MAJOR ARTICLE

HIV/AIDS

What Is the Impact of Home-Based HIV

Counseling and Testing on the Clinical Status
of Newly Enrolled Adults in a Large HIV Care
Program in Western Kenya?
Juddy Wachira,1,4 Sylvester Kimaiyo,4,5 Samson Ndege,4,6 Joseph Mamlin,2,4,5 and Paula Braitstein,2,3,4,5,7
1School

of Health Physical Education and Recreation and 2School of Medicine, Indiana University, Bloomington, 3Regenstrief Institute, Indianapolis;
(US Agency for International DevelopmentAcademic Model Providing Access to Healthcare) Partnership, 5Moi University School of
Medicine, 6Moi University School of Public Health, Eldoret, Kenya; and 7Dalla Lana School of Public Health, University of Toronto, Canada
4USAID-AMPATH

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(See the Editorial Commentary by Mills and Ford, on pages 2824.)

Background. This article describes the effect point of entry into the human immunodeficiency virus (HIV) care
program had on the clinical status of adults presenting for the first time to USAID-AMPATH (US Agency for
International DevelopmentAcademic Model Providing Access to Healthcare) Partnership clinics for HIV care.
Methods. All patients aged $14 years enrolled between August 2008 and April 2010 were included. Points of
entry to USAID-AMPATH clinics were home-based counseling and testing (HBCT), provider-initiated testing and
counseling (PITC), HIV testing in the tuberculosis clinic, and voluntary counseling and testing (VCT). Tests for
trend were calculated, and multivariable logistic regression was used to compare the effect of HBCT versus other
points of entry on primary outcomes controlling for age and sex.
Results. There were 19 552 eligible individuals. Of these, 946 tested in HBCT, 10 261 in VCT, 8073 in PITC,
and 272 in the tuberculosis clinic. The median (interquartile range) enrollment CD4 cell counts among those who
tested HIV positive was 323 (194491), 217 (87404), 190 (70371), and 136 cells/mm3 (59266) for HBCT, VCT,
PITC, and the tuberculosis clinic, respectively (P , .001). Compared with those patients whose HIV infection was
diagnosed in the tuberculosis clinic, those who tested positive in HBCT were, controlling for age and sex, less likely
to have to have World Health Organization stage III or IV HIV infection at enrollment (adjusted odds ratio [AOR],
0.04; 95% confidence interval [CI], .03.06), less likely to enroll with a CD4 cell count of ,200 cells/mm3 (AOR,
0.20; 95% CI, .14.28), and less likely to enroll into care with a chief complaint (AOR, 0.08; 95% CI, .05.12).
Conclusions. HBCT is effective at getting HIV-infected persons enrolled in HIV care before they become ill.

Human immunodeficiency virus (HIV) infection

continues to spread despite considerable efforts to
prevent new infections and reduce HIV mortality and
morbidity rates [13]. In Kenya, 1.4 million adults
(7.8%) are infected with the virus [1]. Even more
concerning, only 50% of adults are receiving

Received 10 May 2011; accepted 30 August 2011.

Correspondence: Paula Braitstein, PhD, Indiana University School of Medicine,
1001 W 10th St, OPW-M200, Indianapolis, IN 46202 (pbraitstein@yahoo.com).
Clinical Infectious Diseases 2012;54(2):27581
The Author 2011. Published by Oxford University Press on behalf of the Infectious
Diseases Society of America. All rights reserved. For Permissions, please e-mail:
journals.permissions@oup.com.
DOI: 10.1093/cid/cir789

treatment for their HIV infection according to the

2010 World Health Organization (WHO) HIV treatment guidelines [3]. Late presentation of HIV-infected patients to care is an issue of paramount
importance because of its association with lower
treatment response rates, higher mortality rates,
higher treatment costs [4, 5] and possible increased
HIV transmission rates [5, 6]. In sub-Saharan Africa,
including Kenya, high percentages (40%73%) of
patients present for treatment at advanced stages of
disease (WHO stage III/IV [79]). To get persons into
care at earlier stages of their HIV disease, calls have
been made for intensified efforts to promote early diagnosis and treatment of HIV-infected cases [10, 11].
HIV/AIDS

