Understanding Home-Based Voluntary Counseling and Testing

How can home-based or mobile services for HIV counseling and testing improve community responses?

Voluntary counseling and testing (VCT) services are a key component of HIV prevention, treatment, and care programs. Individuals learn about behaviors that put them at risk of HIV infection and how they can reduce this risk through the counseling process, and this information can be a catalyst for people to alter their behaviors.

Individuals who undergo VCT also find out whether or not they are HIV infected (see November 2005 Primer onUnderstanding HIV Testing). VCT services, therefore, are often the primary entry point for infected individuals into treatment and care programs. These important outcomes make VCT programs a critical part of the community's response to HIV/AIDS.

There are various types of VCT services, including those given before enrollment in a vaccine trial or research study or sessions specifically tailored for couples (see April 2005 Primer on Understanding Research Voluntary Counseling and Testing and October 2005 Primer on Understanding Couples Voluntary Counseling and Testing). These almost always occur at community health clinics or clinical trial sites, but the stigma associated with HIV in many communities, as well as the distance people are required to travel to clinics in rural areas, can prevent people from seeking these services on their own. Since VCT is such a powerful tool in getting people information on HIV and access to treatment if needed, researchers have looked for ways to maximize the number of people utilizing these services. One of these approaches is taking VCT services directly to people in their homes or neighborhoods. Such home-based or mobile VCT services, while limited, have been successful in getting more people to be tested for HIV infection.

The process

The VCT services administered in people's homes are conducted similarly to those in clinics. Community healthcare workers are trained to provide HIV counseling and testing and must obtain consent from all individuals before administering VCT. The only difference is that these healthcare workers go door-to-door offering these services.

Some organizations, such as The AIDS Support Organization (TASO) in Mbale, Uganda, couple their home-based VCT services with at-home care programs. So when field officers deliver antiretrovirals (ARVs) directly to the homes of infected individuals they also offer VCT services to other family members in the household.

Others, like the AIDS Information Centre (AIC) in Uganda, have implemented a stand alone home-based VCT program in an effort to increase the number of people being tested for HIV. National surveys in the country reported that although 70% of people want to be tested for HIV infection, only about 10% have actually participated in VCT.

A pilot project, funded by the US Centers for Disease Control and Prevention (CDC) was started by AIC in 2004 in the districts of Tororo and Busia in Uganda in an attempt to reach as many people as possible in these districts and offer them home-based VCT services. Trained outreach teams visited each home and offered all family members information so they could decide if they wished to participate. Adults in the household were given the choice to receive these services individually, or as couples. Anyone who was found to be HIV infected during this process received referrals to treatment and care programs in their community.

Judging success

Many organizations have found that offering home-based VCT programs is an effective way to increase access to treatment and prevention services. The AIC program lasted for one year and during this time over 5000 individuals received VCT services in their homes, which was more than double the study's target. The outreach teams visited more than 2000 homes in these two districts of Uganda and in 65% of them at least one household member agreed to participate in VCT.

The results of this program were presented at the International AIDS Society meeting on HIV Pathogenesis and Treatment, which took place last year in Rio de Janeiro, Brazil, and the CDC plans to use this program to create guidelines that will allow additional home-based VCT programs to be started in Uganda.

The AIC concluded that stigma seemed to be much less of an influence on a person's decision to undergo HIV testing when VCT services are administered in the home, instead of in clinics. Home-based VCT services could also be a promising strategy for reaching disempowered individuals, especially women.

Another option is providing just the test results and post-test counseling at home. In settings where rapid tests are unavailable, people sometimes do not return to the clinic to find out the results of their HIV test. In a study conducted by the Medical Research Council in Entebbe, Uganda, researchers found that offering test results in a person's home was an effective way to ensure that people received them.

Mobile units

Another method for bringing VCT services directly to communities is to utilize mobile VCT units. The Foundation Agency for Rural Development, a non-governmental organization in Nairobi, Kenya, uses bicycles to bring VCT to local communities. Four mobile sites are set up in different areas throughout the city and each week several individuals undergo VCT. Like home-based services, these mobile units can reach people who may be unable to travel to a clinic to receive VCT.

From community to country

The most ambitious home-based VCT program is currently taking place in Lesotho, where on World AIDS Day last year the president announced plans to take VCT services door-to-door in an effort to reach every household in the country by 2007. To meet this challenge the government trained 6500 healthcare workers to provide VCT services. Prior to this universal HIV testing initiative, it was estimated that only 1% of the population had accessed VCT.