Finding the missing cases: Integrating lay-provider HIV testing services (HTS) for people with presumptive tuberculosis (TB) during household TB screening campaigns in the Democratic Republic of the Congo (DRC)

BACKGROUND: Missing cases fuel the dual HIV and TB epidemics in the DRC. 2019 DRC data show only 56% of PLHIV are diagnosed and on antiretroviral therapy, and only 68% of people with TB know their HIV status. New approaches are needed to reach undiagnosed PLHIV who are outside the reach of the current healthcare system. PATH, through the USAID-funded Integrated HIV/AIDS Project, integrated lay-provider HTS services into a household TB screening campaign to improve HIV case-finding.
DESCRIPTION: Under this model, National TB Program community health volunteers conducted household TB screening in geographies with poor healthcare coverage. PATH trained these volunteers to offer directly assisted HIV self-testing (HIVST) to individuals who screened with presumptive TB, with accompanied referrals to project-supported health facilities for those with reactive HIVST results for confirmatory diagnosis and treatment initiation. Samples were collected from people with presumptive TB and sent to facilities with GeneXpert for confirmatory diagnosis. We tested this strategy during two campaigns (14 days each in July and August/September 2020) in 41 health areas across 5 health zones of Haut-Katanga province, using descriptive statistics for analysis.
LESSONS LEARNED: 1,660 people with presumptive TB were offered HIVST (57% female; 81% between 20 and 49 years of age). 51% (843) accepted HIVST (all first-time testers). 29% (243) received a reactive HIVST result, among whom, 97% (236) were confirmed HIV-positive. Overall HIV prevalence was 28%, with a higher prevalence among females (31%) than males (25%). Among those with presumptive TB, 8% (127/1,660) were diagnosed with TB; TB was more frequent among those between 15 and 44 years. Overall TB/HIV co-infection rate was 2% (17/843). The overall HIV testing yield was higher than the project's average yield during the same period (28% versus 5.9%), indicating this strategy's success in identifying undiagnosed PLHIV who were first-time testers.
CONCLUSIONS: These results show the feasibility and acceptability of using lay providers to offer HIVST, and this strategy's success in diagnosing hard-to-reach PLHIV. PATH will replicate this model in other geographies to increase access to and uptake of HIV and TB services among hard-to-reach populations in support of epidemic control in the DRC.