ELC, MTB, SC, PRM, AEB, PGF, and RJH conceived and wrote the initial study proposal. ELC, ED, RM, BM, and SM made substantial contributions to acquisition of data. ELC, YBC, and RH analysed the data. All authors provided input into the drafting and revision of the final manuscript.
The authors have declared that no competing interests exist.
HIV counselling and testing is a key component of both HIV care and HIV prevention, but uptake is currently low. We investigated the impact of rapid HIV testing at the workplace on uptake of voluntary counselling and testing (VCT).
The study was a cluster-randomised trial of two VCT strategies, with business occupational health clinics as the unit of randomisation. VCT was directly offered to all employees, followed by 2 y of open access to VCT and basic HIV care. Businesses were randomised to either on-site rapid HIV testing at their occupational clinic (11 businesses) or to vouchers for off-site VCT at a chain of free-standing centres also using rapid tests (11 businesses). Baseline anonymised HIV serology was requested from all employees.
HIV prevalence was 19.8% and 18.4%, respectively, at businesses randomised to on-site and off-site VCT. In total, 1,957 of 3,950 employees at clinics randomised to on-site testing had VCT (mean uptake by site 51.1%) compared to 586 of 3,532 employees taking vouchers at clinics randomised to off-site testing (mean uptake by site 19.2%). The risk ratio for on-site VCT compared to voucher uptake was 2.8 (95% confidence interval 1.8 to 3.8) after adjustment for potential confounders. Only 125 employees (mean uptake by site 4.3%) reported using their voucher, so that the true adjusted risk ratio for on-site compared to off-site VCT may have been as high as 12.5 (95% confidence interval 8.2 to 16.8).
High-impact VCT strategies are urgently needed to maximise HIV prevention and access to care in Africa. VCT at the workplace offers the potential for high uptake when offered on-site and linked to basic HIV care. Convenience and accessibility appear to have critical roles in the acceptability of community-based VCT.
Since the first case of AIDS (acquired immunodeficiency syndrome) was reported 25 years ago, AIDS has become a major worldwide epidemic, with 3 million people dying from it in 2005. AIDS is caused by the human immunodeficiency virus (HIV), which is usually spread through unprotected sex with an infected partner. HIV damages the immune system, leaving infected individuals unable to fight off other viruses and bacteria. HIV infections can be treated with drugs know as “antiretrovirals,” and in an effort to deal with the global epidemic, world leaders have committed themselves to providing universal access to these drugs for everyone who needs them by 2010. Unfortunately, although access to antiretrovirals is rapidly increasing, so is the number of people infected with HIV. Last year, there were about 5 million new HIV infections, suggesting that more emphasis on prevention will be needed to halt or reverse the spread of HIV and AIDS. An important part of prevention is testing for HIV infection, but globally only 10% of people who need testing can access it. And even where such services are available, few people use them because of the stigma attached to HIV infection and fear of discrimination.
There is limited understanding about the factors that determine whether an individual will decide to have an HIV test. Yet, to reduce HIV spread, as many people at risk of infection must be tested as possible. Previous studies on VCT—a combination of voluntary testing and counseling about the implications of HIV infection and how to avoid transmitting the virus—have indicated that the convenience of getting the test, whether the test is directly offered, and the attitude of staff supplying it are all very important. In this study, the researchers asked whether providing VCT in the workplace could improve the “uptake” of HIV testing in Africa, where the HIV/AIDS epidemic is most widespread.
The researchers identified businesses with occupational health clinics in Zimbabwe, a country where 25% of adults carry HIV, and divided them into two “intervention” groups. Employees at half the businesses were offered “on-site VCT”—pre-test counseling followed by same-day on-site rapid testing, results, and post-test counseling. Employees at the other businesses had the same pre-test counseling but were offered a voucher for an HIV test at an off-site testing center and a later appointment to discuss the results—so-called off-site VCT. Everyone had the same access to limited HIV care should they need it. Although half of the employees at the on-site VCT businesses took up the option of HIV testing, only a fifth of employees at the off-site VCT businesses accepted vouchers for testing, and only one in five of these people actually used their voucher. This means that on-site VCT resulted in about 12 times as many HIV tests as off-site VCT. In both interventions, most of the people who accepted testing did so soon after entering the study and very few people were tested more than once. Finally, people 25 years old or younger, manual workers, and single people were most likely to accept testing in both interventions.
These results suggest that on-site VCT in the workplace might be one way to improve uptake of HIV testing in Africa from its current low level and that providing VCT intermittently might be as effective as continuous provision. Importantly, say the researchers, the results of their study show that a relatively minor change in accessibility to testing can translate into a major difference in test uptake. This may hold true in non-occupational settings. However, these observations need to be repeated in more businesses and other settings, including those where there is no linked HIV care, before they can be generalized. Also, this study reports on the acceptability of this approach to providing VCT, but not on its impact on HIV prevention. As such the results do not indicate whether workplace VCT prevents HIV spread as effectively as other ways of delivering VCT. This will require research investigating how HIV incidence among HIV-negative employees and the partners of HIV-positive employees are affected by different VCT strategies.
