Abstract
Background:
Mobile HIV counseling and testing (HCT) has been effective in reaching men, women, and adolescents in South Africa. However, there is limited understanding of effective mobile HCT programs utilizing tools like technology and edutainment to increase HIV counseling and testing rates. The authors examine data from the Shout-It-Now (S-N) program that uses such tools in South Africa.
Methods:
The S-N program utilizes various forms of technology and ongoing telephonic counseling within a 6-step program of HIV testing and linkage-to-care support, and program data were analyzed over an 18-month period. Data were analyzed from women, men, and adolescent program participants. Summative statistics was conducted on participant registration, HIV risk assessment, and HIV testing profiles. HIV prevalence were estimated along with the related 95% confidence intervals using the Clopper-Pearson method.
Results:
Over an 18-month period, there were 72 220 program participants with high representation of men, women, and adolescents and 40% of the participants being men at each site. There were 3343 participants who tested HIV positive, and a higher proportion of women tested positive.
Discussion:
Integrating technology, quality assurance measures, and edutainment with mobile HCT has the potential to increase the number of those who test within communities. Research is needed to understand the effectiveness of this model in facilitating regular testing and linkage to care.
Introduction
The HIV epidemic remains generalized in South Africa, with 7.2% HIV prevalence among 15- to 24-year-old individuals and 19.2% among those aged 25 to 49 years. More than 6.7 million South Africans over the age of 15 years are living with HIV/AIDS and many engage in behaviors that put them at risk of infecting others. 1 While South Africa has demonstrated increased uptake of HIV counseling and testing (HCT) through both clinic- and community-centered initiatives, some estimate that as many as 50% of HIV-positive people remain undiagnosed with continued needs to increase and diversify testing options. 2 –7
To complement clinic-based testing initiatives, South Africa needs scalable and sustainable community-based HCT (CBHCT) models that foster routine testing habits and overcome the linkage-to-care challenges common among many CBHCT models. 8 The World Health Organization has recommended increasing the diversity of CBHCT models that work in conjunction with clinic-based HCT. 9 Common CBHCT models proven to increase HCT access include stand-alone centers and mobile units that serve venues such as shopping centers, transportation hubs, workplaces, and schools. 10 Studies examining mobile HCT have shown increased uptake among first-time testers, women, and men and youth who are reluctant to test in a clinic. 11 –16 Mobile community-based testing utilizes HCT along with screening for other health conditions, and this standard design has proven effective in both urban and rural settings, but the integration of technology and edutainment into a mobile HCT model may further enhance this participation, especially for those less likely to use clinic-based testing. 2,17,18
We present the Shout-It-Now (S-N) program of mobile CBHCT, which utilizes a mix of client-centered services and technology to increase CBHCT scalability, acceptability, and accountability. Shout-It-Now differs from most mobile HCT providers in that it uses process-driven procedures supported by technology and edutainment. We analyzed the data collected over 18 months of S-N implementation (January 2012-June 2013) to assess HCT rates. We discuss how S-N is an effective, scalable CBHCT model that has high participation rates especially by those who are hard to reach and less likely to use clinic-based HIV testing services.
Methods
The S-N program combines technology (ie, biometrics, video edutainment, telephonic linkage-to-care counseling) with culturally competent HCT services and a software system that seamlessly supports staff and clients through every step of the S-N process from registration to linkage to care. Technology is utilized to streamline and track quality assurance measures for organizational processes as well as participant education and support through each step of the program.
Sites and Participant Recruitment
Shout-It-Now operated two 14-person mobile teams in 2 South African districts—Tshwane district (an urban area including the City of Pretoria, population 2.9 million) in Gauteng province and Capricorn district (a rural area, population 1.3 million) in Limpopo province. The teams set up in shopping centers, markets, and central business districts, utilizing a prescribed operations protocol. In all, 8 to 10 counselor tents (3 × 3 m) were pitched in a horseshoe formation. At the entrance were 2 additional tents, 1 for registration and 1 for a computer lab where participants watched S-N’s educational/risk assessment video on laptops. Shout-It-Now sites were made highly visible, with colorful banners, music playing through a public announcement system, and S-N staff engaged passersby about the program and invited them to participate. Participants were 15 to 49 years of age and not asked about their previous testing history or HIV status.
Shout-It-Now Model
Six sequential steps form the S-N HCT program and are explained below. The first 5 steps were conducted during the HCT encounter at the mobile site and the final sixth step was conducted telephonically via a centralized call center for up to 7 weeks after an HIV-positive diagnosis. For every client, each step was tracked using technology and the result of each step was automatically collected for program monitoring and evaluation via of S-N’s integrated software program.
