More choice in community-based HIV testing leads to higher uptake in South Africa

A South African programme that enabled people to take HIV tests in a variety of community settings, such as homes and workplaces, has resulted in high rates of young people getting tested, particularly young women, and reached more men.

Despite being at heightened risk of HIV in South Africa, adolescent girls and young women (ages 15-24) are often reluctant to get tested in health facilities for various reasons, including the fear of encountering judgemental attitudes. Men are less likely than women to get tested, partly because women are routinely offered HIV testing through antenatal care and family planning services. Providing HIV testing in settings that both groups feel more comfortable with is therefore needed.

To this end, a multiple-option community-based testing programme was implemented in 12 districts across South Africa with high HIV prevalence. Through the scheme, people could take an HIV test at home, or in a mobile unit at their workplace or neighbourhood. Index testing, where the partners of someone with a positive diagnosis are offered testing, and  ‘twilight’ testing, which targets marginalised groups at night, was also provided.

Between 2015 and 2017, the programme conducted around 944,500 tests.

Most tests (48%) were performed on people aged 25 to 49, followed by young people (ages 20 to 24) at 19.5%, adolescents (ages 15 to 19) at 14%, over 50s at 10% and under 14s at 9.5%.

But when comparing testing rates, young people tested the most at 14,303 tests per 100,000 people, followed by adolescents at 11, 432 tests per 100,000 people.

By age and sex, young women had the highest testing rate (at 16,328 per 100,000) in all districts but one. Adolescent girls had the second highest rate (12,817 per 100,000) and young men had the third (12,307 per 100,000).

More women than men got tested (54% vs. 46%), and the testing rate was higher for women than men across all age groups. But the gap between the sexes was smaller than in other studies. In fact, in three districts men were significantly more likely to test than women due to the availability of neighbourhood testing. This shows the importance of understanding how different approaches can reach different groups in different contexts.

Home‐based testing accounted for 61% of HIV tests performed, followed by mobile testing (30%). Workplace testing accounted for 5% of tests, index testing for 3%, and twilight testing for 1%.

More women than men accessed home‐based testing (56% vs. 44%) and index testing (57% vs. 43%). But more men than women accessed work‐place testing (57% vs. 43%) and twilight testing (58% vs. 42%). There was no difference between the sexes in relation to neighbourhood testing.

When adjusted for age, the testing rate was highest in rural areas (21,230 per 100,000) followed by suburban areas (8,315 per 100,000) and urban areas (5,198 per 100,000).

When analysed by sex, women had a higher testing rate than men in urban and rural areas but a similar rate in suburban areas. When taking age into consideration, more men than women over 50 tested in urban areas. In suburban areas, young men and adolescent females had the highest testing rates.

Index testing was the most successful strategy for reaching under-15s, home‐based testing was the most successful strategy for reaching adolescents, and neighbourhood testing was the most successful for reaching young people. But as each district had different targets for different approaches, all options were not equally available, so definite conclusions on each group’s preference cannot be made.

Given how successful community-based testing was at reaching adolescent girls and young women, similar strategies should be considered to increase this group’s access to HIV prevention services, particularly PrEP.