The effectiveness of home-based HIV counselling and testing on reducing stigma and risky sexual behavior among adults and adolescents: a systematic review protocol
Authors: Tolu Garumma , Lockwood Craig , Munn Zachary 
Published: December 2014

Review question/objective
The objective of this review is to determine the effectiveness of home-based HIV counselling and testing in reducing HIV related stigma and risky sexual behavior among adults and adolescents. As a secondary outcome, the review will also determine the effect of home-based HIV counselling and testing on clinical outcomes.

Background
Human immunodeficiency virus and acquired immunodeficiency syndrome (HIV/AIDS) is one of the leading causes of mortality and morbidity worldwide.1 In a 2010 analysis of disease burden, it was ranked first among leading causes of disability adjusted life years (DALYs) in Southern Sub-Saharan Africa and Eastern Sub-Saharan Africa and the fifth leading cause of DALYs globally.1 In the same year, HIV/AIDS was the main cause of DALYs for young adults globally.1 According to the Joint United Nations Programme on HIV/AIDS (UNAIDS) report, at the end of 2013, there were 35 million people living with HIV worldwide.2 Of these, 24.7 million were living in Sub-Saharan Africa, where nearly one in every 25 adults (4.4%) were living with the virus.2 Since 2001, new HIV infections have increased by 31% in the Middle East and North Africa, where trends in rising new infections are causes for concern.2 In Western Europe and North America, new HIV infections had increased by 6% at the end of 2013 from where it was in 2001.2

Specific groups that have behaviors that do not conform to social norms and groups that are legally criminalized in some countries, such as people who inject drugs, men who have sex with men and sex workers and sex workers are highly affected by HIV.2 The UNAIDS report indicated that worldwide the HIV prevalence among sex workers is 12 times greater than that among the general population.2 This report also indicates that, there are an estimated 12.7 million people who inject drugs worldwide, and 13% of them are living with HIV.2

There are three aspects to the HIV/AIDS epidemic: the epidemic of HIV, the epidemic of AIDS, and the epidemic of stigma, discrimination, and denial. The third aspect is the epidemic of social, cultural, economic and political responses to AIDS.3 Stigma is typically a social process, experienced or anticipated, characterized by exclusion, rejection, blame or devaluation that results from experience, perception or reasonable anticipation of an adverse social judgment about a person or a group.4 HIV/AIDS-related stigma builds upon and reinforces earlier negative thoughts.5,6 People living with HIV/AIDS (PLHIV) may be considered to have deserved becoming infected with the virus by doing something wrong. Often these "wrongdoings" are linked to sex or to illegal or socially "frowned upon" activities, such as injecting drug use. Men who become infected may be seen as homosexual, bisexual or as having had sex with prostitutes.5 HIV-related stigma may be manifested in the form of anticipated stigma (expectation of social rejection, violence or discrimination by PLHIV), enacted stigma (actual experience of social rejection, violence or discrimination by PLHIV) and self/felt/internalized stigma (feelings and beliefs of PLHIV that they are disgusting and immoral).7

Researchers have validated scales for the measurement of stigma and discrimination. Genberg and colleagues use three dimensions of stigma: negative attitude (shame, blame, and social isolation), discrimination; and equity.8 The first component (negative attitude) encompasses items regarding the shame of PLHIV, items related to labelling, devaluing and isolation of PLHIV.8 It also includes blame for the responsibility for HIV infection on the HIV positive person, feelings about PLHIV and attitudes regarding the proper treatment of PLHIV and their families.8 The second component is discrimination (enacted stigma).8 The third component (equity) focuses on the endorsement of views that PLHIV should be considered equal members of the society as those who are HIV-free.8 Visser and colleagues have also developed the parallel stigma scale that enables comparison both within groups and across different populations.9 They developed three parallel scales (personal stigma, attributed stigma, and internalized stigma) that use the same items.9 Personal stigma refers to stigmatizing attitude held by individuals within a group or community.9 Attributed stigma measures the level of stigma that individuals attribute to others in their group or community.9 Internalized stigma assesses the extent to which an HIV infected individual feels stigmatized because of the disease.9 Therefore, these validated scales measure stigma from the perspective of the victims (PLHIV), from the perspective of the community about their own perceptions about PLHIV and from the perspective the community about their perceptions of how others think/act about PLHIV.
Stigma and discrimination related to HIV act as barriers to the uptake of testing and treatment services. Stigma and discrimination also affect economic, social and emotional outcomes of individuals.10,11 Studies have shown that the fear of experiencing stigma and discrimination inhibits disclosure of HIV-positive status, thus contributing to spreading the virus further.12 Lack of knowledge of HIV serological status acts as a major obstacle to HIV prevention and access to care and support services, thereby exacerbating HIV-related complications.13 Researchers have suggested that massive scale-up of universal voluntary HIV testing with immediate initiation of antiretroviral therapy (ART) could nearly stop transmission and drive HIV into an elimination phase in a high-burden setting.14

