Quality of in home rapid HIV testing by community lay counsellors in rural South Africa

Low rates of HIV testing in health facilities suggests that expansion of HIV counselling and testing (HCT) to non-clinical settings is critical to the achievement of national goals for prevention, care and treatment. As such, due consideration must be given to the ability of lay counsellors to perform HCT in community settings.

As part of a community randomized controlled trial, we implemented a home-based HCT intervention. Using the same rapid HIV test kits used by district health facilities, trained lay counsellors conducted door-to-door HIV testing in the Sisonke District of South Africa. To monitor test quality and counsellor skill, additional dry blood spots were sent for laboratory-based ELISA testing. Cross tabulations were done to assess result correspondence. Sensitivity and specificity were also calculated using the laboratory test as the gold standard and 95% confidence intervals were calculated using the Wilson method.

From a total of 3,861 samples, the counselor and lab results matched in all but eleven cases. We found a sensitivity of 98.3% (95% CI: 96.5 - 99.2%) and a specificity of 99.9% (95% CI: 99.7 - 99.9%) for the lay counselor field-based rapid tests. Both measures are high and the lower confidence bound for specificity meets the international standard for assessing HIV rapid tests.

These findings indicate that adequately trained lay counsellors are capable of conducting high quality rapid HIV tests and accurately interpreting the results. This will have important implications for the expansion of HCT services in community-based settings.