title: How home HIV testing and counselling with follow-up support achieves high testing coverage and linkage to treatment and prevention: a qualitative analysis from Uganda.
abstract: The successes of HIV treatment scale-up and the availability of new prevention tools have raised hopes that the epidemic can finally be controlled and ended. Reduction in HIV incidence and control of the epidemic requires high testing rates at population levels, followed by linkage to treatment or prevention. As effective linkage strategies are identified, it becomes important to understand how these strategies work. We use qualitative data from The Linkages Study, a recent community intervention trial of community-based testing with linkage interventions in sub-Saharan Africa, to show how lay counsellor home HIV testing and counselling (home HTC) with follow-up support leads to linkage to clinic-based HIV treatment and medical male circumcision services.
  
  
  
  We conducted 99 semi-structured individual interviews with study participants and three focus groups with 16 lay counsellors in Kabwohe, Sheema District, Uganda. The participant sample included both HIV+ men and women (N=47) and HIV-uncircumcised men (N=52). Interview and focus group audio-recordings were translated and transcribed. Each transcript was summarized. The summaries were analyzed inductively to identify emergent themes. Thematic concepts were grouped to develop general constructs and framing propositional statements.
  
  
  
  Trial participants expressed interest in linking to clinic-based services at testing, but faced obstacles that eroded their initial enthusiasm. Follow-up support by lay counsellors intervened to restore interest and inspire action. Together, home HTC and follow-up support improved morale, created a desire to reciprocate, and provided reassurance that services were trustworthy. In different ways, these functions built links to the health service system. They worked to strengthen individuals' general sense of capability, while making the idea of accessing services more manageable and familiar, thus reducing linkage barriers.
  
  
  
  Home HTC with follow-up support leads to linkage by building "social bridges," interpersonal connections established and developed through repeated face-to-face contact between counsellors and prospective users of HIV treatment and male circumcision services. Social bridges link communities to the service system, inspiring individuals to overcome obstacles and access care.
authors.affiliation: Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA, USA.|Division of Global Health Equity, Department of Medicine, Brigham & Women's Hospital, Boston, MA, USA; norma_ware@hms.harvard.edu.
authors.forename: Norma C
authors.initials: NC
authors.lastname: Ware
authors.affiliation: Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA, USA.|Harvard Global, Cambridge, MA, USA.
authors.forename: Monique A
authors.initials: MA
authors.lastname: Wyatt
authors.affiliation: Kabwohe Clinical Research Centre, Kabwohe, Uganda.
authors.forename: Stephen
authors.initials: S
authors.lastname: Asiimwe
authors.affiliation: Kabwohe Clinical Research Centre, Kabwohe, Uganda.
authors.forename: Bosco
authors.initials: B
authors.lastname: Turyamureeba
authors.affiliation: Kabwohe Clinical Research Centre, Kabwohe, Uganda.
authors.forename: Elioda
authors.initials: E
authors.lastname: Tumwesigye
authors.affiliation: Human Sciences Research Council, Pretoria, South Africa.
authors.forename: Heidi
authors.initials: H
authors.lastname: van Rooyen
authors.affiliation: Department of Global Health, School of Medicine, School of Public Health, University of Washington, Seattle, WA, USA.
authors.forename: Ruanne V
authors.initials: RV
authors.lastname: Barnabas
authors.affiliation: Department of Global Health, School of Medicine, School of Public Health, University of Washington, Seattle, WA, USA.
authors.forename: Connie L
authors.initials: CL
authors.lastname: Celum
mesh_terms: D015492:AIDS Serodiagnosis; D000328:Adult; D002944:Circumcision, Male; D003376:Counseling; D003695:Delivery of Health Care; D005260:Female; D005500:Follow-Up Studies; D015658:HIV Infections / Q000175:diagnosis* / Q000517:prevention & control / Q000628:therapy*; D006699:Home Care Services; D006801:Humans; D008297:Male; D008403:Mass Screening; D011446:Prospective Studies; D014454:Uganda
keywords: HIV prevention; HIV treatment; Uganda; community-based HIV services; follow-up support; home HIV testing and counselling; lay counsellors; linkage