Optimizing HIV treatment through point-of-care CD4 testing – ACHAP Botswana community-based pilot

Abstract

Background: With 17.6% of the population infected with HIV, Botswana ranks high among the HIV/AIDS burdened countries globally. Tutume district, with a population of 92,124 has a higher HIV prevalence at 20.7% (BAIS, 2008). Despite this, only 54% of the infected actually know their HIV status. The project objective is to increase access to HIV testing and provide point-of-care CD4 testing to minimize delays to ART initiation. Methods: Lay Counsellors were recruited and trained on the use of PIMA CD4 machines. ART-providing clinics were allocated 2 PIMA machines each. Validation of the PIMA CD4 machines against the FACS Calibur CD4 machine, as the instrument of reference, was done. Community entry meetings were held with the community leaders. Community mobilizers were identified for each targeted village and oriented on HIV/AIDS. Door-to-door testing, Community outreaches and Kgotla meetings were conducted. . Workplace-based HIV/CD4 testing in schools and Copper mines was organized. Road shows were organized to attract youths to test. External quality assurance was done quarterly. Data was recorded on HCT registers and Point-of-Care CD4 registers; entered into the CSPro Treatment Optimization database and Bland-Altman graphs generated. Results: Findings showed that 6,274 clients were tested for HIV in 4 months. Of these, 52 % were new testers, with 501 clients testing HIV positive (8%). Of these, 157 (31.3%) were enrolled on ART. Of a total of 2,717 CD4 tests performed, 73.4% were conducted either at home, or at outreach sites. Majority (65%) of new testers were women aged 15- 49 years. Youths preferred to test at night during moonlight testing. There were no statistically significant differences in CD4+ T cell counts obtained using the PIMA instrument and those observed using FACS Calibur. Differences tended to be significant at CD4+ T cell counts greater than 350 cell / �l (-21.2 (95% CI -45.3, +2.9)) whereby PIMA instruments gave slightly lower values. The time from HIV testing to ART-initiation was reduced from 6 to 3 weeks. Conclusions: Provision of point-of-care CD4 testing can drastically reduce time to ART initiation, thereby contributing to reduction in HIV/AIDS morbidity and mortality.