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Home visits give instant HIV results and data set to guide more than a dozen African countries’ programmes

The population assessments of the epidemic in sub-Sahara yields information of benefit to patients and to each nation’s plan of action.

It’s a pale wintry day in June. Lincoln Ruguwa* (35) shifts in his chair, chuckling uncomfortably.

“Have you used a condom to protect yourself against unsafe sex?” asks the middle-aged woman sitting on the verandah at the back of his house. Ruguwa only met her a few minutes earlier when she came knocking at his door in Kuwadzana, a high density suburb on the southwestern side of Harare, Zimbabwe’s capital.

“My God, what sort of a question is that?” he exclaims, but then relents under her steady gaze. “Not here at home,” he confides. “Stopping to put on a condom is embarrassing and by the time it is on, the passion will be gone.”

Sex is not discussed openly, especially not with strangers. But on this morning, four months ago, Ruguwa found himself not only opening up about his sex life, but undergoing sophisticated tests for HIV and syphilis in his own home. Within minutes he knew the results.

“It is better testing here at home,” he says after the healthcare provider had counselled him. “Nobody asks me what I have gone to do at the clinic.”

Studies could determine future HIV policies in up to 20 countries 
Ruguwa is one of hundreds of thousands of people across Africa who will find out their status in a $125-million project to conduct population-based HIV assessments (Phia) in 15 to 20 countries in sub-Saharan Africa, including Zimbabwe, Malawi, Zambia, Uganda, Tanzania, Swaziland, Lesotho, Namibia and Cameroon.

The household surveys will help provide a snapshot of HIV epidemics and guide HIV programmes in the participating countries over the next decade, according to project updates from the Icap programme at Columbia University in the United States.

Icap, which provides technical support for the campaign, works in partnership with governments. Funding comes mainly from the President’s Emergency Plan for Aids Relief through the United States Centers for Disease Control.

Between 20 000 and 30 000 people in each country will be interviewed, tested and counselled by teams of healthworkers.

The aim of the Phias is not only to estimate the magnitude of epidemics but also to measure access to prevention, care and treatment services in the various countries.

The survey will help to assess the effect HIV programmes have had on the trajectory of epidemics and determine how such information could be used to adjust methods and projects to fight HIV in the coming years, according to an Icap press release.

Early Zimbabwe results could be released this year
The Zimbabwean project, known as Zimphia, and the first of the household surveys in the programme, started in October last year. More than 100 nurses, as well as 15 laboratory scientists and 40 interviewers were given special training. Field teams systematically made their way through the country, moving from province to province. The field workers were armed with tablets containing the questionnaires, picking preselected houses to speak to people.

About 15 000 households have participated and more than 30 000 individuals have been interviewed and tested, says Icap. 

Zimphia measured HIV prevalence in children, as well as what percentage of HIV-infected people on treatment have become resistance to antiretroviral drugs, says Mutsa Mhangara, strategic information co-ordinator in the Aids and TB unit of the ministry of health and childcare. It also assesses what percentage of adults have syphilis.

“We give them prevention information regardless of them being HIV positive or negative,” Mhangara explains.

“We have been able to link clients with other social service providers. When we identify that someone is a survivor of gender-based or sexual violence, we link them to social protection providers.”

Unlike many other population-based surveys that have collected a small amount of blood through a finger prick, the Phia surveys collect two test tubes of blood to perform a number of household- and laboratory-based tests.

If people are HIV-positive, they are referred to their healthcare facility for treatment. The blood is sent to nearby satellite laboratories to retest the field results, using a more specialised test, called a Geenius HIV-1/HIV-2 test, according to Icap.

“We are also [doing] a CD4 count at the household,” Mhangara explains. A CD4 count measures the strength of someone’s immune system.

The “viral load” of HIV-infected people on treatment is also measured. These tests are done at a central laboratory 24 hours after obtaining them. The results are then sent to health facilities where a healthcare provider will explain them to participants. These results also help doctors manage treatment.

The Phia field tests in Zimbabwe have been completed and the data is now being analysed.

A preliminary report for Zimphia is expected before the end of the year.

Data collection has also been completed in Malawi and Zambia, according to Icap’s project update.

In Malawi’s household survey, more than 23 000 people have been tested and counselled, the Icap update states, and in Zambia more 27 000 people have participated in the programme.

Field work in Uganda, Tanzania, Swaziland and Lesotho has either started or is scheduled to start.

According to Herbert Longwe, one of Icap’s regional lab advisers for the Phia project and whom Icap quoted in a recent press release: “It was a challenge” to create effective procedures, but the Phia project “now has a simple, workable quality assurance system in place”.

“This is one of the most exciting things I’ve seen in my career.”

*Not his real name.

Adri Kotze is a senior investigative journalist and Bhekisisa's former Africa editor. Follow her on Twitter @adrikotze.