Application of psychosocial models to Home-Based Testing and Counseling (HBTC) for increased uptake and household coverage in a large informal urban settlement in Kenya

Introduction Home Based Testing and Counselling (HBTC) aims at reaching individuals who have low HIV risk perception and experience barriers which prevent them from seeking HIV testing and counseling (HTC) services. Saturating the community with HTC is needed to achieve the ambitious 90-90-90 targets of knowledge of HIV status, ARV treatment and viral suppression. This paper describes the use of health belief model and community participation principles in HBTC to achieve increased household coverage and HTC uptake. Methods This cross sectional survey was done between August 2009 and April 2011 in Kibera slums, Nairobi city. Using three community participation principles; defining and mobilizing the community, involving the community, overcoming barriers and respect to cultural differences and four constructs of the health belief model; risk perception, perceived severity, perceived benefits of changed behavior and perceived barriers; we offered HTC services to the participants. Descriptive statistics were used to describe socio-demographic characteristics, calculate uptake and HIV prevalence. Results There were 72,577 individuals enumerated at the start of the program; 75,141 residents were found during service delivery. Of those, 71,925 (95.7%) consented to participate, out of which 71,720 (99.7%) took the HIV test. First time testers were (39%). The HIV prevalence was higher (6.4%) among repeat testers than first time testers (4.0%) with more women (7.4%) testing positive than men (3.6%) and an overall 5.5% slum prevalence. Conclusion This methodology demonstrates that the use of community participation principles combined with a psychosocial model achieved high HTC uptake, coverage and diagnosed HIV in individuals who believed they are HIV free. This novel approach provides baseline for measuring HTC coverage in a community.


Introduction
HIV testing and counseling (HTC) is the primary entry point to HIV prevention, care and treatment services [1]. Knowing one's HIV status provides those who are negative with the chance to remain HIV-free and those who are HIV positive, critical links to treatment, care, support and prevention interventions to reduce re-infection and transmission of HIV to others. There has been rapid expansion of HIV testing and counseling services in Kenya with changing models of service delivery moving from client initiated counseling and testing at static voluntary counseling and testing (VCT) sites to diagnostic testing and counseling (DTC) which was done at the discretion of the attending clinician for purposes of patient management to provider initiated testing and counseling (PITC) [2] where all clients visiting the health facility are offered services.
When PITC was introduced in Kenya in 2008, the testing coverage was low with only 36% of Kenyans having ever tested for HIV [3].
Although an important approach for increasing coverage, PITC in health facilities reaches only clients who are sick and may miss those who perceive themselves to be HIV negative. Although the testing coverage has improved over the years, [4,5], Kenya has not attained universal access to HIV testing. A major reason that hinders individuals from accessing HIV testing and counseling services in Kenya is low HIV risk perception [3]. Low HTC coverage has been associated with stigma [6,7], lack of transport to testing sites and lack of time for testing and counseling [8,9].
Home based testing and counseling (HBTC) is a community approach which takes HTC services to the individual with the aim of mitigating the challenges and barriers faced by clients. [10,11].
Several studies demonstrated that HBTC was feasible and acceptable to clients from around the African continent and is also a cost effective strategy to increase access [12,13]. A successful HBTC program achieves saturation of the target population with services [14]. Saturation is defined as obtaining at least 80% coverage of the target population [15]. Successful public health programs have embraced community participation and psychosocial models in helping communities change and adopt better strategies in dealing with health challenges [16]. In particular, community participation has been shown to be critical for successful HIV prevention behavior change interventions [17]. HBTC takes services to the individual in their home and community and should embrace the critical elements of successful community participation [16] which include: community entry, community mobilization and involvement, quality service provision and sensitivity and respect to the community's culture. Community entry is the first contact with community leaders and mapping process to promote understanding of community composition and dynamics. Community mobilization helps the community become motivated and involved to participate in identifying and solving their problems through dialogue [16]. This dialogue process promotes understanding of community dynamics for meaningful engagement, provision, uptake of quality service, referral and follow up to ensure linkage of individuals to additional appropriate services [18] including care and treatment for those who are diagnosed with HIV. Understanding of specific cultural influences on social norms and behaviors that foster healthy and safe lifestyles is key to community response in disease prevention for behavior change [19].
Behavior change communication is most successful when based on a social cognitive theory to increase health impact [20]. The Health Belief Model, (HBM), a cognitive psychosocial behavioral model with six constructs was designed to motivate individuals' health seeking behavior [21]. Four constructs are relevant in HIV prevention and include: 1) perceived susceptibility or risk; 2) perceived severity or seriousness or consequences; 3) perceived benefits or advantages if the behavior is changed and 4) lastly perceived barriers or costs of adopting alternative course of action. The degree to which these constructs are operationalized in counselling have the potential of increasing uptake of HTC services and influence behavior change.
The degree to which the community embraces an intervention known as responsiveness; an inclusive approach of inquiry and action to foster effective program, is an important factor in increased utilization of services [22]. HBTC being a community service, its acceptance will be influenced by the community's views of about it and therefore use of sound community participation principles should obtain community saturation. Several studies on HBTC report its feasibility, acceptance and usefulness in identifying individuals who are HIV infected in Kenya [1,23,24] and in other African countries [11-13, 25, 26]. We did not find reports in literature on the aspect of community saturation with HTC services which HBTC should achieve. One of the envisaged benefits of HBTC is to increase access to HTC and achieve full coverage of the target population. This study incorporated the use of community participation principles and health belief model constructs in the HBTC program to increase uptake and achieve saturation with HTC services. This paper describes the processes we employed and outcomes for public health impact to achieve high uptake and persons, low average income (US $ 20/month) and high rates of unemployment among young adults [27]. HIV associated risk behaviors include high alcohol consumption, prostitution and child labour and petty offences with HIV prevalence higher than the national average [24]. The households are tin and mud single rooms, very close to each other and arranged in distinct clusters [27] with each cluster forming a small administrative unit.

