Shout-It-Now: A Mobile HCT Model Employing Technology and Edutainment in South Africa

Biometric registration

The registration process begins with fingerprint registration that links clients anonymously and confidentially to an electronic profile (e-profile) that is populated as they progress through S-N’s 6-step HCT process. Once their fingerprint is registered, they are issued a unique identifier printed on a wristband that they wear to track progression through S-N’s HCT process. Participants then complete a brief online demographic profile including socioeconomic measures, cultural and racial identity, date of birth, and language. The use of biometric technology by S-N program is supported by studies demonstrating that such technology is feasible and acceptable in low-resource settings and has been shown to be a significant factor in the engagement of participants in HCT and linkage to care. ^{24 –26}

HIV edutainment

Online social networking, gaming, edutainment, and telenovelas have been successfully used to deliver health knowledge, education, and messaging. ^{19 –21} The S-N’s HIV education content is delivered by a 13-minute edutainment video viewed by each client on a personal laptop. The video features young South African celebrities (sports stars, musicians, designers, and television personalities), animation, dance, and docudrama to teach clients about HIV risk, testing, disease development, and living healthy with HIV. In the video, messages addressing both men’s and women’s HIV risk factors were delivered by men and women in order to create an inclusive educational experience. ⁷

Online risk assessment and culturally competent pretest counseling

Embedded in the educational video was a set of HIV risk assessment questions. Participants were informed that questions about their health behaviors and opinions would appear during the video and that by answering these questions, they could improve the relevance and quality of their subsequent counseling session. The HIV risk assessment questions addressed sexual risk, tuberculosis, and sexually transmitted infection history; medical history; lifestyle; physical health; and medical male circumcision. The video ran automatically and was available in all local languages, with counselors assisting participants who had low literacy levels. At the end of the video, clients were asked if they would like to consent for an HIV test.

Once a client consented to HIV testing, participants met privately with a counselor trained in key population cultural competence in a tent for pretest counseling and testing. Previous testing history was discussed as part of the pretest counseling session. Counselors reviewed risk assessment profiles with their clients and then assessed their level of comprehension of relevant HIV educational content. The online risk assessments helped counselors tailor their HIV risk reduction messaging to each client’s needs. When pretest counseling was completed, counselors asked the participant again if they consented to HIV testing. If participants declined testing, the counselor attempted to motivate the client to accept testing by addressing the reasons for refusal. If the client could not be convinced to test, they were encouraged to return and seek testing for HIV at another site and then they exited the program at this point. Participants consenting to HIV testing were then tested.

HIV testing

Counselors administered rapid HIV testing using kits certified by the South African National Department of Health and supplied by the respective provincial Departments of Health. There were 2 steps in the S-N testing process. First, a counselor collected a specimen using the test kit, which was linked to the client by a sticker bearing their unique identifier already stored in the S-N database. Participants were then escorted to a waiting area with activities and music videos while the test was processed. Second, the test kit and specimen were delivered to a dedicated staff member who read the HIV test result (the S-N database time stamped all test kits to protect against HIV test results being read too early or too late) and recorded the result in the S-N database by scanning the barcode on the test kit and inputting the result.

Post-HIV test results counseling

The S-N database notified counselors on their laptops, when their clients’ results were accessible via the client’s electronic record. At that time, counselors called clients back to their tent to deliver results and posttest counseling using a script specific to the client’s HIV result.

Telephonic linkage-to-care support program

Participants opting to receive S-N’s ongoing linkage-to-care services were provided free telephonic support from care coordinators at the S-N call center. Care coordinators had training in linkage-to-care counseling and were fluent in all South African languages. Within 48 hours of an HIV-positive diagnosis, a care coordinator called the client and commenced the process of motivating them to visit a local clinic for HIV care. Care coordinators read and updated each participant’s e-profile stored in the S-N database to guide and document the telephonic support they provided to the participant until they linked to HIV care. Generally, this support was provided over multiple phone calls up to 7 weeks after diagnosis, though most clients who were linked to care did so within 30 days. Documentation of linkage to care was from the clients’ self-report and was verified by descriptions of clinic-delivered CD4 results or enrollment in ART or in wellness programs.