Home initiation of HIV care increases anti-retroviral therapy use in Malawi

1. Among adults who underwent HIV self-testing in Malawi, offering home initiation of care increased anti-retroviral therapy initiation compared to standard HIV care.

2. Combined across both study groups, 72.5% of ART initiators were still taking ART six months after diagnosis.

Evidence Rating Level:  1 (Excellent)

Study Rundown: Testing for HIV and providing access to care for individuals who do test positive remain challenging in sub-Saharan Africa. While HIV self-testing allows for privacy and convenience, there is a risk of a delay to HIV treatment initiation. This is one of the first studies to assess the association between HIV self-testing and the initiation of HIV care.

These study findings suggest an effective method for controlling the HIV epidemic—anti-retroviral therapy (ART) initiation at home increases when HIV self-testing occurs at home. Strengths of this study include the use of randomized clusters within a city with a high prevalence of HIV and high number of participants. Limitations of the study include the fact that reporting results was optional to maintain privacy and confidentiality; as a result, individual HIV self-testing participants were not followed up as a cohort. Additionally, there were few ART initiators; these individuals were followed up for only six months and clinical outcomes were not assessed. Thus, a larger and longer study may be warranted to provide conclusive evidence.

Click to read the study in JAMA

Relevant Reading: Rates of virological failure in patients treated in a home-based versus a facility-based HIV-care model in Jinja, southeast Uganda: a cluster-randomised equivalence trial

In-Depth [cluster randomized trial]: This study was conducted in Blantyre, Malawi. Fourteen clusters underwent randomization into one of two groups: 1) HIV self-testing, then optional home initiation of care, or 2) HIV self-testing followed by facility-based care. The primary outcome was the proportion of adults who initiated ART within six months of HIV self-testing. During the study period, 58% of adults underwent HIV self-testing, and participants in the home group were more likely to report positive test results compared to those in the facility group (6.0% vs. 3.3%, Risk Ratio [RR] 1.23, 95% CI, 1.16-2.97, p= 0.006). A significantly greater proportion of adults in the home group initiated ART compared to the facility group, at 2.2% vs. 0.7%, respectively (RR 2.94, 95% CI 2.10-4.12, p<0.001). With consideration of other factors and an absolute difference of 1.5% between the two groups, an additional 7.9 per 100 HIV-infected adult residents initiated ART when both HIV self-testing and home initiation of HIV care were offered.

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