This study revealed high levels of uptake of HIV testing and counseling and overall satisfaction with HBHCT. The percentage of respondents who had ever tested was much higher than the national average of 38% at the time . All individuals who tested received their results immediately, facilitated by the use of rapid test kits. Similar results have been reported by other HBHCT studies andprograms [16–18, 30, 33], suggesting that if expanded, HBHCT could increase uptake of HIV testing and reach many first-time testers.
The quality of services and the attitude of healthcare providers are often cited as limiting factors in the use of HIV counseling and testing services [31, 34]. In our study, both male and female clients reported largely positive experiences with HBHCT: the information they received during pre- and post-test counseling, the consent procedure, and general handling by providers. Most respondents were counseled before the test and felt that the information they received from providers was sufficient. Allowing clients to ask questions was highly valued.
We found high adherence to consent requirements on the part of the HBHCT providers, in particular explanation of the opt-out option. Nearly all (94%) respondents (both male and female) acknowledged being given the chance to opt out of the test; and they valued this. The Kumi HBHCT teams were able to allocate considerable time to conduct comprehensive individual counseling since they controlled the number of households and individuals served on each day.
Contrary to our expectation that privacy within homes would be problematic due to limited space and the presence of other family members, clients considered their own homes as more private than healthcare facilities. Most respondents were satisfied with the privacy offered by HBHCT. Other studies have described the involvement of families in seeking private counseling space within and outside the home . The participation of clients in identifying private spaces within the home was experienced as empowering, in contrast to facilities where users have no say over the setting of testing and counseling.
While most clients were satisfied with the level of privacy, more than a quarter cast doubt on whether their test results would be safeguarded after providers left their homes. In this study, no direct question was asked about breach of confidentiality by the provider. Nonetheless, in order to build trust and confidence, HBHCT clients should be informed about the practical issues of confidentiality beyond the test process and what happens to records when providers leave their homes.
It is widely assumed that individuals do not want others to know that they have tested for HIV . In the context of HBHCT, anonymity may be impossible. Family members and neighbors knew about the visiting HBHCT team and tried to find out whether others had taken the test. Almost half of the respondents were asked by other community members if they had taken the HIV test. Nevertheless, we found that anonymity was not a major concern among respondents as there was no stigma attached to testing: most household and community members were in the same boat. Those who declined to test were the minority. This is unlike testing in a voluntary testing and counseling facility where lone individuals who go for testing prefer to hide their identity . HBHCT opened up space within the home to talk about HIV and testing. To some extent, interactions and discussions among partners and other family members influenced individual decisions to test at home, though others stated, that testing was a personal responsibility. The dynamics of these discussions varied between respondents; patterns of influence often did not conform to the traditional hierarchy of many African families (e.g. parents over children, husbands over wives). For example, we found sons and daughters to have encouraged their parents to take the test.
Prior mobilization allows potential clients to think about, discuss and make a decision before the team arrives. This is similar to VCT where an individual can take time to consider whether or not to be tested. Individuals who do not wish to be tested could, for example, leave home before the arrival of the HBHCT team. The involvement of local leaders in the mobilization process can influence individual decisions to take the test; their involvement encouraged trust in the program and community cooperation. Although not a focus of this study, the widespread mobilization and discussions around HIV within the homes and community may change the norms around HIV testing and impact on HIV stigma, discrimination and access to services.
Disclosure levels were found to be high: 78% of HBHCT clients had disclosed their HIV test results to someone, often to more than one person. However, the disclosure was selective as reported in other studies [37, 38]. Men were found to disclose significantly more to others in the household and to friends than women. This is an interesting finding, as other studies suggest that men are more secretive about their status than women. It is important to note here that 96% of our informants were negative. For those who test negative, disclosing is perhaps not a big deal. Disclosure problems are more likely to occur for those who test positive. However, some previous studies have demonstrated no increases in domestic violence or other negative social outcomes after HBHCT . Our findings show that all of the HIV positive respondents had disclosed their results to someone. Many clients tested (69%) were counseled with their partners, suggesting that home-based testing is a good way to promote couple-counseling. Couple counseling and testing may also explain the high disclosure rates to sexual partners, in comparison to other studies [30, 40].
The findings from this study may have some limitations: 1) Recall bias (some respondents had tested more than a year prior to the interview); 2) This study gathered information on only individuals who were present at home at the time of the interview, which may exclude the views of those who were out (at work); 3) The study generally relied on respondent accounts which may be subject to bias due to social desirability. However, in real life, it is users’ perceptions that trigger many health actions including care, and it is thus important to explore the client perspectives.
The number of HIV infected individuals was too small to exhaustively explore linkage to and access to HIV care and treatment as well as outcomes of HIV status disclosure among the HIV infected individuals. However, most of the HIV infected respondents confirmed referral to medical care and support groups, similar to another study of HBHCT in western Uganda . Even with the linkage to care challenges, HBHCT can still play a major role since several studies demonstrate that knowing one’s status if a person is HIV-infected, has a substantial benefit in terms of risk reduction [41, 42].
Several studies show that HBHCT increases uptake of HIV testing, identifies infected individuals earlier, and reaches more couples and children, in comparison to other HCT approaches [21, 30]. Despite the ethical concerns, our study shows good adherence to standard HIV counseling and testing recommendations (consent, counseling, confidentiality and referral to care) and appreciation of the HBHCT approach by the community.