A hybrid mobile HIV testing approach for population-wide HIV testing in rural East Africa: an observational study

BACKGROUND: Despite large investments in HIV testing, only 45% of HIV-infected persons in sub-Saharan Africa are estimated to know their status. Optimal methods for maximizing population-level testing remain unknown. We sought to demonstrate the effectiveness at achieving population-wide testing coverage of a hybrid mobile HIV testing approach. METHODS: From 2013–2014, we enumerated 168,772 adult (≥15 years) residents of 32 communities in Uganda (N=20), and Kenya (N=12) using a door-to-door census. “Stable” residence was defined as living in community for ≥6 months over the past year. In each community we performed 2-week multi-disease community health campaigns (CHC) that included HIV testing, counseling, and referral to care if HIV-infected; CHC non-participants were approached for home-based testing (HBT) over 1–2 months. We determined population HIV testing coverage, and predictors of testing via HBT (vs. CHC) and non-testing. FINDINGS: HIV testing was achieved in 89% of stable adult residents (131,307/146,906). HIV prevalence was 9.6% (13,043/136,033 stable and non-stable adults); median CD4(+) T-cell count was 514 cells/μL (IQR: 355–703). Among stable adults tested, 43% (56,106/131,307) reported no prior testing. Among HIV-infected adults, 38% (4,932/13,043) were unaware of their status. Among stable CHC attendees, 99.5% (104,635/105,170) accepted HIV testing. Of stable adults tested, 80% (104,635/131,307, range: 60–93%) tested via CHCs. In multivariable analyses of stable adults, predictors of non-testing included male gender (risk ratio [RR]: 1.52, 95% CI: 1.48–1.56), single marital status (RR: 1.70, 95% CI: 1.66–1.75), Kenyan residence (RR: 1.46, 95% CI: 1.41–1.50, vs. Ugandan), and out-of-community migration for ≥1 month in past year (RR: 1.60, 95% CI: 1.53–1.68). Testing was more common among farmers (RR: 0.73, 95% CI: 0.67–0.79) and adults with primary education (RR: 0.84, 95% CI: 0.80–0.89). INTERPRETATION: High HIV testing coverage was achieved in rural Ugandan and Kenyan communities using a hybrid, mobile approach of multi-disease CHCs followed by HBT. This approach allowed for flexibility at the community and individual level in reaching testing coverage goals. Men and mobile populations remain challenges for universal testing.