The impact of lay counselors on HIV testing rates: quasi-experimental evidence from lay counselor redeployment in KwaZulu-Natal, South Africa

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 counselors was 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.