CID 2012:54 (15 January)

275

METHODS
Study Area

AMPATH was initiated in 2001 as a joint partnership between

Moi University School of Medicine (Eldoret, Kenya), the Indiana
University School of Medicine (Indianapolis, Indiana), and the
Moi Teaching and Referral Hospital (Eldoret, Kenya). In 2004,
USAID became a major partner and the USAID-AMPATH
Partnership was inaugurated. Since 2001, the program has
enrolled more than 130 000 HIV-infected adults and children
in 25 Ministry of Health facilities and numerous satellite clinics
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CID 2012:54 (15 January)

HIV/AIDS

in western Kenya. All HIV- and tuberculosis-related care and

treatment are provided free at the point of care for patients
through AMPATH and the Kenyan National Leprosy, Tuberculosis and Lung Disease Program. A more detailed description
of the program can be found elsewhere [19, 20].
AMPATH provides comprehensive HIV care services including HIV counseling and testing services through VCT, PITC
(inpatient and outpatient clinical departments, antenatal clinics,
and tuberculosis clinics) and HBCT strategies. Currently, HBCT
services are being rolled out in western Kenya through this
partnership. HBCT targets residents/household members who
are $13 years old; a more detailed description of the ongoing
HBCT program is available elsewhere [16]. At the time of the
study, HBCT had been implemented in 3 catchment areasnamely, Kosirai Division and Turbo Division in Rift Valley
Province and Bungoma East District in Western Province.
Study Design

This was a retrospective observational study based on routine

clinical data obtained between August 2008 and April 2010.
Ethical approval was obtained from the Institutional Research
and Ethics Committee at Moi University School of Medicine,
Eldoret, Kenya, and Indiana Universitys Institutional Review
Board in Indianapolis, Indiana.
Study Population

Eligible for inclusion in the analysis were adults aged $14 years
who enrolled in HIV care in any of the AMPATH clinics from
August 2008 to April 2010 and who had their point of entry
documented on their initial clinical encounter form.
Data Collection

Clinicians complete standardized forms capturing demographic,

clinical, and pharmacologic information at each patient visit.
These data are then entered by trained data clerks into the
AMPATH Medical Record System, a secure, computerized database designed for clinical management, with data entry validated by random review of 5% of the forms entered. At the time
of registration, patients are provided with a unique identifying
number. For this study, all data were stripped of identifying
information prior to analysis. The point of entry into care is
captured on an initial encounter form. The HBCT program has
been described in detail elsewhere [21]. In brief, after extensive
community consultations and mobilizations, HIV counselors
work in teams going door-to-door, village by village, offering
HIV counseling and testing to all individuals aged $13 years, as
well as children aged ,13 years if their mother is HIV positive or
has an unknown HIV status or if the mother has died or her vital
status is unknown.
The points of entry considered were HBCT, PITC, tuberculosis
clinic, and VCT. PITC includes individuals tested in the antenatal
clinic, inpatient wards, labor and delivery, and some outpatient

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In spite of the widespread availability of counseling and

