Many countries with generalized HIV epidemics routinely conduct nationally-representative, population-based surveys e.g., [Demographic and Health Surveys (DHS) or AIDS Indicator Surveys (AIS)] with an HIV testing component to quantify HIV prevalence, plan prevention, care and treatment services and evaluate the national HIV program [1, 2]. In recent years, discourse on the ethics of HIV testing in population-based surveys has highlighted the right of survey participants to learn their HIV status in order to access increasingly available HIV health services [3, 4]. These arguments stem from the belief that research and survey participants have rights to appropriate information before, during and after studies to help them make informed choices and access appropriate services [5].

In 2009, a UNAIDS/WHO consultation on Ethics in HIV Surveillance recommended use of HIV surveillance approaches that maximize beneficial outcomes for individuals and communities [6]. Additionally, countries were advised to make informed decisions on how best to balance the benefits and risks of returning HIV and other test results to participants. In 1995, the United States (U.S.) discontinued unlinked anonymous testing (UAT) for HIV infection among mothers and infants due to availability of HIV treatment and subsequently ended funding of all UAT surveys of HIV [7].

In developing countries, reporting biological results to survey participants needs to be balanced against several factors, including where tests are performed, social meaning of the disease, the physical and social contexts in which reporting occurs and the health care delivery system [4]. Past surveys in Kenya and elsewhere have used several approaches to help survey participants learn their HIV status. These approaches include referral for free voluntary counseling and testing (VCT) services, mobile VCT, and travel reimbursement to HIV testing sites [2, 8]. In the 2003 Kenya DHS, participants were either referred to the nearest VCT site or to a mobile VCT site in regions with no VCT services to learn their HIV status [9]. The survey did not effectively measure uptake of VCT services among survey participants, however, available data indicate that females (15-49 years) who accessed VCT had a higher HIV prevalence (13%) compared to the national female HIV prevalence (9%) while male participants who accessed VCT had HIV prevalence similar to the national male HIV prevalence (5%).

Surveys that have directly returned results to participants have done so either in the home at the time of the interview [10] or they have made results available in designated health facilities after centralized laboratory testing [11]. In rural southwestern Uganda, rapid home-based HIV testing and counseling (HBTC) of population-based cohort study participants in selected clusters in a population-based sero-survey resulted in a significant three-fold (37%) increase of HIV testing and counseling compared to an uptake of less than 10% in previous surveys [12]. The 2007 Kenya AIDS Indicator Survey (KAIS) used a facility-based approach to inform participants of their HIV test results [11]. To inform planning of future surveys, we report uptake and describe the characteristics of individuals and couples who collected HIV test results in the 2007 KAIS and examine factors associated with individual and couple collection of results.

The 2007 KAIS was a cross-sectional, two stage cluster sampling survey of Kenyan adults aged 15-64 years designed to provide national and provincial estimates of socio-demographic, behavioral, and biologic correlates of HIV infection. In addition to a structured questionnaire, venous blood samples were drawn from consenting participants for HIV antibody testing (Vironostika HIV-1/2 antigen/antibody EIA for screening, Murex HIV.1.2.O EIA for confirmation, with discrepancies resolved by Roche Amplicor HIV DNA PCR v1.5). For participants who could not provide venous blood, dried blood spots were collected for HIV testing (Vironostika HIV UNIFORM II Plus O v 3.3 and Murex HIV 1.2.0). Samples were tested at the Kenya National HIV Reference Laboratory and underwent quality assurance testing at the Kenya Medical Research Institute laboratory. Final HIV test results were recorded by laboratory staff on a paper form using a participant’s unique study identification number and delivered to selected health facilities in each survey cluster.

Returning HIV test results through health facilities in the 2007 KAIS resulted in close to half of the survey participants learning their HIV status, higher than the national uptake of lifetime HIV testing of 33% found in KAIS [11]. Moreover, 42.8% of all participants who had never been tested for HIV and over a third (39.4%) of those living with HIV but unaware due to never testing in the past collected their HIV test results. These findings demonstrate that in Kenya and other countries with similar HIV epidemics and social contexts, population-based surveys can contribute towards universal awareness of HIV status while still meeting a country’s HIV surveillance needs.

