title: Uptake of Home-Based HIV Testing, Linkage to Care, and Community Attitudes about ART in Rural KwaZulu-Natal, South Africa: Descriptive Results from the First Phase of the ANRS 12249 TasP Cluster-Randomised Trial.
abstract: BACKGROUND
  The 2015 WHO recommendation of antiretroviral therapy (ART) for all immediately following HIV diagnosis is partially based on the anticipated impact on HIV incidence in the surrounding population. We investigated this approach in a cluster-randomised trial in a high HIV prevalence setting in rural KwaZulu-Natal. We present findings from the first phase of the trial and report on uptake of home-based HIV testing, linkage to care, uptake of ART, and community attitudes about ART.
  
  
  RESULTS
  Between 9 March 2012 and 22 May 2014, five clusters in the intervention arm (immediate ART offered to all HIV-positive adults) and five clusters in the control arm (ART offered according to national guidelines, i.e., CD4 count ≤ 350 cells/μl) contributed to the first phase of the trial. Households were visited every 6 mo. Following informed consent and administration of a study questionnaire, each resident adult (≥16 y) was asked for a finger-prick blood sample, which was used to estimate HIV prevalence, and offered a rapid HIV test using a serial HIV testing algorithm. All HIV-positive adults were referred to the trial clinic in their cluster. Those not linked to care 3 mo after identification were contacted by a linkage-to-care team. Study procedures were not blinded. In all, 12,894 adults were registered as eligible for participation (5,790 in intervention arm; 7,104 in control arm), of whom 9,927 (77.0%) were contacted at least once during household visits. HIV status was ever ascertained for a total of 8,233/9,927 (82.9%), including 2,569 ascertained as HIV-positive (942 tested HIV-positive and 1,627 reported a known HIV-positive status). Of the 1,177 HIV-positive individuals not previously in care and followed for at least 6 mo in the trial, 559 (47.5%) visited their cluster trial clinic within 6 mo. In the intervention arm, 89% (194/218) initiated ART within 3 mo of their first clinic visit. In the control arm, 42.3% (83/196) had a CD4 count ≤ 350 cells/μl at first visit, of whom 92.8% initiated ART within 3 mo. Regarding attitudes about ART, 93% (8,802/9,460) of participants agreed with the statement that they would want to start ART as soon as possible if HIV-positive. Estimated baseline HIV prevalence was 30.5% (2,028/6,656) (95% CI 25.0%, 37.0%). HIV prevalence, uptake of home-based HIV testing, linkage to care within 6 mo, and initiation of ART within 3 mo in those with CD4 count ≤ 350 cells/μl did not differ significantly between the intervention and control clusters. Selection bias related to noncontact could not be entirely excluded.
  
  
  CONCLUSIONS
  Home-based HIV testing was well received in this rural population, although men were less easily contactable at home; immediate ART was acceptable, with good viral suppression and retention. However, only about half of HIV-positive people accessed care within 6 mo of being identified, with nearly two-thirds accessing care by 12 mo. The observed delay in linkage to care would limit the individual and public health ART benefits of universal testing and treatment in this population.
  
  
  BACKGROUND
  ClinicalTrials.gov NCT01509508.
authors: Africa Centre for Population Health, University of KwaZulu-Natal, Durban, South Africa.|Research Department of Infection and Population Health, University College London, London, United Kingdom.
authors: Collins C
authors: CC
authors: Iwuji
authors: Centre INSERM U1219 Bordeaux Population Health, Université de Bordeaux, Bordeaux, France.|Institut de Santé Publique, d'Epidémiologie et de Développement, Centre INSERM U1219 Bordeaux Population Health, Université de Bordeaux, Bordeaux, France.
authors: Joanna
authors: J
authors: Orne-Gliemann
authors: Africa Centre for Population Health, University of KwaZulu-Natal, Durban, South Africa.|Centre Population & Développement UMR 196, Université Paris Descartes, Institut de Recherche pour le Développement, Paris, France.
authors: Joseph
authors: http://orcid.org/0000-0001-7097-700X
authors: J
authors: Larmarange
authors: Africa Centre for Population Health, University of KwaZulu-Natal, Durban, South Africa.
authors: Nonhlanhla
authors: N
authors: Okesola
authors: Africa Centre for Population Health, University of KwaZulu-Natal, Durban, South Africa.|School of Nursing and Public Health, University of KwaZulu-Natal, Durban, South Africa.
authors: Frank
authors: F
authors: Tanser
authors: Centre INSERM U1219 Bordeaux Population Health, Université de Bordeaux, Bordeaux, France.|Institut de Santé Publique, d'Epidémiologie et de Développement, Centre INSERM U1219 Bordeaux Population Health, Université de Bordeaux, Bordeaux, France.
authors: Rodolphe
authors: R
authors: Thiebaut
authors: Agence Nationale de Recherches sur le Sida et les Hépatites Virales, Paris, France.
authors: Claire
authors: C
authors: Rekacewicz
authors: Africa Centre for Population Health, University of KwaZulu-Natal, Durban, South Africa.|Human Health and Development and Global Health Research Institute, Faculty of Medicine, University of Southampton, Southampton, United Kingdom.
authors: Marie-Louise
authors: ML
authors: Newell
authors: Centre INSERM U1219 Bordeaux Population Health, Université de Bordeaux, Bordeaux, France.|Institut de Santé Publique, d'Epidémiologie et de Développement, Centre INSERM U1219 Bordeaux Population Health, Université de Bordeaux, Bordeaux, France.
authors: Francois
authors: http://orcid.org/0000-0002-1614-8857
authors: F
authors: Dabis
mesh_terms: D015492:AIDS Serodiagnosis / Q000379:methods*; D000328:Adult; D019380:Anti-HIV Agents / Q000627:therapeutic use*; D001294:Attitude to Health; D003266:Continuity of Patient Care / Q000458:organization & administration; D005260:Female; D015658:HIV Infections / Q000175:diagnosis* / Q000188:drug therapy / Q000523:psychology; D006801:Humans; D008297:Male; D008875:Middle Aged; D012424:Rural Population / Q000706:statistics & numerical data; D012648:Self Care / Q000379:methods*; D012747:Sexual Partners; D013019:South Africa / Q000453:epidemiology; D055815:Young Adult
chemical_list: D019380:Anti-HIV Agents