Division of HIV, Infectious Diseases and Global Medicine, San Francisco, CA, USA.
Division of HIV, Infectious Diseases and Global Medicine, San Francisco, CA, USA.
Lancet HIV. 2016 Mar;3(3):e111-9. doi: 10.1016/S2352-3018(15)00251-9. Epub 2016 Jan 26.
BACKGROUND: Despite large investments in HIV testing, only an estimated 45% of HIV-infected people in sub-Saharan Africa know their HIV status. Optimum methods for maximising population-level testing remain unknown. We sought to show the effectiveness of a hybrid mobile HIV testing approach at achieving population-wide testing coverage. METHODS: We enumerated 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 the community for at least 6 months in the past year. In each community, we did 2 week multiple-disease community health campaigns (CHCs) that included HIV testing, counselling, and referral to care if HIV infected; people who did not participate in the CHCs were approached for home-based testing (HBT) for 1-2 months within the 1-6 months after the CHC. We measured population HIV testing coverage and predictors of testing via HBT rather than CHC and non-testing. FINDINGS: From April 2, 2013, to June 8, 2014, 168,772 adult residents were enumerated in the door-to-door census. HIV testing was achieved in 131,307 (89%) of 146,906 adults with stable residence. 13,043 of 136,033 (9·6%, 95% CI 9·4-9·8) adults with and without stable residence had HIV; median CD4 count was 514 cells per μL (IQR 355-703). Among 131,307 adults with stable residence tested, 56,106 (43%) reported no previous testing. Among 13,043 HIV-infected adults, 4932 (38%) were unaware of their status. Among 105,170 CHC attendees with stable residence 104,635 (99%) accepted HIV testing. Of 131,307 adults with stable residence tested, 104,635 (80%; range 60-93% across communities) tested via CHCs. In multivariable analyses of adults with stable residence, predictors of non-testing included being male (risk ratio [RR] 1·52, 95% CI 1·48-1·56), single marital status (1·70, 1·66-1·75), age 30-39 years (1·58, 1·52-1·65 vs 15-19 years), residence in Kenya (1·46, 1·41-1·50), and migration out of the community for at least 1 month in the past year (1·60, 1·53-1·68). Compared with unemployed people, testing for HIV was more common among farmers (RR 0·73, 95% CI 0·67-0·79) and students (0·73, 0·69-0·77); and compared with people with no education, testing was more common in those with primary education (0·84, 0·80-0·89). INTERPRETATION: A hybrid, mobile approach of multiple-disease CHCs followed by HBT allowed for flexibility at the community and individual level to help reach testing coverage goals. Men and mobile populations remain challenges for universal testing. FUNDING: National Institutes of Health and President's Emergency Plan for AIDS Relief.
背景:尽管在艾滋病毒检测方面投入了大量资金,但撒哈拉以南非洲估计只有 45%的艾滋病毒感染者知晓其艾滋病毒状况。最大限度地提高人群检测水平的最佳方法仍不清楚。我们试图展示混合移动艾滋病毒检测方法在实现全面人群检测覆盖方面的有效性。 方法:我们使用逐户普查的方式对乌干达(n=20)和肯尼亚(n=12)的 32 个社区的成年(≥15 岁)居民进行了计数。稳定居住定义为过去一年中在社区居住至少 6 个月。在每个社区,我们进行了为期 2 周的多种疾病社区卫生运动(CHC),其中包括艾滋病毒检测、咨询和如果感染艾滋病毒则转诊治疗;在 CHC 后的 1-6 个月内,未参加 CHC 的人会接受 1-2 个月的家庭检测(HBT)。我们通过 HBT 而不是 CHC 和未检测来衡量人群艾滋病毒检测覆盖率和检测的预测因素。 结果:从 2013 年 4 月 2 日至 2014 年 6 月 8 日,通过逐户普查对 168772 名成年居民进行了计数。在有稳定居住的 146906 名成年人中,有 131307 人(89%)接受了艾滋病毒检测。有和没有稳定居住的 136033 名成年人中有 13043 人(9.6%,95%CI 9.4-9.8)感染了艾滋病毒;中位数 CD4 计数为 514 个细胞/μL(IQR 355-703)。在有稳定居住的 131307 名成年人中,有 56106 人(43%)报告以前没有接受过检测。在 13043 名艾滋病毒感染者中,有 4932 人(38%)不知道自己的状况。在有稳定居住的 104635 名 CHC 参与者中,有 99%(范围在 60-93%,社区之间)接受了艾滋病毒检测。在有稳定居住的成年人的多变量分析中,未检测的预测因素包括男性(风险比[RR]1.52,95%CI 1.48-1.56)、单身婚姻状况(1.70,1.66-1.75)、年龄 30-39 岁(1.58,1.52-1.65 与 15-19 岁)、居住在肯尼亚(1.46,1.41-1.50)和过去一年中至少外出一个月(1.60,1.53-1.68)。与失业者相比,农民(RR 0.73,95%CI 0.67-0.79)和学生(0.73,0.69-0.77)进行艾滋病毒检测的情况更为常见;与没有受过教育的人相比,接受过小学教育的人(0.84,0.80-0.89)进行检测的情况更为常见。 解释:多种疾病 CHC 与 HBT 相结合的混合移动方法在社区和个人层面上具有灵活性,有助于实现检测覆盖目标。男性和流动人口仍然是普及检测的挑战。 资金:美国国立卫生研究院和总统艾滋病紧急救援计划。
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