Individual collection of HIV test results increased with age and was associated with rural residence, willingness to be tested for HIV at home and correct knowledge of HIV status. The high results collection rate among rural residents and those living outside Nairobi province could be attributed to the limited availability or accessibility of routine HIV testing services in rural areas compared to urban areas, including Nairobi. The KAIS survey may have presented a unique opportunity for participants living in underserved regions to learn their HIV status. Similarly, survey response rates were higher among households and residents in rural clusters than in urban clusters [11]. Additionally, our analysis identified segments of the surveyed population that are less likely to collect HIV test results through health facilities, highlighting the need to consider alternative approaches in future surveys that could increase uptake of results among the youth, urban residents and persons living with undiagnosed HIV infection.

The 2007 KAIS [11] found high acceptance of HIV HBTC nationally (83.5% among adults 15-64 years). This finding and the high acceptance of HBTC among participants who did not collect their HIV test results in our analysis suggest that offering HBTC within a survey could increase knowledge of HIV status among survey participants.

We encouraged all survey participants to collect results with their sexual/marital partners. However, only two out of ten married/cohabiting adults collected results as a couple. Similar proportions of couples who had never been tested for HIV and of those living with HIV but unaware of their status learned their HIV status during KAIS. Given that most new HIV infections in Kenya occur among heterosexual couples [12, 13], the national HIV/AIDS program has prioritized couples testing, in part by scaling up HBTC. Of note, the next KAIS survey will offer HBTC to all survey participants, a shift that is expected to reach more couples and other segments of the population that were less likely to collect results through health facilities. The logistics of this approach, including participant and household burden needs careful consideration.

The test results uptake in KAIS could have been influenced by several factors. Owing to the 6-week delay in returning HIV test results to health facilities and referrals provided during the survey, some participants could have sought VCT and saw no need to collect survey results. Further, unexpected delays in the central laboratory and in health facilities following the 2007-2008 post-election violence in Kenya could have negatively affected collection of test results in affected study clusters.

While the 6-week period allowed for centralized laboratory testing and quality assurance, HIV infected participants unaware of their HIV status could have unknowingly infected sexual partners or unborn babies. Although we referred all participants for HIV testing, those in underserved areas had limited or no other options of learning their HIV status. Reducing the time between specimen collection and availability of results in health facilities is an important consideration when planning future surveys.

In Uganda, survey participants cited inconvenience, fear of stigmatization and emotional vulnerability of receiving HIV test results from public facilities as the most common reason for selecting to participate in HBTC [14]. We provided participants the option of collecting results in a health facility in a neighboring cluster and trained counselors to observe strict confidentiality. Similar concerns about confidentiality in KAIS [11] could have negatively impacted collection of results in our survey.

Our analysis has some limitations. In the couple analysis, we only included one primary partner who had taken part in KAIS since we did not collect information on non-KAIS partners. This and the fact that individuals may have accessed HIV testing services in the 6-week waiting period may explain the lower results collection rates in the survey. Despite these limitations, our analysis demonstrates the importance of availing results to survey participants and identifies key gaps in using a facility-based approach that will inform planning of future surveys. Our findings also demonstrate the need for countries that conduct household HIV sero-surveys to systematically analyze uptake of test results.

The ultimate goal of returning HIV test results in surveys is to facilitate access to HIV prevention, care and treatment services. Though appropriate referrals were made, the KAIS did not track uptake of referral. In Uganda, lack of HIV care and treatment services for HIV-infected participants was cited as a major drawback of providing HIV test results to survey participants [10]. As HIV surveillance and HIV service delivery become intertwined, surveys that return HIV test results should systematically monitor and evaluate current referral systems. With recent findings supporting earlier treatment [15], HIV-infected persons could seek services earlier. Systematic evaluation of referrals in surveys could help monitor this shift, in contexts where this policy is adopted. Despite the challenges in monitoring survey referrals, data from multiple countries has demonstrated that knowledge of HIV status alone reduces HIV transmission risk by up to 60%; thus HIV testing in surveys provides important HIV prevention benefits [16-18]. The low uptake of HIV test results among young people in urban areas in our analysis coupled with the high prevalence of HIV and risky sexual behaviors among individuals living in urban areas¹⁰ emphasizes the need to intensify HIV testing and prevention efforts targeting youth in urban areas.

As more countries plan population-based surveys with HIV testing, developing efficient and effective approaches to increase opportunities for participants to learn their HIV status and by extension access available HIV services is critical. With the existence of behavioral and bio-medical interventions proven to prevent HIV infection and life-saving HIV care and treatment, the benefits of returning HIV test results in surveys are considerable. Other countries may draw important lessons from KAIS 2007 which demonstrated some benefits and limitations of using a facility-based approach to returning HIV test results but also suggested that higher results uptake might occur with a home-based approach.