Biometric registration
The registration process begins with fingerprint registration that links clients anonymously and confidentially to an electronic profile (e-profile) that is populated as they progress through S-N’s 6-step HCT process. Once their fingerprint is registered, they are issued a unique identifier printed on a wristband that they wear to track progression through S-N’s HCT process. Participants then complete a brief online demographic profile including socioeconomic measures, cultural and racial identity, date of birth, and language. The use of biometric technology by S-N program is supported by studies demonstrating that such technology is feasible and acceptable in low-resource settings and has been shown to be a significant factor in the engagement of participants in HCT and linkage to care. 24 –26
HIV edutainment
Online social networking, gaming, edutainment, and telenovelas have been successfully used to deliver health knowledge, education, and messaging. 19 –21 The S-N’s HIV education content is delivered by a 13-minute edutainment video viewed by each client on a personal laptop. The video features young South African celebrities (sports stars, musicians, designers, and television personalities), animation, dance, and docudrama to teach clients about HIV risk, testing, disease development, and living healthy with HIV. In the video, messages addressing both men’s and women’s HIV risk factors were delivered by men and women in order to create an inclusive educational experience. 7
Online risk assessment and culturally competent pretest counseling
Embedded in the educational video was a set of HIV risk assessment questions. Participants were informed that questions about their health behaviors and opinions would appear during the video and that by answering these questions, they could improve the relevance and quality of their subsequent counseling session. The HIV risk assessment questions addressed sexual risk, tuberculosis, and sexually transmitted infection history; medical history; lifestyle; physical health; and medical male circumcision. The video ran automatically and was available in all local languages, with counselors assisting participants who had low literacy levels. At the end of the video, clients were asked if they would like to consent for an HIV test.
Once a client consented to HIV testing, participants met privately with a counselor trained in key population cultural competence in a tent for pretest counseling and testing. Previous testing history was discussed as part of the pretest counseling session. Counselors reviewed risk assessment profiles with their clients and then assessed their level of comprehension of relevant HIV educational content. The online risk assessments helped counselors tailor their HIV risk reduction messaging to each client’s needs. When pretest counseling was completed, counselors asked the participant again if they consented to HIV testing. If participants declined testing, the counselor attempted to motivate the client to accept testing by addressing the reasons for refusal. If the client could not be convinced to test, they were encouraged to return and seek testing for HIV at another site and then they exited the program at this point. Participants consenting to HIV testing were then tested.
HIV testing
Counselors administered rapid HIV testing using kits certified by the South African National Department of Health and supplied by the respective provincial Departments of Health. There were 2 steps in the S-N testing process. First, a counselor collected a specimen using the test kit, which was linked to the client by a sticker bearing their unique identifier already stored in the S-N database. Participants were then escorted to a waiting area with activities and music videos while the test was processed. Second, the test kit and specimen were delivered to a dedicated staff member who read the HIV test result (the S-N database time stamped all test kits to protect against HIV test results being read too early or too late) and recorded the result in the S-N database by scanning the barcode on the test kit and inputting the result.
Post-HIV test results counseling
The S-N database notified counselors on their laptops, when their clients’ results were accessible via the client’s electronic record. At that time, counselors called clients back to their tent to deliver results and posttest counseling using a script specific to the client’s HIV result.
HIV-negative results
Counselors followed a 3-step procedure: (1) deliver the result and ascertain accurate comprehension of the result, (2) encourage routine HIV testing, and (3) summarize the participant’s risk profile and help them devise a prevention plan to minimize their risk of HIV infection.
HIV-positive results
Counselors followed a multistep procedure: (1) deliver the preliminary test result and ascertain accurate comprehension of the result, (2) administer a different rapid HIV test to confirm results, (3) address individual concerns and questions, and (4) confirm the results of second test. If the second test was negative, participants were referred to a clinic for a laboratory confirmation test. If the second test was positive, the counselor proceeded with a second set of steps: (1) deliver the HIV-positive diagnosis in a clear unambiguous way, (2) check for understanding of the result, (3) allow for emotional response, (4) assess participant’s support system, (5) discuss disclosure, (6) emphasize importance of accessing HIV care (including the importance of CD4 testing), and (7) discuss prevention options. After these steps were completed, individuals testing HIV positive were provided a referral letter to a local clinic for follow-up care and were encouraged to participate in S-N’s ongoing linkage-to-care service delivered via a centralized call center.
Telephonic linkage-to-care support program
Participants opting to receive S-N’s ongoing linkage-to-care services were provided free telephonic support from care coordinators at the S-N call center. Care coordinators had training in linkage-to-care counseling and were fluent in all South African languages. Within 48 hours of an HIV-positive diagnosis, a care coordinator called the client and commenced the process of motivating them to visit a local clinic for HIV care. Care coordinators read and updated each participant’s e-profile stored in the S-N database to guide and document the telephonic support they provided to the participant until they linked to HIV care. Generally, this support was provided over multiple phone calls up to 7 weeks after diagnosis, though most clients who were linked to care did so within 30 days. Documentation of linkage to care was from the clients’ self-report and was verified by descriptions of clinic-delivered CD4 results or enrollment in ART or in wellness programs.
Data Analysis
Quantitative data from participant registration, HIV risk assessment, and HIV testing profiles were analyzed to generate summative statistics using R software 3.0. 22 For HIV prevalence estimates, binomial confidence intervals were calculated using the Clopper-Pearson method.
