1. No conflicts of interest to declare.
Feasibility and Acceptability of Home-based HIV Testing Among Refugees: A Pilot Study in Nakivale Refugee Settlement in SW Uganda O’Laughlin KN, He W, Greenwald KE, Kasozi J, Chang Y, Mulogo E, Faustin ZM, Njogu P, Walensky RP, Bassett IV
Kelli O’Laughlin, MD, MPH
Massachusetts General Hospital
Brigham and Women’s Hospital
Harvard Medical School
26 July 2017
Thank you. We have no conflicts of interest.
Supported by the Brigham and Women’s Department of Emergency Medicine, Harvard University Center for AIDS Research (NIH/NIAID 5P30AI060354), the Harvard Global Health Institute, the National Institute of Allergies and Infectious Diseases (R37 AI093269), and the National Institute of Mental Health (K23 MH and R01MH108427)
No conflicts of interest to declare.

2. Background
Refugees in Uganda risk exposure to HIV and many struggle to access HIV testing
Nakivale Refugee Settlement in SW Uganda, est. 1960, 68,000 refugees
Refugees are housed in zones by country of origin
4 health clinics in Nakivale serve refugees and nationals and provide free HIV testing and free ART
In 2013, our routine clinic-based HIV testing study in Nakivale increased the mean HIV-positive clients identified per week from 0.9 to 5.6 (O’Laughlin et al, JAIDS 2014)
Refugees in Uganda risk exposure to HIV and many struggle to access HIV testing
Nakivale Refugee Settlement in SW Uganda, est. 1960, 68,000 refugees: 52% Democratic Republic of the Congo, 16% Somalia, 15% Burundi, 15% Rwanda, 2% Other; refugees are housed in zones by country of origin
Four health clinics in Nakivale serve refugees and nationals and provide free HIV testing and free antiretroviral therapy
In 2013, a routine clinic-based HIV testing intervention study our team conducted in Nakivale increased the mean HIV-positive clients identified/week from 0.9 to 5.6

3. Objectives
Assess feasibility and acceptability of home-based testing
Compare home and clinic-based HIV testing participants
Methods
Home-based HIV testing in Nakivale visiting homes up to 3 times (different days and times of day) in 3 distinct zones
Feasibility: proportion of eligible participants at home
Acceptability: proportion of those at home that tested
Assessed effect of number of individuals at home and sex on willingness to test
Compared age, gender, refugee status, distance to clinic, and HIV testing history of home and clinic-based testing participants
Our first objective was to: “Assess the feasibility and acceptability of home-based HIV testing” in Nakivale
Our second objective, was to compare characteristics of home-based and clinic-based testers
To do this,
We conducted home-based testing in Nakivale; visiting homes up to 3 times (different days/times) in 3 distinct geographic zones
To evaluate feasibility, we assessed the proportion of eligible participants encountered at home
To evaluate acceptability, we assessed the proportion of those at home that participated in HIV testing
We also assessed the effect of the number of individuals at home as well as sex on willingness to test
We compared age, gender, refugee status, distance to clinic, HIV testing history of home and clinic-based HIV testing participants
[Note: gender and number of individuals at home and willingness to test--- evaluated with logistic regression models with general estimating equations (GEE) approach to account for clustering.]
[Note 2: home-based and clinic-based testers compared using Wilxocon rank sum tests and Pearson’s chi-square tests]

4. Table 1. Feasibility and acceptability of home-based HIV testing,
of 319 households with 566 eligible individuals
Variable
At home, N (%)
HIV tested, N (%)
HIV +, N (%)
Visit 1
353 (62%)
272 (77%)
6 (2.2%)
Visit 2
127 (22%)
93 (72%)
1 (1.1%)
Visit 3
27 (5%)
13 (44%)
0 (0%)
Total
507 (90%)
378 (75%)
7 (1.9%)
Table 2. Predictors of willingness to test
Variable
At home, N
HIV tested, N (%)
1 person 99
73 (74%)
2 people
318
238 (75%)
3-5 people 77
67 (87%)
Female
277
212 (77%)
Male
217
166 (77%)
For each additional person present, testing increased
(OR 1.52, p=0.007)
No difference in willingness to test by sex (p=0.66)
Table 1- Demonstrates the Feasibility and acceptability of home-based HIV testing- of 319 households visited with 566 eligible individuals living in these households
The column titled “At home” shows the number of eligible individuals encountered at home during visits 1-3 and in total.
The next column titled “HIV tested” shows the number tested for HIV by visit, and the % tested of those at home during that visit.
The final column shows the number found to be HIV+ in each visit.
We found home-based testing to be FEASIBLE with 90% of eligible individuals encountered at home after 3 visits, and ACCEPTABLE with 75% of those at home willing to test for HIV. As noted in column 4, 7 participants were diagnosed as HIV+, and these were all found in the first 2 visits.
Table 2. Titled “Predictors of willingness to test”
The first column shows the variables 1 person, 2 people, 3-5 people present at time of the home visit; and then female and male.
The second column shows the number present.
The final column shows the number and % tested of those present.
We found that for each additional person present, the odds of testing increased by 1.52 (OR 1.52, p=0.007).
We found there was no difference in willingness to test by gender. (p=0.66)

5. Clinic-Based Testers*
Table 3. Characteristics of home-based and clinic-based HIV
testing participants
Variable*
Home-Based Testers
N=378
Clinic-Based Testers*
N=6443
P-value
Age, median (IQR)
30 (24-40)
28 (22-37)
<0.001
Refugee
93%
79%
≥ 1 hour to clinic
74%
52%
HIV-positive
1.9%
3.4%
0.27
Table 3. Titled “Characteristics of home-based and clinic-based HIV testing participants” demonstrates differences among home-based testers in column two and clinic-based testers in column three, using data gathered during our routine clinic-based HIV testing intervention study at Nakivale Health Center.
Looking at Row 1, median age, home-based testers were older than clinic-based testers with a median age of 30 compared to 28.
Row 2 shows Home-based testers were more often refugees, with the proportion refugees 93% compared to 79%.
Row 3 demonstrates home-based testers were more likely to live greater than or equal to 1 hour from clinic, 74% home-based testers reported this compared to 52% clinic-based testers.
The final row shows the HIV prevalence among those tested which was 1.9% for home-based testers and 3.4% for clinic-based testers, HIV prevalence was NOT statistically different between the two groups.
Additional covariates assessed but found to not have statistically significant differences were gender and previous HIV test.
*Sex and previous HIV test were assessed but were not statistically significant
* O’Laughlin et al, JAIDS 2014

6. Conclusions: Home-based HIV testing in Nakivale
Feasible with 90% eligible encountered in 3 visits
Acceptable with 75% of those at home tested for HIV
Individuals were more willing to test with others home
Reached a larger proportion of refugees and those living further from clinic compared to clinic-based testing
Implications
Home-based testing visits in refugee settlements should occur during times when multiple people will be home
Given limited resources 2 home visits may be sufficient
Will need to assess linkage to care for home-based testers as distance to clinic in this setting may impact linkage
To conclude, our home-based HIV testing study in Nakivale
Conclusions
Home-based HIV testing in Nakivale Refugee Settlement was feasible with 90% eligible encountered in 3 visits
Home-based HIV testing in Nakivale was acceptable with 75% of those home participating in testing
Individuals were more willing to test with others home
Home-based testing reached a larger proportion of refugees and those living further from clinic
Implications
Home-based testing visits in refugee settlements should occur during times when multiple people will be home
Will need to assess linkage to care for home-based testers as distance to clinic in this setting may impact linkage