A special research report by Diana Inegbenebor of African Health Policy Network, and Celia Fisher, of Leicestershire AIDS Support Services
Leicester City has almost the most diverse population for a city in England, with predictions that there will be no ethnic majority by 2012. There are many different African communities in the city, this increases the challenges for HIV awareness, HIV testing and prevention interventions as there are many different aspects and cultural differences to consider. Leicester City has an above average number of people with diagnosed HIV, with a current prevalence of 3.2 per 1000.
This is the 7th highest rate in England. In this context LASS (Leicestershire AIDS Support Service) launched its Rapid HIV testing service in June 2009, supported by a Clinical Governance Group.
The uptake of testing within the African communities was low during the first year of the Rapid HIV testing service compared to the uptake from other communities in Leicester. The Community tester volunteer project was initiated to empower African communities with knowledge about HIV and the skills to deliver Rapid HIV testing as community volunteers in association with LASS. Groups of people from different African communities have taken the Rapid HIV testing training, with a total of 28 of these community volunteers completing the training to 1st September 2011. The benefit of the community tester approach is that each person trained understands their community and can adapt and tailor an approach as necessary.
This research report is focused on the effects of the LASS Community Rapid Testing training with different African communities in Leicester and the influence of trained community testing volunteers on the uptake of HIV testing. Key objectives are:
- To compare the uptake of POCT HIV testing in the different African communities before and after the LASS community HIV tester project was initiated.
- To determine the cost benefits and savings of using Rapid HIV tests delivered in the communities in non-clinical settings and by non-clinical volunteers.
- To find out the motivation for people volunteering to become testers, keeping in mind the training includes an HIV test for each person.
- To provide recommendations about using and evolving the community tester model in what will become a resource limited environment.
A literature review was undertaken to determine what information is available about Community HIV Testing models. The review summarises evidence sourced 3 from Medline/Pub med, Global Health/Global Health Archive, Cochrane, and Google scholar. Review of material about Rapid HIV Testing reiterates the effectiveness of HIV rapid test kits in early detection of HIV especially for use in the community. There are models of practice for using volunteers in HIV prevention and care work. A study in Zambia looked at the role of community volunteers in voluntary counselling and testing. They concluded that community volunteers, with approved training and on-going supervision can play a major role to provide counselling and testing services of quality. Research into “training to test” shows that volunteer testing programmes have been tried and proved successful in other countries.
Analysis of the uptake of Rapid HIV testing by people from African communities is compared between 2 periods – before and after the community tester project was started. The analysis clearly shows the effectiveness of focused interventions with 100% increase in uptake over similar periods of time. The benefits of focused interventions alongside accessible HIV testing are evident – in particular taking HIV testing out to the community, with significant numbers of people getting tested at these events. The trained community testing volunteers understand the benefits of being tested and have a significant effect on the acceptability of testing in the communities. There are more tests carried out in the office based setting after these interventions, with 3 new diagnoses in one period due to these influences.
The experience with the different communities highlights that it is important for HIV to be openly discussed to enable people to have the confidence to get tested. When communities are openly talking about HIV and the benefits of testing more people will get tested. The community testing volunteer approach gives an ideal opportunity for people to practice sharing strong messages about HIV and HIV testing.
Results from the qualitative research show that people who have been trained to test were generally very satisfied with the knowledge they had accrued from the training course, and were willing to take what they had learned to their communities, to educate and empower others. People are motivated by doing things for their community. In this model the testing is encapsulated in a ‘bigger’ outcome for the individual.
The effect of the community tester model increases the confidence within the community generally as they have access to new skills and knowledge. The majority of people in each African community here in Leicester have direct experience of people living with HIV, whether locally or back home. LASS have anecdotal reports of people using their up to date HIV knowledge globally: being able to provide clarity and facts for a person who knows mainly myths. Others are planning to use these skills when they return to their country – as they can now deliver with confidence.
The community testing model using volunteers is cost effective. Comparison of the cited potential cost savings to those of the Community testing model delivered by LASS, immediately highlight the benefits of using this model:
Potential cost savings for 8 new diagnoses are between £2.24 million and £2.88 million with between £7,840 and £14,000 spent to achieve this delivering 556 tests.
Recommendations from the research are as follows;
- Take the model into different communities and continue to evaluate the benefits.
- Deliver HIV testing in different community settings on a regular basis to increase accessibility and acceptability, in particular using the outreach van.
- Research to consider and evaluate the benefits of community HIV testing volunteer training in local communities and with their global connections.
- Initiate research into how community testing and involvement of people in seeing their blood make the positive result affects acceptance of diagnosis and onward management of HIV. This recommendation is based on observations during the research for already diagnosed HIV positive people.
- Develop the community volunteer tester model to include testing for other health conditions, for example Hepatitis.
The authors would like to acknowledge the involvement of community testing volunteers and all those involved in organising and delivering the interventions.
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