Should home-based HIV testing and counseling services be offered periodically in programs of ARV treatment as prevention? A case study in Likoma (Malawi)

To reduce HIV incidence, prevention programs centered on the use of antiretrovirals require scaling-up HIV testing and counseling (HTC). Home-based HTC services (HBHTC) increase HTC coverage, but HBHTC has only been evaluated during one-off campaigns. Two years after an initial HBHTC campaign ("round 1"), we conducted another HBHTC campaign ("round 2") in Likoma (Malawi). HBHTC participation increased during round 2 among women (from 74 to 83 %, P < 0.01). New HBHTC clients were recruited, especially at ages 25 and older. Only 6.9 % of women but 15.9 % of men remained unreached by HBHTC after round 2. HIV prevalence during round 2 was low among clients who were HIV-negative during round 1 (0.7 %), but high among women who received their first ever HIV test during round 2 (42.8 %). The costs per newly diagnosed infection increased significantly during round 2. Periodically conducting HBHTC campaigns can further increase HTC, but supplementary interventions to enroll individuals not reached by HBHTC are needed.