Please access these Web sites via the online version of this summary at
• United States National Institute of Allergy and Infectious Diseases factsheet on
• United States Department of Health and Human Services information on
• US Centers for Disease Control and Prevention information on
• UNAIDS (Joint United Nations Programme on HIV/AIDS) information on
•
• MedlinePlus encyclopedia entry on
Voluntary counseling and testing for HIV has the potential for high uptake when it is offered on-site at the workplace and linked to basic HIV care.
Rapid scale-up of HIV care programs is ongoing in Africa, driven by ambitious targets set by the World Health Organization in 2003 and accompanied by the simultaneous need to intensify HIV prevention [
Three previous randomised trials have compared uptake under different HIV testing strategies. These have established that rapid HIV testing with same day results reduced non-receipt of results, but had little effect on uptake when the indications for testing were pregnancy and sexually transmitted infections [
Workplace-based initiatives have the potential to expand access to HIV care in Africa at minimal cost to government [
Businesses operating within Harare were identified with the assistance of an HIV prevention project working with businesses (Zimbabwe AIDS Prevention Project), and were eligible if they had (i) 100 to 600 employees, (ii) an occupational or first aid clinic, and (iii) individual-based absenteeism records. Payrolls, used to identify all employees, were re-examined every three months for new employees and loss to employment. All employees expected to remain employed for at least 3 mo were eligible to participate.
Businesses were categorised into high, medium, or low absenteeism strata using 3 mo of summary records. Allocation to the two VCT strategies used stratified randomisation within these three absenteeism strata (computer program written and run by ELC in S TATA 6.0; Stada, College Station, Texas, United States). Sample size was based on the potential impact of the intervention on health outcomes (to be reported separately). Randomisation occurred between enrolment and baseline interviews.
All eligible employees, including new employees during follow-up, were invited for interview when VCT was offered with pre-test counselling, individual risk assessment, and risk reduction plans. Participants at sites randomised to on-site rapid testing then had testing, results, and post-test counselling on the same day. Employees at sites randomised to the off-site strategy were given vouchers for off-site VCT and a 2-wk appointment to discuss results. The off-site VCT providers (New Start) had multiple branches in and around Harare situated at convenient locations (bus terminals and major shopping centres) that offered services after normal working hours and at weekends. After three reminders employees who had taken vouchers but reported not having used them were considered to have taken a voucher but not had VCT. This trial is reported in accordance with CONSORT guidelines (
Counselling sessions were periodically observed by a supervisor who also conducted exit interviews. Debriefing meetings and refresher training were held every 2 wk and 6 mo, respectively.
HIV-positive employees were offered a package of care delivered through their occupational clinic, including post-test counselling, health education, vouchers for HIV testing of partners, and isoniazid preventive therapy and/or cotrimoxazole prophylaxis when indicated (tuberculin skin test positive with no evidence of active tuberculosis [TB] disease, and World Health Organization HIV clinical stages 2 to 4, respectively). The benefits of antiretroviral therapy, which was not part of this intervention, were discussed, and referral was made to local providers who became available during the second year of the study. Study nurses visited each clinic according to a schedule (at least three times a week) to provide ongoing HIV care, and open access to primary health care and the allocated VCT strategy for 2 y, after which service provision was continued by Zimbabwe AIDS Prevention and Support Organization. The start of intervention was staggered over 10 mo across the 22 businesses. Follow-up was for 2 y at each site and was completed for the last businesses in July 2004.
All employees, whether accepting VCT or not, were asked to complete a questionnaire and provide venous or finger-prick blood or oral mucosal transudate for anonymised HIV testing, with written informed consent, at both the start and the finish of the intervention. Results of anonymised HIV tests were not made available to participants or clinic staff.
Anonymised HIV testing used Determine (Abbott, Wiesbaden, Germany) for blood and Vironostika II plus O (bioMerieux, Durham, North Carolina, United States) for oral mucosal transudate. One in ten specimens were retested for quality assurance (Unigold [Trinity Biotech, Dunblane, United Kingdom] for serum specimens, Vironostika II plus O for dried blood spots, and OraQuick [OraSure Technologies, Bethlehem, Pennsylvania, United States] for oral mucosal transudate).
On-site VCT was carried out by trained nurse-counsellors, using parallel Determine and Unigold with either venous or finger-prick blood. A written policy for discordant results and a quality assurance program were in place.
Anonymised HIV specimens were run, stored, and held apart from all personal identifiers other than a laboratory number. These were merged to other data using a linking file and computer program that immediately deleted all personal identifiers to maintain complete confidentiality during analysis.
Written informed consent was obtained from all participants. The study was approved by the ethics committees of the London School of Hygiene and Tropical Medicine and the Medical Research Council of Zimbabwe, Harare.
