HIV Testing and Counselling
We used a combination of home-based testing (with visits to each household in the intervention community and offer of HIV testing of all residents age 16-64), as well as testing in tents and at local health facilities. In addition, study participants in the intervention communities were screened for TB symptoms. Those with symptoms were referred to the local clinic for evaluation. Study participants who tested negative for HIV were counselled on HIV prevention strategies.
Antiretroviral Treatment and Linkage to Care
Once tested, PLWH who were not already on ART were referred to the local government health facility for ART initiation and given an appointment date. Those who did not keep the appointment were sent an SMS reminder, followed by a telephone call. If a participant still failed to show up (and had given permission for home visits), a visit was made to determine why the person was not linking to care.
Safe Male Circumcision
In intervention communities, HIV-negative men or men with unknown HIV status were linked to nearby Safe Male Circumcision (SMC) services by community mobilizers who could assist with transportation to a circumcision tent set up in the community or to a community health facility offering circumcision.
In standard-of-care communities, HIV-negative men participating in the Household Survey were advised to go for Safe Male Circumcision at the nearest health facility.
Evolution of Strategy
In response to our initial findings, field experience, and developments in global HIV knowledge and recommendations, we adapted some aspects of the study intervention over time.
A review of HIV testing data from the first two years of the study showed that, with the initial strategy, men and young people were under-represented among persons tested. To address this, the second phase of HIV testing was targeted to settings frequented by men or youth. Strategies to find men and young people included focusing on high traffic areas where men and/or youth congregate, including workplaces, markets, bars, cattle posts, and farms.
Our initial intervention included expanded ART that was targeted at persons with high HIV viral load (in addition to treating all persons who met treatment criteria according to CD4 count). However new global research showed that earlier treatment (regardless of CD4 count) has health benefits to PLWH. Starting in 2016, all persons (in both study arms) with HIV were offered ART regardless of CD4 count or viral load.
Our ART strategy also evolved to offer rapid treatment. Persons referred for treatment started ART at the first clinic visit (after verification HIV testing and making sure the patient did not have conditions which would make rapid ART start unsafe). Safety labs were drawn at that same visit.