Background

HIV counselling and testing are essential to control the HIV epidemic. However, HIV testing uptake is low in sub-Saharan Africa, where many people use informal health-care resources such as traditional healers. We hypothesised that uptake of HIV tests would increase if provided by traditional healers. We aimed to determine the effectiveness of traditional healers delivering HIV testing at point of care compared with referral to local clinics for HIV testing in rural southwestern Uganda.

Methods

We did a mixed-methods study that included a cluster-randomised trial followed by individual qualitative interviews among a sample of participants in Mbarara, Uganda. Traditional healers aged 18 years or older who were located within 8 km of the Mbarara District HIV clinic, were identified in the 2018 population-level census of traditional healers in Mbarara District, and delivered care to at least seven clients per week were randomly assigned (1:1) as clusters to an intervention or a control group. Healers screened their clients for eligibility, and research assistants confirmed eligibility and enrolled clients who were aged 18 years or older, were receiving care from a participating healer, were sexually active (ever had intercourse), self-reported not having received an HIV test in the previous 12 months (and therefore considered to be of unknown serostatus), and had not previously been diagnosed with HIV infection. Intervention group healers provided counselling and offered point-of-care HIV tests to adult clients. Control group healers provided referral for HIV testing at nearby clinics. The primary outcome was the individual receipt of an HIV test within 90 days of study enrolment. Safety and adverse events were recorded and defined on the basis of prespecified criteria. This study is registered with ClinicalTrials.gov, NCT03718871.

Findings

Between Aug 2, 2019, and Feb 7, 2020, 17 traditional healers were randomly assigned as clusters (nine to intervention and eight to control), with 500 clients of unknown HIV serostatus enrolled (250 per group). In the intervention group, 250 clients (100%) received an HIV test compared with 57 (23%) in the control group, a 77% (95% CI 73–82) increase in testing uptake, after adjusting for the effect of clustering (p<0·0001). Ten (4%) of 250 clients in the intervention group tested HIV positive, seven of whom self-reported linkage to HIV care. No new HIV cases were identified in the control group. Qualitative interviews revealed that HIV testing delivered by traditional healers was highly acceptable among both providers and clients. No safety or adverse events were reported.

Interpretation

Delivery of point-of-care HIV tests by traditional healers to adults of unknown serostatus significantly increased rates of HIV testing in rural Uganda. Given the ubiquity of healers in Africa, this approach holds promise as a new pathway to provide community-based HIV testing, and could have a dramatic effect on uptake of HIV testing in sub-Saharan Africa.

Funding

US National Institute of Mental Health, National Institutes of Health.

中文翻译：

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乌干达农村地区对血清状态未知的成年人进行传统治疗师提供的护理点艾滋病毒检测与转诊至临床机构的比较：一项混合方法、整群随机试验

 背景

艾滋病毒咨询和检测对于控制艾滋病毒流行至关重要。然而，撒哈拉以南非洲地区的艾滋病毒检测率较低，那里许多人使用传统治疗师等非正式医疗资源。我们假设，如果由传统治疗师提供艾滋病毒检测，那么接受艾滋病毒检测的人数将会增加。我们的目的是确定传统治疗师在护理点提供艾滋病毒检测与转诊至乌干达西南部农村地区当地诊所进行艾滋病毒检测的有效性。

 方法

我们进行了一项混合方法研究，其中包括一项整群随机试验，然后对乌干达姆巴拉拉的参与者样本进行个人定性访谈。位于姆巴拉拉区艾滋病毒诊所 8 公里范围内、在 2018 年姆巴拉拉区传统治疗师人口普查中确定、每周至少为 7 名客户提供护理的 18 岁或以上的传统治疗师被随机分配（ 1:1）作为干预组或对照组的聚类。治疗师筛选其客户的资格，研究助理确认资格，并登记年龄在 18 岁或以上、正在接受参与治疗师的护理、性活跃（曾经有过性交）、自我报告未在之前 12 个月内（​​因此被认为血清状态未知），并且之前未诊断出感染 HIV。干预小组治疗师为成年客户提供咨询和艾滋病毒即时检测。对照组治疗师转介到附近诊所进行艾滋病毒检测。主要结果是个人在研究注册后 90 天内接受 HIV 检测。根据预先指定的标准记录和定义安全性和不良事件。本研究已在 ClinicalTrials.gov 注册，NCT03718871。

 发现

2019年8月2日至2020年2月7日期间，17名传统治疗师被随机分配为一组（9名干预组，8名对照组），并登记了500名HIV血清状态未知的客户（每组250名）。在干预组中，250 名客户 (100%) 接受了 HIV 检测，而对照组有 57 名客户 (23%) 接受了 HIV 检测，调整聚类效果后，检测率增加了 77% (95% CI 73–82) (p<0·0001)。干预组的 250 名客户中有 10 名 (4%) 检测出 HIV 呈阳性，其中 7 名患者自我报告与 HIV 护理有联系。对照组中没有发现新的艾滋病毒病例。定性访谈显示，传统治疗师提供的艾滋病毒检测在提供者和客户中均得到高度认可。没有安全性或不良事件的报告。

 解释

传统治疗师向血清状态未知的成年人提供护理点艾滋病毒检测，显着提高了乌干达农村地区的艾滋病毒检测率。鉴于非洲治疗师无处不在，这种方法有望成为提供基于社区的艾滋病毒检测的新途径，并可能对撒哈拉以南非洲地区艾滋病毒检测的采用产生巨大影响。

 资金

美国国立卫生研究院国家心理健康研究所。