Loss of lay counsellors leads to sharp fall in HIV testing

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The withdrawal of lay counsellors from primary health clinics in KwaZulu-Natal led to a sharp fall in the number of people taking an HIV test in 2015, a study by researchers at Duke University, Durham, North Carolina, the Harvard TH Chan School of Public Health, Médecins Sans Frontières, eShowe, South Africa, Africa Health Research Institute, Somkhele, KwaZulu-Natal, Southern African Medical Unit, Médecins Sans Frontières, Cape Town, Centre for Infectious Disease Epidemiology and Research, University of Cape Town, School of Nursing and Public Health, University of KwaZulu-Natal, Institute of Health and Wellbeing, University of Glasgow, University of Goettingen, Germany, University College London and the University of Heidelberg, has shown. The findings highlight the important role that lay counsellors play in increasing the number of people diagnosed with HIV in a sub-Saharan African setting, the researchers say.

Lay counsellors may provide HIV counselling and testing at health facilities, as well as adherence support and HIV treatment education to people preparing for treatment. Lay counsellors take on tasks that do not require extensive medical training, freeing healthcare workers to do other work. This process, known as task shifting, has been adopted in many African countries in order to increase the capacity of the health system to provide HIV treatment.

Lay counsellors are used in different ways in sub-Saharan Africa. Even in South Africa, employment practices vary – including rates of pay and the types of work that lay counsellors may be called on to do. Not every facility uses lay counsellors, and in 2014 lay counsellors in KwaZulu-Natal began to be redeployed, leaving some clinics without their help.

The redeployment was designed to address the lack of career development opportunities for lay counsellors. Lay counsellors complain of a lack of training and support and lack of payment. Lay counsellors were offered training in nursing and social work from the beginning of 2015 but were not replaced with a new cadre of lay counsellors. Instead, nurses or remaining lay counsellors were expected to take up their work.

Researchers looked at the impact of lay counsellors on the uptake of HIV testing by comparing HIV testing rates before and after the removal of lay counsellors from nine clinics in the uMlalazi district of KwaZulu-Natal. Redeployment began in January 2015 and was completed in a second wave in June 2015.

The study compared testing rates in 2014 and after each wave of redeployment. In 2014 the clinics employed 27 lay counsellors, 15 between January and May 2015 and six in the period June-December 2015.

A total of 24,526 HIV tests took place at the nine clinics, two-thirds in the period prior to redeployment. A further 21% of tests took place between January and May 2015, and 13% between June and December 2015. The average number of tests fell from 93 women and 37 men tested per month in 2014 to 35 women and 15 men tested per month by the second half of 2015.

Analysis of individual clinics showed that HIV tests per month declined markedly in five out of nine clinics as lay counsellor numbers fell and remained stable only in two clinics, one of which was able to retain two lay counsellors until the end of the study period. Overall, HIV testing numbers fell by 4.9% for every 10% loss of lay counsellor capacity. Losing one lay counsellor was associated with 30 fewer HIV tests at a clinic each month (P < 0.001).

The researchers say that their findings “support the recent announcement by UNAIDS that it will lead a major international effort to train and deploy two million additional community health workers in sub-Saharan Africa (with a primary focus on HIV)” by 2020.

They point out that ‘test and treat’ policies will require widespread and regular HIV testing to achieve the goals of 90% of people with HIV diagnosed by 2020. Increasing testing capacity will be essential and lay counsellors will be one essential element in increasing capacity, the authors conclude.

Abstract
Objectives: This study aimed to determine the causal effect of the number of lay counselors employed at a primary care clinic in rural South Africa on the number of clinic-based HIV tests performed.
Design: Fixed effects panel analysis.
Methods: We collected monthly data on the number of lay counselors employed and HIV tests performed at nine primary care clinics in rural KwaZulu-Natal from January 2014 to December 2015. Using clinic- and month-level fixed effects regressions, we exploited the fact that lay counselors were removed from clinics at two quasi-random time points by a redeployment policy.
Results: A total of 24,526 HIV tests were conducted over the study period. 21 of 27 lay counselors were removed across the nine clinics in the two redeployment waves. A ten percent reduction in the number of lay counselorswas associated with a 4.9% (95% confidence interval [CI]: 2.8 – 7.0, p < 0.001) decrease in the number of HIV tests performed. In absolute terms, losing one lay counselor from a clinic was associated with a mean of 29.7 (95% CI: 21.2 – 38.2, p < 0.001) fewer HIV tests carried out at the clinic per month.
Conclusions: This study provides evidence for the crucial role that lay counselors play in the HIV response in rural South Africa. More broadly, this analysis supports the use of lay cadres in the HIV response and by extension UNAIDS’ and the African Union’s goal to triple the number of community health workers in sub-Saharan Africa by 2020.

Authors
Hu, Janice; Geldsetzer, Pascal; Steele, Sarah Jane; Matthews, Philippa; Ortblad, Katrina; Solomon, Tsion; Shroufi, Amir; van Cutsem, Gilles; Tanser, Frank; Wyke, Sally; Vollmer, Sebastian; Pillay, Deenan; Mcconnell, Margaret; Bärnighausen, Till

Aidsmap material
AIDS journal abstract


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