Comparison of the characteristics of participants used robust standard errors that took clustering at workplace level into account [
Multivariate analysis was used to adjust for the stratified randomisation and other potential confounders, using logistic regression to predict the expected number of VCT users and the ratio of observed and expected numbers of events (standardised incidence ratio) as the outcome measure [
A total of 29 businesses were assessed, of which 26 were eligible. Two withdrew before randomisation, and two were withdrawn between randomisation and intervention (
Baseline Characteristics according to Randomisation Group
Uptake of VCT with on-site rapid testing was significantly and substantially greater than voucher uptake (
Each point represents uptake at one business. The horizontal bars denote the mean site uptake within each category. aRR, risk ratio adjusted for age, sex, marital status, education, household contact with TB patients, self-rated health, and randomisation strata (see
Uptake of Vouchers and Off-Site VCT versus Uptake of On-Site VCT
Previous VCT episodes were reported by 73 (12.5%) of the 586 employees who took vouchers and by 293 (15.0%) of employees accepting VCT at the workplace. A similar percentage of HIV-positive and HIV-negative clients reported previous VCT, suggesting that prior knowledge of HIV infection did not have a major impact on participation under either randomisation arm.
Having accepted vouchers, only 125 employees reported having attended off-site VCT by their third reminder (21.3% of those taking vouchers; mean uptake per site 4.3%). Assuming that late or concealed attendance was negligible, the adjusted risk ratio for accepting on-site VCT compared to attending off-site VCT was 12.5 (95% CI 8.2 to 16.8), as shown in
VCT was available for 2-y at each site, but direct offer was made to each employee only once, unless HIV testing was indicated because of an HIV-related illness. The timing of first uptake among participants who accepted at least one on-site VCT or voucher is shown in
Broken line denotes on-site VCT uptake; solid line denotes off-site voucher uptake.
Individual employees were not limited to a single VCT episode, but could access services repeatedly for the 2-y study period, with the only constraint being a minimum time interval of 3 mo between VCT episodes. As part of post-test counselling, HIV-negative individuals were routinely encouraged to attend for repeat testing at 3 mo to exclude the “window period” of early HIV infection without detectable antibodies. However, apart from 388 participants in a sub-study investigating routine repeat testing at 3 mo [
Multivariate analysis of uptake of on-site VCT showed that the following factors were significantly associated with accepting VCT: age below 25 y (adjusted odds ratio [OR] 1.8; 95% CI 1.3 to 2.4) or 45 y or older (OR 1.7; 95% CI 1.1 to 2.8), being single (OR 1.3; 95% CI 1.1 to 1.5), having had past household exposure to TB (OR 1.2; 95% CI 1.0 to 1.4), having a manual job (OR 1.7; 95% CI 1.3 to 2.1), and poorer self-rated health (OR 1.4 per category below most healthy; 95% CI 1.2 to 1.7) (
Univariate and Multivariate Adjusted OR (95% CI) of Factors Associated with VCT/Voucher Uptake
The results of this study demonstrate the high potential of rapid HIV testing and counselling at the workplace when this is linked to basic HIV care (not including antiretroviral therapy). Uptake of on-site rapid testing was significantly and substantially higher than that achieved through standard-of-care provision of free vouchers for off-site VCT linked to the same HIV care package (mean uptake of VCT by site 51.1% and 4.3%, respectively). The time course of uptake at our study sites (
HIV testing and counselling is the gateway to HIV care, and may also contribute to HIV prevention by reducing high-risk sexual behaviour among individuals who know themselves to be HIV-positive [
Evidence of high readiness to test but limited means and motivation is available from other settings in Africa. Direct offer of HIV testing in a convenient location usually leads to high uptake in both health-care settings [
Limitations of the current study are that the VCT intervention was combined with basic HIV care, so the acceptability of workplace VCT not linked to follow-up care is uncertain. Serious adverse reactions to testing HIV-positive, which we did not observe, could be more problematic when ongoing counselling is not provided. These factors may become less critical as public sector HIV care is scaled up in Africa. Businesses were identified through an organisation providing HIV prevention, and so there may be a selection bias towards those that are unusually receptive to addressing HIV issues. Operational studies of VCT uptake in the wider business community, with and without linked HIV care provision, are needed before our results can be more broadly generalised.
Individual factors associated with accepting VCT and vouchers were younger age, being single, manual work, suboptimal health, HIV status, and previous household contact with TB. The last may indicate greater readiness to test among individuals from HIV-affected households, as TB is strongly HIV-related in Harare [
A study of population-based counselling in Uganda also reported that HIV prevalence in VCT clients was very similar to that of anonymised HIV testing, but with over-representation of individuals with symptomatic HIV disease and under-representation of individuals with asymptomatic HIV infection [
Policies towards the provision of diagnostic HIV testing services in Africa have undergone a major transformation in the last few years, from stressing the potential harm to stressing the need to achieve greater accessibility [
This trial has the registration number ISRCTN44114250 in the International Standard Randomized Controlled Trial Number Register.
Found at:
(50 KB DOC)
(459 KB PDF)
We thank all employees, management, and study staff for their enthusiasm and willingness to contribute.
confidence interval
odds ratio
tuberculosis
voluntary counselling and testing