Abbreviated HIV counselling and testing and enhanced referral to care in Uganda: a factorial randomised controlled trial

Abstract

SummaryBackgroundHIV counselling and testing and linkage to care are crucial for successful HIV prevention and treatment. Abbreviated counselling could save time; however, its effect on HIV risk is uncertain and methods to improve linkage to care have not been studied.MethodsWe did this factorial randomised controlled study at Mulago Hospital, Uganda. Participants were randomly assigned to abbreviated or traditional HIV counselling and testing; HIV-infected patients were randomly assigned to enhanced linkage to care or standard linkage to care. All study personnel except counsellors and the data officer were masked to study group assignment. Participants had structured interviews, given once every 3 months. We compared sexual risk behaviour by counselling strategy with a 6·5% non-inferiority margin. We used Cox proportional hazards analyses to compare HIV outcomes by linkage to care over 1 year and tested for interaction by sex. This trial is registered with ClinicalTrials.gov (NCT00648232).FindingsWe enrolled 3415 participants; 1707 assigned to abbreviated counselling versus 1708 assigned to traditional. Unprotected sex with an HIV discordant or status unknown partner was similar in each group (232/823 [27·9%] vs 251/890 [28·2%], difference −0·3%, one-sided 95% CI 3·2). Loss to follow-up was lower for traditional counselling than for abbreviated counselling (adjusted hazard ratio [HR] 0·61, 95% CI 0·44–0·83). 1003 HIV-positive participants were assigned to enhanced linkage (n=504) or standard linkage to care (n=499). Linkage to care did not have a significant effect on mortality or receipt of co-trimoxazole. Time to treatment in men with CD4 cell counts of 250 cells per μL or fewer was lower for enhanced linkage versus standard linkage (adjusted HR 0·60, 95% CI 0·41–0·87) and time to HIV care was decreased among women (0·80, 0·66–0·96).InterpretationAbbreviated HIV counselling and testing did not adversely affect risk behaviour. Linkage to care interventions might decrease time to enrolment in HIV care and antiretroviral treatment and thus might affect secondary HIV transmission and improve treatment outcomes.FundingUS National Institute of Mental Health.

Interventions to improve the rate or timing of initiation of antiretroviral therapy for HIV in sub‐Saharan Africa: meta‐analyses of effectiveness

“…Five tested the effect of POC testing using Alere Pima machines [8,19,20,22,29] and two used same day BD FACS Count results [11,21]. One study did not report the sample size or a CI for its reported RR so could not be included in the meta-analysis [22].…”

Quality of HIV Counselling in South Africa

“…Disclosure of HIV status and partner referral are important in establishing social support and helping prevent transmission of the virus to sexual partners as well as enabling both patients and partners to access appropriate HIV services (Chersich and Temmer-man 2008). The main aim of HCT services is to ensure clients testing HIV positive are linked care and treatment services, however a study conducted in Uganda by Wanyenze et al (2013) has suggested an enhanced linkage approach that has significantly reduced ART initiation time. As opposed to merely providing information about nearby support services this approach includes counselling about barriers to care, assisted disclosure and a scheduled appointment at an ART clinic as well as reminders by phone or home visits.…”

“…There is also evidence that counsellors modify rules in the course of doing their jobs due to several factors including an attempt to tailor the counselling to individual needs (Angotti 2010), however in so doing they may exclude key messages and consequently compromise the quality of service rendered to clients. Wanyenze et al (2013) have suggested that HIV testing can be integrated into routine health care without a lengthy counselling session particularly in settings where there are shortages of health workers however it is crucial that clients that test HIV positive are provided with more intensive post-test counselling and follow-up to ensure enrolment into care and timely treatment initiation.…”

Gender and HIV Testing Service Uptake: Trend in Northern Nigeria

“…Increasing the coverage of HTS through community outreach testing when provided within WHO's essential 5Cs: Consent, Confidentiality, Counselling, Correct test results and Connection has the benefit of early Positive client linkage to care [1]. This further improves the overall treatment outcome and reduces the risk of possible transmission of infection, while negative clients are offered other prevention models to adopt, aiding them to remain negative with an added advantage of increased HIV risk perception index which is associated with improved motivation for risk reduction [2,3].…”