Research in context
Evidence before this study
We searched PubMed, Embase, and conference abstracts for community-based HIV testing and linkage studies published between Jan 1, 2000, and Jan 31, 2016, with the terms “HIV infections/diagnosis” AND “Africa South of the Sahara” AND (“mass screening” OR test OR tests OR testing OR screen* OR diagnosis OR “counseling”). We identified 156 abstracts for review, including three systematic reviews. A 2015 review by Sharma and colleagues showed that linkage to care, defined as visits to a clinic after community testing, was reported in 18 studies: ten home, six mobile, and two campaign testing studies. With use of random-effects meta-analysis, home testing achieved 95% linkage (95% CI 87–98) when paired with enhanced linkage to care interventions (ie, lay counsellor follow-up to encourage clinic visit) compared with home testing interventions without facilitated linkage to care, which achieved 26% linkage (18–36). Similarly, the mobile testing strategies that did not include facilitated linkage strategies achieved 37% linkage (95% CI 24–51) and the one campaign testing strategy, with enhanced linkage, achieved linkage rates of 81% (76–85). Four home testing studies reported initiation of antiretroviral therapy (ART) in ART-eligible participants, with higher linkage rates for interventions with enhanced linkage to care than for those without (76% [95% CI 68–82] vs 16% [12–20]). In a review by Wynberg and colleagues, point-of-care CD4 cell count testing decreased time to ART eligibility assessment, but did not change ART adherence. In a meta-analysis of text message interventions to promote ART adherence, improvements in viral suppression or CD4 outcomes were associated with two-way, less frequent than daily, and personalised text messages. Finally, a review of community support groups showed that peer-delivered or lay-counsellor-delivered ART can overcome barriers to retention in care and decongest health services in sub-Saharan Africa.
Added value of this study
Our findings add to the evidence about the effectiveness of community-based testing, with 98% of individuals approached agreeing to testing, and about the role of linkage strategies to deliver combination HIV prevention. Specifically, all three linkage strategies for HIV-positive people (ie, clinic referral, clinic facilitation, and lay counsellor home visits) achieved a linkage rate of more than 90%, but only a third of all HIV-positive participants initiated ART, and no strategy was more effective in the proportion of HIV-positive people who achieved viral suppression after 9 months, probably because of limits of ART supply. Encouragingly, uptake of HIV testing and HIV clinic follow-up was very high in the standard referral group and in the intervention groups, showing that community-based HIV testing and counselling achieves an effect in the early part of the HIV testing and care cascade, but that strategies to simplify and expedite ART initiation are needed. For HIV-negative uncircumcised men, text message support and lay counsellor visits almost doubled the uptake of male circumcision.
Implications of all the available evidence
The community-based strategies achieved high rates of linkage of HIV-positive people to HIV clinics, modestly increased ART uptake, and doubled linkage to male circumcision in two countries in rural Africa, supporting the generalisability of this approach in high and medium HIV prevalence settings in Africa. These coordinated, decentralised strategies involving lay counsellors have the potential to cost-effectively achieve high population coverage for combination HIV prevention. Evaluation of the effectiveness and cost of implementation will add to the evidence to guide HIV prevention.