Ethics, Consent, and Funding
Shout-It-Now received a nonresearch determination by the US-based Center for Global Health institutional review board within the Centers for Disease Control and Prevention (CDC), and the program received ethical approval to provide HCT services from the CDC/PEPFAR Office of the Associate Director for Science. This approval included electronic and verbal consent processes for HCT. Shout-It-Now asked participants for consent during the video education session, where they clicked either “yes” or “no” on the computer screen after listening to S-N HCT procedures. Also, participants reconfirmed their agreement to test verbally with the counselor in the HCT tent before they were offered HCT. Shout-It-Now was funded via CDC Cooperative Agreement: 1U2GGH000285, Strengthening Prevention in South Africa through Innovative Mobile HCT. The funding source had no role in the study design to include the collection, analysis, and interpretation of data, writing the manuscript, and submitting it for publication.
Results
HIV Testing Engagement
A total of 72 220 individuals participated in S-N across the 2 districts from June 2012 to June 2013 (Table 1), with an average program completion time of 30 minutes per participant. Higher numbers of women than men completed the S-N program though the representation of men was over 40% in each site. The highest representation of participants by age was the 20 to 29 age-group at 56.47% in Gauteng and 59.08% in Limpopo. Participant representation decreased sequentially from the 30 to 39, 15 to 19, and 40 to 49 age-groups.
Characteristics of Testers by Site.
HIV Case Findings
In Table 2, HIV prevalence rates by sex and age are shown along with confidence intervals. In this analysis of data collected over 1 year, the S-N program identified 3343 HIV-positive participants at 4.6% HIV prevalence. The HIV prevalence rates among testers in S-N were higher among women who were 30 years of age or older compared to men. In this age range, the HIV prevalence rate for women was 8.5% to 13.0% across the sites, whereas it was 5.6% to 6.9% for men in the same age categories. Within the 20- to 29-year-old group that had the highest number of testers, HIV prevalence rate for women was the highest at 5.3% and 4.4% in Gauteng and Limpopo, respectively, compared to men at 2.2% for each province. The HIV prevalence rate range for both men and women aged 15 to 29 years was 0.6% to 5.3%, with 2.38% as the average rate. Most S-N participants tested HIV negative across the sites, and the confidence intervals remained small for HIV testing based on gender alone.
HIV Prevalence Rates by Sex and Age.a
Abbreviation: CI, confidence interval.
aBoth men and women.
Discussion
The findings from the S-N program demonstrate exceptionally high HIV testing rates among underserved communities including men, women, and youth who are less likely to test in a clinical setting. This HCT model had more than 70 000 participants over an 18-month period and maintained a high representation of both men and women including adolescents 15 to 17 years of age which is comparable to similar mobile HCT models. 23
High Numbers of HIV Testers and HIV Cases Detected
There was a 4.6% mean HIV prevalence across age, sex, and site among testers in the S-N model, with rates for women comparable to their national prevalence in South Africa. 3 Although the mean HIV prevalence is lower than the national prevalence, the number of HIV testers in S-N per site was significantly higher than comparable clinic-based testing methods and other mobile models. 18,24 Further, HIV testing rates for men was less than women in S-N but high compared to national rates. This finding supports studies that show mobile testing increases the numbers of men in HCT and knowing their results within a context, where 17% of men have ever tested for HIV. 2 With high numbers of HIV testers, the number of HIV-positive cases detected was high in S-N as well, such as 20- to 39-year-old women with nearly double the number of cases detected compared to clinics. 18
Shout-It-Now Program Addresses Mobile HCT Gaps
Technological tools allow mobile HIV-testing programs monitor processes and address quality improvement opportunities, provide improved support to clients, and demonstrate outcomes. 5,25 We show how technology allows participants to build a voluntary S-N e-profile as they proceed through the program steps. This e-profile gives the program data to provide tailored HCT as well as follow-up linkage-to-care support, and this profile is longitudinally accessible when a participant retests with the program at a later date. These findings suggest that S-N engaged participants by using technology and educational media, which resulted in a high number of testers and allows it to be comparable to other mobile HCT models. 21,26,27 This technology was easily adaptable to urban and rural areas with high HIV prevalence and low numbers of testers with the greatest appeal to both men and women in the age-group of 20 to 29 years. 3,5
Conclusion
Scaling up affordable HCT models that effectively engage large numbers of people to learn their HIV status and then efficiently link them to clinical care is a key priority in the global AIDS response. A highly organized service delivery process, use of multiple technologies to engage clients in education and track their HIV testing progression, risk profiles, and test results can improve the effectiveness and scalability of mobile HCT programs. We show how the S-N program is highly efficient and offers an engaging model for a large scale-up of mobile CBHCT services.
Footnotes
Author Contributions
All authors conceived and participated in the design and coordination of the study. J.D., A.K., S.S., and K.P. carried out the analyses of data. B.F., S.S., and K.P. collected the data and acquired participants’ approval. J.D. was the main writer but was edited by all authors. All authors read and approved the final manuscript.
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The author(s) received no financial support for the research, authorship, and/or publication of this article.