybrid mobile approach for population-wide HIV testing in rural east Africa: an observational study.
abstract: BACKGROUND
  Despite large investments in HIV testing, only an estimated 45% of HIV-infected people in sub-Saharan Africa know their HIV status. Optimum methods for maximising population-level testing remain unknown. We sought to show the effectiveness of a hybrid mobile HIV testing approach at achieving population-wide testing coverage.
  
  
  METHODS
  We enumerated adult (≥15 years) residents of 32 communities in Uganda (n=20) and Kenya (n=12) using a door-to-door census. Stable residence was defined as living in the community for at least 6 months in the past year. In each community, we did 2 week multiple-disease community health campaigns (CHCs) that included HIV testing, counselling, and referral to care if HIV infected; people who did not participate in the CHCs were approached for home-based testing (HBT) for 1-2 months within the 1-6 months after the CHC. We measured population HIV testing coverage and predictors of testing via HBT rather than CHC and non-testing.
  
  
  RESULTS
  From April 2, 2013, to June 8, 2014, 168,772 adult residents were enumerated in the door-to-door census. HIV testing was achieved in 131,307 (89%) of 146,906 adults with stable residence. 13,043 of 136,033 (9·6%, 95% CI 9·4-9·8) adults with and without stable residence had HIV; median CD4 count was 514 cells per μL (IQR 355-703). Among 131,307 adults with stable residence tested, 56,106 (43%) reported no previous testing. Among 13,043 HIV-infected adults, 4932 (38%) were unaware of their status. Among 105,170 CHC attendees with stable residence 104,635 (99%) accepted HIV testing. Of 131,307 adults with stable residence tested, 104,635 (80%; range 60-93% across communities) tested via CHCs. In multivariable analyses of adults with stable residence, predictors of non-testing included being male (risk ratio [RR] 1·52, 95% CI 1·48-1·56), single marital status (1·70, 1·66-1·75), age 30-39 years (1·58, 1·52-1·65 vs 15-19 years), residence in Kenya (1·46, 1·41-1·50), and migration out of the community for at least 1 month in the past year (1·60, 1·53-1·68). Compared with unemployed people, testing for HIV was more common among farmers (RR 0·73, 95% CI 0·67-0·79) and students (0·73, 0·69-0·77); and compared with people with no education, testing was more common in those with primary education (0·84, 0·80-0·89).
  
  
  CONCLUSIONS
  A hybrid, mobile approach of multiple-disease CHCs followed by HBT allowed for flexibility at the community and individual level to help reach testing coverage goals. Men and mobile populations remain challenges for universal testing.
  
  
  BACKGROUND
  National Institutes of Health and President's Emergency Plan for AIDS Relief.
authors.affiliation: Division of HIV, Infectious Diseases and Global Medicine, San Francisco, CA, USA. Electronic address: gabriel.chamie@ucsf.edu.
authors.forename: Gabriel
authors.initials: G
authors.lastname: Chamie
authors.affiliation: Division of HIV, Infectious Diseases and Global Medicine, San Francisco, CA, USA.
authors.forename: Tamara D
authors.initials: TD
authors.lastname: Clark
authors.affiliation: Makerere University-University of California Research Collaboration, Kampala, Uganda.
authors.forename: Jane
authors.initials: J
authors.lastname: Kabami
authors.affiliation: Centre for Microbiology Research, Kenya Medical Research Institute, Nairobi, Kenya.
authors.forename: Kevin
authors.initials: K
authors.lastname: Kadede
authors.affiliation: Makerere University-University of California Research Collaboration, Kampala, Uganda.
authors.forename: Emmanuel
authors.initials: E
authors.lastname: Ssemmondo
authors.affiliation: Division of HIV, Infectious Diseases and Global Medicine, San Francisco, CA, USA.
authors.forename: Rachel
authors.initials: R
authors.lastname: Steinfeld
authors.affiliation: Makerere University-University of California Research Collaboration, Kampala, Uganda.
authors.forename: Geoff
authors.initials: G
authors.lastname: Lavoy
authors.affiliation: Makerere University-University of California Research Collaboration, Kampala, Uganda.
authors.forename: Dalsone
authors.initials: D
authors.lastname: Kwarisiima
authors.affiliation: Centre for Microbiology Research, Kenya Medical Research Institute, Nairobi, Kenya.
authors.forename: Norton
authors.initials: N
authors.lastname: Sang
authors.affiliation: Division of HIV, Infectious Diseases and Global Medicine, San Francisco, CA, USA.
authors.forename: Vivek
authors.initials: V
authors.lastname: Jain
authors.affiliation: Gillings School of Global Public Health, University of North Carolina at Chapel Hill, NC, USA.
authors.forename: Harsha
authors.initials: H
authors.lastname: Thirumurthy
authors.affiliation: Division of HIV, Infectious Diseases and Global Medicine, San Francisco, CA, USA.
authors.forename: Teri
authors.initials: T
authors.lastname: Liegler
authors.affiliation: Department of Biostatistics, Harvard T H Chan School of Public Health, Boston, MA, USA.
authors.forename: Laura B
authors.initials: LB
authors.lastname: Balzer
authors.affiliation: University of California Berkeley School of Public Health, Berkeley, CA, USA.
authors.forename: Maya L
authors.initials: ML
authors.lastname: Petersen
authors.affiliation: Department of Obstetrics, Gynecology and Reproductive Sciences, San Francisco, CA, USA.
authors.forename: Craig R
authors.initials: CR
authors.lastname: Cohen
authors.affiliation: Centre for Microbiology Research, Kenya Medical Research Institute, Nairobi, Kenya.
authors.forename: Elizabeth A
authors.initials: EA
authors.lastname: Bukusi
authors.affiliation: Department of Medicine, School of Medicine, Makerere University College of Health Sciences, Kampala, Uganda.
authors.forename: Moses R
authors.initials: MR
authors.lastname: Kamya
authors.affiliation: Division of HIV, Infectious Diseases and Global Medicine, San Francisco, CA, USA.
authors.forename: Diane V
authors.initials: DV
authors.lastname: Havlir
authors.affiliation: Department of Medicine, Center for AIDS Prevention Studies, University of California San Francisco, San Francisco, CA, USA.
authors.forename: Edwin D
authors.initials: ED
authors.lastname: Charlebois
mesh_terms: D000328:Adult; D005260:Female; D015658:HIV Infections / Q000175:diagnosis*; D006293:Health Promotion; D006801:Humans; D007630:Kenya; D008297:Male; D008403:Mass Screening / Q000379:methods*; D008875:Middle Aged; D008952:Mobile Health Units; D014454:Uganda; D055815:Young Adult