The effectiveness of home-based HIV counseling and testing in reducing stigma and risky sexual behavior among adults and adolescents: a systematic review and meta-analysis

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Abstract

Background

Human immunodeficiency virus (HIV) counselling and testing (HCT) is a critical and essential gateway to HIV prevention, treatment, care and support services. Though some primary studies indicate that home-based HCT is more effective than facility based HCT to reduce stigma and risky sexual behavior, to the best of the author's knowledge, no systematic review has tried to establish consistency in the findings across populations.

Objectives

The objective of this review was to determine the effectiveness of home-based HIV counselling and testing (HBHCT) in reducing HIV-related stigma and risky sexual behavior among adults and adolescents.

Inclusion criteria

Types of participants

Inclusion criteria

All adults and adolescents aged 13 years or above

Inclusion criteria

Type of intervention

Inclusion criteria

This review considered any studies that evaluated home-based HIV counseling and testing (HBHCT) as an intervention.

Inclusion criteria

Types of studies

Inclusion criteria

This review considered quantitative (experimental and observational) studies.

Inclusion criteria

Types of outcomes

Inclusion criteria

This review considered studies that included the following outcome measures: stigma, violence, sexual behavior and clinical outcomes

Search strategy

The search strategy aimed to find both published and unpublished studies reported in English Language from 2001 to 2014 in MEDLINE, Web of Science, EMBASE, Scopus and CINAHL. The search for unpublished studies included: WHO International Clinical Trials Registry Platform, Clinicaltrials.gov, Mednar, Google Scholar, AIDSinfo and ProQuest Dissertations and Theses Database (PQDT).

Methodological quality

Papers selected for retrieval were assessed by two independent reviewers for methodological validity prior to inclusion in the review using standardized critical appraisal instruments from the Joanna Briggs Institute (JBI).

Data extraction

Data were extracted from papers included in the review using the standardized data extraction tool from the Joanna Briggs Institute Qualitative Assessment and Review Instrument.

Data synthesis

Quantitative data were pooled using the meta-analysis software provided by JBI. Effect sizes were calculated using fixed effects model. Where the findings could not be pooled using meta-analyses, results were presented in a narrative form.

Results

Nine studies were included in this review, five of them reporting on stigma and related outcomes, three of them on sexual behavior and four of them on clinical outcomes.

Results

Meta-analysis indicated that the risk of observing any stigmatizing behavior in the community was 16% (RR=0.84, 95% CI 0.79 to 0.89] lower among the participants exposed to home-based HCT when compared to the risk among those participants not exposed to home-based HCT. The risk of experiencing any stigmatizing behavior by HIV positive patients was 37% (RR 0.63, 95% CI 0.45 to 0.88) lower among the intervention population compared to the risk among the control population. The risk of intimate partner violence was 34% (RR 0.66, 95% CI 0.49 to 0.89) lower among participants exposed to home-based HCT when compared to the risk among participants in the control arm.

Results

Compared to the control arm, the risk of reporting more than one sexual partner was 58% (RR 0.42, 95% CI 0.31 to 0.58) lower among participants exposed to home-based HCT. The risk of having any casual sexual partner in the past three months was 51% (RR 0.49, 95% CI 0.40 to 0.59) lower among the population exposed to home-based HCT when compared to the risk among those participants not exposed to home-based HCT. The risk of having ever been forced for sex among participants exposed to home-based HCT was 20% (RR 0.8, 0.56 to 1.14) lower when compared to the risk among the control arm; however this result was not statistically significant and the wide confidence interval indicates that the risk estimate was imprecise.

Conclusions

Home-based HCT is protective against intimate partner violence, stigmatizing behavior, having multiple sexual partners, and having casual sexual partners.

Conclusions

Implications for practice

Conclusions

The low quality of studies included makes it difficult to formulate clear recommendations regarding the effectiveness of home-based HCT on the above outcomes as compared to other models of HCT. However, the current findings may help in designing HIV prevention programs, especially in high prevalence settings and where stigma is higher and there is limited access or barriers to utilizing facility-based services.

Conclusions

Implications for research

Conclusions

Randomized controlled trials that assess the effectiveness of home-based HCT on stigma, sexual behavior, viral load and viral suppression are needed.

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