Consideration of cultural differences: HTC service providers
were trained on household dynamics and respect for the culture of the clients and how to identify specific risk behaviours. Specific attention was given to dressing and language to gain community acceptance. The language used varied with both age and cultural groups and service providers adapted appropriately. This was specifically important when discussing issues around sexual activities, for example younger participants used the expression of "getting into the box" to mean that one consented to casual sex. HIV prevalence: A total of 3,949 (5.5%) participants tested positive for HIV. There was significantly higher HIV prevalence rates (6.4%) among those ever tested for HIV than those testing for the first time (4.0%) (p < 0.0001). Women were more likely to test positive for HIV (7.4%) than men (3.6%) (Figure 1).

Reasons for HIV testing:
Participants were asked reasons why they accepted or declined testing for HIV. The majority (61.1%) of the participants accepting testing reported they "wanted to know their HIV status and plan for future" followed by "because the service provider had gone to the household and recommended the test (24.6%)". Reasons for not testing were varied including; "already know their status (16.4%), "too old to get HIV" (9.3%) and "too busy" (8.2%) ( Table 2).

The Kenyan National Community Based Testing and Counseling
Services operational manual recommends that a successful HBTC program should achieve population saturation of the targeted geographical area. Saturation in this context is defined as reaching and providing HTC services to at least 80% of the population in the targeted area [14]. The population coverage with HBTC services in the Kibera program surpassed the targeted population at the census by 3.4% as there were an additional 2,564 persons identified during implementation of services. Overall uptake (where uptake is the number of individuals who actually took the HIV test) of testing was at 99.7%. This demonstrates a higher acceptability of HBTC than (previously published reports ranging from 65.9% [29] through to 69% [30,31] and the highest ever reported coverage being 81.7% [24] in a controlled pilot research program in the same area. We provision by the service providers and sensitivity to diverse cultural practices. Culture not only refers to race and/or ethnicity, but also to unique characteristics of a community's population related to factors such as geography, age, gender, language, local history and economics [19] which the program was sensitive to. Our findings and experience with community participation in this program are consistent with earlier reported results in other primary health care programs for disease control where community participation was the central strategy including; control of dengue fever in urban Thailand [34]; schistosomiasis control in Kenya [35]; control of Chagas disease in Brazil [36] and HIV/AIDS control in an African community in Toronto [37]. can be affectively applied in HBTC and may have the potential of increasing demand for and uptake of services. Among the population that consented to testing, 39% tested for the first time demonstrating that there were individuals who experience barriers [25,38] in accessing HTC services on their own. There were more men testing for the first time than females, this confirms that HBTC is an effective strategy in reaching men compared to other approaches [13,25,39].
Although the majority of the individuals had tested for HIV before, the HIV prevalence was significantly higher among those who had ever had an HIV test than those who were testing for the first time.
This finding demonstrates that HBTC is effective in diagnosing HIV among persons who believe they are HIV negative on account of a previous negative test and who would not seek testing again and only benefit when services are taken to them. The finding may suggest that individuals who test HIV negative become complacent and do not take preventive measures against HIV acquisition or alternatively may have tested in the window period. One of the anticipated benefits of HBTC is to reach and test couples and families together to increase behavior change and promote access to care and treatment [40]. Although the finding of this study demonstrates a higher couple testing coverage than other approaches [13] it remains a challenge as only 19.2% coverage was achieved despite the efforts made by service providers to diversify service provision times. Most spouses were reported to be out of their homes during the day seeking jobs in the city. Flexibility is necessary and this program adopted to test partners of those already tested at a later date when they were available and encouraged partner mutual disclosure of HIV status [41]. Service provision challenges were mitigated by having a rigorous support supervision process and adhering to the national quality assurance measures and requirements [42]. A major limitation of this study was that there was no control group and therefore we cannot report cause and effect but limit our report to associations. Even though there was overwhelming support from the community shown by the increased uptake of services, we may not categorically conclude that

Conclusion
HBTC is an effective strategy to reach and test persons with low risk perception who may not access HTC services outside their homes as well as identify substantial number of persons who believe they are HIV free on account of previous negative result and link them early to care and treatment. HIV prevalence was higher among those who had ever tested (6.4%) than those who tested for the first time  Engaging community members in gainful short term hires during the implementation is a motivator for mobilizing the community.

Competing interests
The authors declare no competing interest.

Authors' contributions
Patricia Oluoch conceived, designed and supervised the study,

Acknowledgments
The authors would like to thank CDC-Kenya for the opportunity accorded to work on this program; the staff of KEMRI who worked odd hours to access the participants; the entire Kibera community for their participation and colleagues who gave valuable inputs during the implementation of the program.