Knowledge of one’s HIV status is vital to accessing treatment and prevention yet only a
fraction of individuals in sub-Saharan Africa are regularly tested for HIV. Community-based
HIV testing and counseling (HTC), defined as HTC conducted outside of a healthcare facility,
has the potential to achieve high population testing coverage and linkage to care. The studies
within this dissertation describe effectiveness and efficiency (cost-effectiveness) of various
modalities of community-based HTC. Aim 1 presents a systematic review of community and
facility-based HTC strategies in sub-Saharan Africa. Aims 2 and 3 evaluate the cost-effectiveness
of two types of community HTC interventions in western Kenya by incorporating primary cost
and effectiveness data from randomized clinical trials into an HIV mathematical model.
Specifically, Aim 2 assesses the health and economic impact of implementing a home-based
partner education and HIV testing (HOPE) intervention for pregnant women and their male
partners. Aim 3 evaluates the cost-effectiveness of scaling up provider notification services for
sexual partners of recently diagnosed HIV-positive persons.
In Aim 1, we found that community HTC (including home, mobile, partner notification,
key populations, campaign, workplace and self-testing) successfully reached target groups (men,
young adults and first-time testers) with higher coverage than facility HTC. Community HTC
also identifies HIV-positive individuals at higher CD4 counts who were likely to be earlier in
their disease course. Combined with the potential of community HTC with facilitated linkage to
achieve high linkage to treatment with similar retention rates as facility HTC, this suggests that
scaling up community interventions can reduce the morbidity, mortality and transmission
associated with late or non-initiation of ART. Of all modalities examined, home HTC attained
the highest population coverage (70%, 95% CI = 58–79) while mobile HTC reached the highest
proportion of men (50%, 95% CI = 47–54%). Self-testing reached the highest proportion of
young adults (66%, 95% CI = 65–67%). As each HTC modality reaches distinct subpopulations,
a combination of modalities (differing by setting) will likely be needed to achieve
high ART coverage.
In Aim 2, we found that the incremental cost of adding the HOPE intervention to standard
antenatal care was $31-37 USD per couple tested; task shifting intervention responsibilities to
community health workers lowered the cost to $14-16 USD per couple tested. At 60% coverage
of male partners, HOPE was projected to avert 6,987 HIV infections and 2,603 deaths in Nyanza
province over 10 years with an incremental cost-effectiveness ratio (ICER) of $886 and $615 per
DALY averted for the program and task-shifting scenario, respectively. The ICERs are below the
threshold of Kenya’s per capita gross domestic product ($1,358) and are therefore considered
cost-effective. We conclude that the HOPE intervention can cost-effectively decrease HIVassociated
morbidity and mortality in western Kenya by linking HIV-positive male partners to
care.
In Aim 3, we found that implementing assisted partner services (aPS) or active tracing, exposure
notification, and home HTC for sexual partners of newly diagnosed HIV-positive persons in
western Kenya is projected to achieve 12% population coverage and reduce HIV infections by
by 2.8% and HIV-related deaths by 1.5%. The incremental cost-effectiveness ratio (ICER) of
implementing aPS is $1,703 USD (range $1,198-2,887) per disability-adjusted life year (DALY)
averted. Task-shifting intervention activities from healthcare professionals to community health
workers decreases the ICER to $1,302 (range $955-2,789) per DALY averted. The task-shifting
scenario falls below Kenya’s per capita gross domestic product (GDP) and is therefore
considered very cost-effective while the full program cost scenario is considered cost-effective
under the higher threshold of 3-times Kenya’s per capita GDP. Intervention cost-effectiveness
and HIV-related deaths averted among aPS partners increased with expanded ART initiation
criteria.
We hope that this dissertation work will be useful in forming policy deliberations
regarding implementation of community HTC in countries of sub-Saharan Africa.