testing services, including targeted mobile campaigns and facility-based services, HIV testing uptake in Kenya, as elsewhere
in sub-Saharan Africa, remains low, and only a fraction of those
living with the virus are aware of their status [1]. These forms of
HIV testing services utilize different approaches with regard to
who receives HIV testing at what point. Voluntary counseling
and testing (VCT) services are usually patient initiated and are
offered at either stand-alone testing centers in a clinical facility
or during targeted HIV campaigns as mobile VCT services [12].
Provider-initiated testing and counseling (PITC) is sometimes
called diagnostic testing and counseling. It is offered through
clinical settings (hospitals) and typically uses the opt-out approach, testing any patient seeking treatment or care in a hospital in a high HIV-burden area for HIV as part of routine care.
It forms an important part of the diagnostic process especially
for patients with tuberculosis because of the strong interactions
between HIV and tuberculosis [13]. Testing in antenatal clinics
and in labor and delivery wards is also part of provider-initiated
services, as pregnant mothers seeking antenatal care are routinely
tested for HIV, with those found positive enrolled into prevention of mother-to-child transmission (PMTCT) services [14].
Recently, home-based counseling and testing (HBCT) for HIV
infection has been advocated to promote early diagnosis of HIV
[15, 16]. Unlike other counseling and testing services, HBCT is
provided at home by specially trained HIV counselors, potentially overcoming some of the challenges inherent in voluntary or institutional testing sites. As countries in Africa
embrace universal testing through HBCT [15, 16], the benefits
can be experienced only if they are coupled with access to timely
treatment of HIV infection. Although limited studies have
documented the efficacy of HBCT in increasing HIV testing
uptake [17, 18], no studies, to our knowledge, have assessed its
impact in promoting timely access to care in comparison to the
other testing points. The primary objective of this study was to
describe the clinical status of HIV-infected adults presenting for
the first time to USAID-AMPATH (US Agency for International
Development Academic Model Providing Access to Healthcare)
Partnership clinics for HIV care from the different testing points.

Table 1. Sociodemographic Characteristics of Patients Aged 14 Years Enrolling in US Agency for International Development Academic
Model Providing Access to Healthcare Clinics, Stratified by Point of Entry (N 5 19 552)
Variable

HBCT (n 5 946)

Age median (IQR), years

37 (3046)

VCT (n 5 10 261)
36 (2944)

PITC (n 5 8073)

Tuberculosis Clinic (n 5 272)

P Value

36 (3044)

,.022

36 (2944)

Sex, No. (%)

,.001

Male

268 (28)

3537 (35)

3050 (38)

136 (50)

Female

678 (72)

6724 (66)

5023 (62)

136 (50)

75 (11)

360 (5)

321 (6)

7 (5)

,.001b

214 (24)

649 (7)

466 (6)

13 (5)

.045b

63 (7)

619 (6)

659 (8)

17 (6)

Pregnant, No. (%)a

HIV discordance, No. (%)
Member of discordant couple
Missing data

No data were missing for age, sex, and pregnancy status.

Abbreviations: HBCT, home-based counseling and testing; HIV, human immunodeficiency virus; IQR, interquartile range; PITC, provider-initiated testing and
counseling; VCT, voluntary counseling and testing.
a

Restricted to women.

P value for trend across points of entry.

variables and the KruskalWallis test for continuous variables.

Medians and interquartile ranges were also calculated for continuous variables (ie, age and CD4 cell count). For ordered
(categorical) variables, we used tests for trends to obtain P values.
With controlling for age and sex, logistic regression was conducted to assess the impact of the point of entry into care on
primary and secondary outcomes. We conducted a subanalysis
comparing those entering from HBCT with those entering from
VCT, hypothesizing that these 2 testing points are the most
similar (because they are not dependent on the individual
seeking healthcare), and we asked whether patients entering from
HBCT had better clinical status at enrollment compared with
those entering from VCT.

