Engaging the first 95 Improving facility-based HIV testing in coastal Kenya

HIV testing is the entry point to prevention, care, and treatment services. This thesis aimed to 1). synthesize evidence on performance and clinical utility of point-of-care (POC) HIV-1 RNA tests; 2)evaluate the impact of a targeted HIV-1 POC RNA testing intervention to detect acute and prevalent HIV in adults 18-39 years seeking primary care for symptoms compatible with acute HIV infection (AHI), with enrolment based on an AHI risk score algorithm; and 3) assess factors associated with uptake of HIV testing services from routine VCT data and primary care settings in coastal Kenya. We found that while POC RNA tests had comparable accuracy and precision to current reference technologies, their use was largely limited to treatment monitoring and early infant diagnosis. Provider-initiated HIV testing (PITC) was poorly implemented with less than 1 in 3 patients offered an HIV test at care seeking. We demonstrated that POC RNA tests are important in acute and early HIV diagnosis, with implementation of our AHI risk score algorithm resulting in twice as many HIV diagnosis compared to standard-of-care PITC. We found that first-time testing (FTT) was more likely among men, men who have sex with men, younger (18–24 years) or single persons, and persons with lower educational attainment. New HIV diagnoses were made among late retesters, FTT, key populations, individuals with lower educational attainment and with current STI symptoms. Approaches focused on engaging the first 95 should include screening for acute HIV infections and target facility-based HIV testing.