Individuals who have never been tested for HIV exhibit significantly greater stigmatizing attitudes towards people living with HIV (PLHIV) compared with those who have been tested for HIV.10 In addition, there is a growing evidence indicating that voluntary counselling and testing (VCT) can change HIV-related sexual risk behaviors, thereby reducing HIV-related risk and confirming its importance as an HIV prevention strategy.15 However, the fear of stigma by itself may act as a barrier to HIV counselling and testing, and the fear of disapproval and discrimination by health care providers may deter many from accessing facility-based health services.16

Interventions designed to increase HIV testing should, therefore, address stigma and perceptions of societal testing (social norms of HIV testing).17 In order to maximize the effectiveness of HIV counselling and testing (HCT), it is essential to understand HCT service delivery strategies that produce significant reductions in stigma and risky behaviors and that lead to the greatest uptake of HCT.15

There are several HCT service delivery models. The first model is free standing HCT service in which HCT is delivered in stand-alone centres outside of health institutions.18 The second model is facility-based integrated HCT in which HCT is integrated into healthcare settings, such as sexually transmitted infection (STI) clinics, tuberculosis clinics, and family planning and maternal and child health clinics.18 The third HCT delivery model is mobile HCT, which involves the provision of HCT by mobile teams equipped with HIV testing facilities.18 The fourth model is routine counselling and testing, in which healthcare providers recommend HCT to persons attending healthcare facilities as a standard component of medical care.18 The fifth model is home-based HCT, in which HIV counsellors provide door-to-door HCT services in clients' homes.18 In home-based HCT programs, lay-counsellors or community health workers provide counselling and testing.18 This strategy addresses the needs of the entire family at once.18

Primary studies have demonstrated that home-based HCT had a larger impact of reducing stigma than institution-based testing among adults and adolescents.10,19,20 These studies indicate that compared to facility based counselling and testing, home-based HIV testing and counselling reduces multiple sexual partnership and casual sex and results in higher uptake of couple counselling and testing,19 reduces the proportion of people who exchange money for sex (transactional sex), increases the proportion of people who use a condom, reduces the proportion of report of genital ulcer/discharge.20 As well, it has been shown that home-based counselling and testing substantially reduces inequalities of uptake of services in terms of gender,21,22 educational status21,22 and place of residence (urban versus rural).22 Contrarily, a study conducted in Kenya reported that home-based HIV testing increased feelings of anger toward HIV-positive individuals but lowered the sense that having HIV was a sign of immoral behavior.23 A study conducted in Uganda indicated that the clients who received home-based HCT were less likely to report having STI symptoms and more likely to be worried about discrimination if they contracted HIV.24 Another study conducted in Uganda indicated that while facility-based HCT promotes abstinence and condom use, home-based HCT promotes faithfulness and disclosure.25 Therefore, it is essential to synthesize the best available evidence on the effects of these interventions on stigma and risky sexual behavior.
A Cochrane systematic review that tried to assess the effect of home-based HIV counselling and testing on uptake of HIV testing in 2010 recommended that further primary studies were needed to determine if home-based VCT is more effective than facility-based VCT in improving uptake of VCT.18 This review reported that home based VCT has potential to enhance VCT uptake.18

A systematic review conducted in 2012 indicated that home-based HIV testing could substantially increase uptake of HIV testing and awareness of HIV serological status in Sub-Saharan Africa.26 Another systematic review reported community-based HCT achieved higher rates of HCT and reached people with higher CD4 counts.27 However, none of the above systematic reviews reported the effectiveness of home-based HCT on outcomes HIV related stigma and sexual behavior.18,26

A preliminary search for systematic reviews on this topic was performed in PubMed, CINAHL, DARE and PROSPERO. No existing systematic reviews were identified in these databases that address the same review objective and use the same inclusion criteria.
Cognizant of this fact, this review seeks to pool the findings of studies that investigate the effectiveness of home-based HCT on HIV-related stigma, social norms to HIV testing and risky sexual behavior. Such evidence is helpful to determine whether there is support for recommending home-based HIV counselling and testing over other HCT services delivery models.