Data Analysis

RESULTS

The primary dependent variable was the patients CD4 cell count
and WHO clinical stage at enrollment, and the secondary dependent variables were having been hospitalized in the past year,
having a chief complaint (a symptom the patient self-reports at
the clinical encounter as being the main reason for coming to the
clinic) at enrollment, being in a discordant relationship, and
being pregnant (for women only). Other variables considered for
their potential explanatory or confounding relationship to the
primary dependent variable included age and sex. We identified
the point of entry to USAID-AMPATH clinics and compared age,
sex, pregnancy in women, discordant couples, the WHO clinical
stage at enrollment, CD4 cell count at enrollment, hospitalization
in the past year, and having a chief complaint at enrollment
between these points of entries and testing points. Patients whose
point of entry was documented as other were excluded from
the analysis. Proportions of missing data were calculated for each
variable and compared for different points of entry.
The data were analyzed using Stata/SE software (version 10).
Comparisons were done using Pearsons v2 test for categorical

There were 28 556 adults enrolled between August 2008 and

April 2010. Of these, 22 974 (80%) had point of entry indicated
on their initial encounter form and were eligible for analysis. We
excluded 3422 adults who had points of entry that were documented as other. Thus there were 19 552 adults included in the
analysis, including 946 from HBCT, 8073 from PITC, 272 from
tuberculosis, and 10 261 from VCT.
As shown in Table 1, there were no major differences in the
median age between the groups. From all the testing points
except the tuberculosis clinic, there was a higher proportion of
women enrolled in care than men (P 5 .001). The highest
proportion (11%) of HIV-positive pregnant women enrolled
had been tested in HBCT and the lowest in VCT and the
tuberculosis clinic. The highest percentage (24%) of individuals
in discordant couples was identified among persons entering via
HBCT, compared with the other points of entry.
As summarized in Table 2, the median (interquartile range)
CD4 cell count at enrollment was the highest for patients who
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clinics, such as the tuberculosis clinic. We hypothesized that the

patients from the tuberculosis clinic would be more likely to have
advanced HIV disease than others tested through PITC, and we
thus examined patients from the tuberculosis clinic separately
from PITC.
As per Kenya Ministry of Health guidelines, tested clients are
typically issued with a card indicating their HIV status. Patients
are requested to present this card during enrollment to care as
evidence of their HIV status. In the event that patients were
tested at multiple testing points, the last point of testing is indicated in their initial medical encounter form. Clinicians are
allowed to choose only one of the point-of-testing options on the
clinical encounter forms.

Table 2. Clinical Characteristics of Patients Aged 14 Years Enrolling in US Agency for International Development Academic Model
Providing Access to Healthcare Clinics Stratified by Point of Entry (N 5 19 552)
HBCT
(n 5 946)

Variable

VCT
(n 5 10 261)

PITC
(n 5 8073)

Tuberculosis Clinic
(n 5 272)

P Value

136 (59266)

,.001

CD4 cell count

Median (IQR), cells/mm3

323 (194491)

Missing data, No. (%)

221 (23)

4697 (45)

4209 (52)

103 (38)

Stage I/II

612 (86)

5271 (62)

3357 (54)

47 (21)

.002a

Stage III/IV
Missing data

97 (14)
237 (25)

3165 (38)
1825 (18)

2843 (46)
1873 (23)

172 (79)
53 (19)

.002a

Yes

18 (2)

843 (8)

1076 (14)

33 (13)

,.001a

Missing data

16 (2)

208 (2)

241 (3)

8 (3)

Yes

264 (35)

6008 (67)

5044 (72)

205 (87)

Missing data

196 (21)

1324 (13)

1051 (13)

36 (13)

217 (87404)

190 (70371)

WHO stage for HIV disease, No. (%)

Hospitalized in past year, No. (%)

Had chief complaint at enrollment, No. (%)

.017a

P value for trend across points of entry.

