Does provider-initiated HIV testing and counselling lead to higher HIV testing rate and HIV case finding in Rwandan clinics?

Background: Provider-initiated HIV testing and counselling (PITC) is promoted as a means to increase HIV case finding. We assessed the effectiveness of PITC to increase HIV testing rate and HIV case finding among outpatients in Rwandan health facilities (HF). Methods: PITC was introduced in six HFs in 2009-2010. HIV testing rate and case finding were compared between phase 1 (pre-PITC) and phase 3 (PITC period) for outpatient-department (OPD) attendees only, and for OPD and voluntary counseling & testing (VCT) departments combined. Results: Out of 26,367 adult OPD attendees in phase 1, 4.7 % were tested and out of 29,864 attendees in phase 3, 17.0 % were tested (p < 0.001). The proportion of HIV cases diagnosed was 0.25 % (67/26,367) in phase 1 and 0.46 % (136/29864) in phase 3 (p < 0.001). In multivariable analysis, both testing rate and case finding were significantly higher in phase 3 for OPD attendees. In phase 1 most of the HIV testing was done in VCT departments rather than at the OPD (78.6 % vs 21.4 % respectively); in phase 3 this was reversed (40.0 % vs 60.0 %; p < 0.001). In a combined analysis of VCT and OPD attendees, testing rate increased from 18.7 % in phase 1 to 25.4 % in phase 3, but case finding did not increase. In multivariable analysis, testing rate was significantly higher in phase 3 (OR 1.67; 95 % CI 1.60-1.73), but case finding remained stable (OR 1.09; 95 % CI 0.93-1.27). Conclusion: PITC led to a shift of HIV testing from VCT department to the OPD, a higher testing rate, but no additional HIV case finding.