tested HIV positive in HBCT (median 323 cells/mm3), followed

by VCT and then PITC. Patients coming from the tuberculosis
clinic had the lowest median CD4 cell count (136 cells/mm3)
(P 5 .001). This trend was similar for patients with WHO stage
I/II disease: 86% of patients who had their HIV status identified
in HBCT had WHO stage I/II disease, compared with 62% in
VCT, 54% in PITC, and 21% in the tuberculosis clinic
(P 5 .002). The trend was reversed for patients with WHO stage
III/IV disease. Patients who were tested in the tuberculosis clinic
had the highest likelihood of having WHO stage III/IV disease at
enrollment (79%), compared with PITC (46%), VCT (38%) and
HBCT (14%), (P 5 .002).
As expected, a higher proportion of patients testing HIV
positive in PITC (14%) and the tuberculosis clinic (13%) had
been hospitalized in the past year, compared with patients in
HBCT (2%) (P 5 .001). Patients coming from either the tuberculosis clinic (87%) or PITC were also much more likely to
present with a chief complaint at enrollment, compared with
those coming from VCT or HBCT (P 5 .017) (Table 2).
In logistic regression, adjusting for the potential confounding
effects of age and sex, individuals who tested HIV positive in
HBCT were less likely to be enrolled into care with a CD4 cell
count ,200 cells/mm3 than were those who tested positive in
the tuberculosis clinic (adjusted odds ratio [AOR], 0.20; 95%
confidence interval [CI], .14.28). They were also less likely
to have WHO stage III/IV disease at enrollment (AOR, 0.04;
95% CI, .03.06), less likely to have been hospitalized in the past
year (AOR, 0.14 95%; 95% CI, .07.25), and less likely to
have a chief complaint (AOR, 0.08; 95% CI, .05.12) (Table 3).
In a subanalysis comparing HBCT with VCT, HBCT was
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consistently independently associated with improved clinical

status at enrollment into HIV care (Table 4).
DISCUSSION
Early diagnosis of HIV infection is critical to providing infected
individuals with antiretroviral therapy and effective prevention
and care services [7, 22, 23]. Late presentation to care as evidenced by advanced clinical HIV disease results in poorer clinical
outcomes [4, 5, 8]. This study suggests that population-based,
HBCT can be an effective strategy for engaging HIV-infected
persons into care earlier in the course of their HIV disease
compared with other testing strategies. HBCT was also effective
at identifying pregnant women in the community and linking
them to care. Although more research is needed, including costeffectiveness analyses, these data call for broad and rapid expansion of HBCT throughout countries with high HIV burdens
as a means of facilitating access to HIV care for HIV-infected
persons with all the resultant downstream positive effects (including improved treatment outcomes and primary prevention
through viral load reduction).
Women represented a greater proportion of patients accessing HIV care from all testing points except the tuberculosis
clinic, where they were equally represented. These data support
findings by our group and others that men are more challenged
than women in accessing HIV care compared with women, even
after adjustment for HIV prevalence among men and women in
individual countries [21, 24]. Our data indicate that as the nature of the access becomes more voluntary (ie, with testing in
HBCT or VCT rather than, for example, the tuberculosis clinic),

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Abbreviations: HBCT, home-based counseling and testing; HIV, human immunodeficiency virus; IQR, interquartile range; PITC, provider-initiated testing and
counseling; VCT, voluntary counseling and testing; WHO, World Health Organization.

Table 3. Logistic Regression Analysis of Impact of Point of Entry

Into HIV Care on Key Markers of Clinical Status at Enrollment,
Adjusted for Age and Sex
Marker at
Enrollment and
Point of Entry Into HIV Care

AOR

95% CI

P Value

WHO clinical stage III/IV disease

Tuberculosis clinic

Reference

PITC

0.24

.17.33

,.001

VCT

0.17

.12.23

,.001

0.04

.03.06

,.001

Reference

PITC

0.62

.45.86

.004

VCT

0.52

.38.72

,.001

HBCT

0.20

.14.28

,.001

HBCT

Table 4. Logistic Regression Subanalysis of Impact of HomeBased Counseling and Testing Versus Voluntary Counseling and
Testing on Key Markers of Clinical Status at Enrollment, Adjusted
for Age and Sex
Marker at
Enrollment and
Point of Entry Into HIV Care
WHO III/IV clinical stage disease
VCT
HBCT
VCT

Having a chief complainta

Tuberculosis clinic

0.39

.27.57

,.001

VCT
HBCT

0.31
0.08

.21.46
.05.12

,.001
,.001

Reference

PITC

1.11

.771.61

.567

VCT

0.64

.44.93

.018

HBCT

0.14

.07.25

,.001

Hospitalized in past year

Tuberculosis clinic

P Value

Reference

0.26

.21.32

,.001

HBCT

Reference

0.38

.32.45

,.001

Having a chief complainta

VCT
HBCT
Hospitalized in past year
VCT
HBCT

Reference

0.25

.21.29

,.001

Reference

0.21

.13.34

,.001

Abbreviations: AOR, adjusted odds ratio; CI, confidence interval; HBCT,

home-based counseling and testing; HIV, human immunodeficiency virus;
VCT, voluntary counseling and testing; WHO, World Health Organization.
a

Abbreviations: AOR, adjusted odds ratio; CI, confidence interval; HBCT, homebased counseling and testing; HIV, human immunodeficiency virus; PITC,
provider-initiated testing and counseling; VCT, voluntary counseling and
testing; WHO, World Health Organization.
a

A symptom the patient self-reports at the clinical encounter as being the

main reason for coming to the clinic.

men are proportionately less well represented. Much more attention needs to be focused on helping HIV-infected men access
care in a timely manner, and more research is needed to understand the issues facing HIV-infected men in sub-Saharan
Africa that prevent them from accessing care.
With improved access to antiretroviral therapy in sub-Saharan
Africa [3, 25], rates of mother-to-child transmission of HIV have
been greatly reduced [3]. Even so, the coverage of PMTCT services
is not optimal, with most countries having not yet reached all
pregnant women with these services [3, 25]. Our findings revealed
that HBCT was able to enroll twice the proportion of HIV-infected
pregnant women compared with VCT, PITC or tuberculosis entry
points. The implication is that HBCT could complement PMTCT
by identifying and referring pregnant women who are not otherwise accessing antenatal or PMTCT services.
Differences in clinical status among persons who tested positive in PITC versus in VCT were rather attenuated, even compared with the differences between VCT and HBCT. This suggests
that persons who test positive in VCT are more likely to come for
care only once their health begins to deteriorate, reducing the

A symptom the patient self-reports at the clinical encounter as being the

main reason for coming to the clinic.

effectiveness of VCT as a testing strategy in high-burden areas. It

may also be that individuals seek out VCT services if they suspect
they are infected, either because of the presence of symptoms or
for other reasons. The clinical characteristics of patients tested at
the tuberculosis clinic support the strong association between
HIV and tuberculosis and the efforts so far made to integrate
tuberculosis and HIV services in the region [26].
The benefits of couple counseling and testing, and most recently the use of combination antiretroviral therapy, have been
widely documented in reducing HIV transmission rates among
discordant couples as well as reducing mother-to-child transmission of HIV [2729]. HBCT identified the highest proportions of discordant couples, with the rest of the testing points
identifying almost identically low percentages. This could be
associated with the fact that HBCT services are offered at home,
presenting a better opportunity to capture couples together
for testing. With reports of low disclosure rates and the
challenges it presents [30, 31], VCT, PITC, and tuberculosis
testing sites might not be effective in promoting couple counseling and testing if this concept is not incorporated within these
strategies.
This study has several strengths. The USAID-AMPATH Partnership provides a unique setting where a variety of counseling
and testing strategies are employed, including HBCT. Moreover,
HIV care and treatment services are provided at no cost to patients. Together these factors enabled a robust analysis without
bias related to whether or not patients could pay for care and
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Reference

PITC

95% CI

CD4 cell count ,200 cells/mm3

CD4 cell count ,200 cells/mm

Tuberculosis clinic

AOR

Notes
Acknowledgments. The authors would like to thank all the clinicians
in all the AMPATH clinics, especially the clinical officers, medical officers,
pediatricians, nutritionists, outreach workers, and social workers, for their
dedication in caring for patients and their attentiveness in accurately recording their patients data. We would also like to thank all the data entry
technicians, data managers, and administrative and clerical staff for enabling the collection, management, interpretation, and publication of these
data. We appreciate Dr Jane Carter and Dr Harsha Triamurthy, who both
made important contributions to earlier versions of the manuscript.

280

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J. W. wrote the first draft of the manuscript and was primarily responsible for incorporating authors comments into subsequent drafts.
S. K., S. N., and J. M. are the principal investigators of the AMPATH HBCT
Program and contributed to the manuscript by revising drafts and assisting
in the interpretation of the findings. P. B. conceived the idea for the
analysis, conducted all statistical analysis, and took primary responsibility
for supervising and mentoring J. W. in developing the paper and making
the final decision about its submission.
Both the Indiana University Institutional Review Board and the Moi
University Institutional Research Ethics Committee provided approval for
retrospective analysis of routinely collected clinical data in AMPATH.
Financial support. The HBCT program was supported by grants from
Abbott Laboratories, the Purpleville Foundation, and the Global Business
Coalition. The United States Agency for International Development as part
of the Presidents Emergency Plan for AIDS Relief (USAID-PEPFAR)
supported care for those found to be HIV positive, and the Abbott Fund
provided test kits and logistical support. AMPATH and the authors are
particularly grateful to the Rockefeller Foundation for funding the development of the AMPATH Medical Records System, and the Kenyan
Division of Leprosy, TB and Lung Disease, formerly the Kenyan National
Leprosy and Tuberculosis Program, for its support.
Potential conflicts of interest. All authors: No reported conflicts.
All authors have submitted the ICMJE Form for Disclosure of Potential
Conflicts of Interest. Conflicts that the editors consider relevant to the
content of the manuscript have been disclosed.

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treatment. We chose to include patients enrolling at all AMPATH

clinics in this analysis, because many patients may test positive in
one place but may choose to attend a clinic in another catchment
because of stigma or other issues. This approach to the analysis
strengthens our findings, because the effect estimates of point of
entry are averaged across all clinics and can thus be considered an
analysis of effectiveness (ie, under routine circumstances), rather
than efficacy (ie, under ideal circumstances), of HBCT.
The study also presented some limitations. There is a potential for some selection bias due to missing entry points and those
classified as other points of entry, both of which were excluded from the analysis. However, we know of no systematic
reason why clinicians would fail to document the point of entry,
thus reducing the potential impact of any selection bias that may
have occurred. There was also the potential for random misclassification bias if clinicians incorrectly documented point of
entry or the patient lied for whatever reason (unlikely but difficult to substantiate). Finally, there was a significant amount of
missing data on enrollment CD4 cell count. We postulate that
this was particularly so among patients who had tested positive
in PITC because, given that they were coming from PITC, they
were probably quite ill at enrollment. It is likely that clinicians
attempt to address the urgent clinical issues before obtaining
a baseline CD4 cell count. Thus, our findings would likely be
even stronger if the CD4 cell count data were complete. These
data should be interpreted with some caution.
In conclusion, our findings provide strong evidence that
HBCT can result in earlier diagnosis of HIV infection with
consequent earlier access to care. Our data demonstrate that
HBCT is effective at getting HIV-infected persons to enroll in
HIV care at much earlier stages of HIV disease and while their
immune systems are still relatively intact. If the treatment as
prevention paradigm is to be successfully rolled out in subSaharan Africa, HBCT and other community support programs
could play an instrumental role in identifying HIV-infected
persons in the community, linking them with care, and helping
to retain them care. These data suggest that efforts to roll out
HBCT in Kenya and elsewhere should be intensified even as other
testing points continue to provide services. Cost-effectiveness
studies are desperately needed to determine the most costeffective testing strategy, taking into account the downstream
consequences of late presentation for HIV care.

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