Access to HIV care in the context of universal test and treat: challenges within the ANRS 12249 TasP cluster‐randomized trial in rural South Africa

Abstract

IntroductionWe aimed to quantify and identify associated factors of linkage to HIV care following home-based HIV counselling and testing (HBHCT) in the ongoing ANRS 12249 treatment-as-prevention (TasP) cluster-randomized trial in rural KwaZulu-Natal, South Africa.MethodsIndividuals ≥16 years were offered HBHCT; those who were identified HIV positive were referred to cluster-based TasP clinics and offered antiretroviral treatment (ART) immediately (five clusters) or according to national guidelines (five clusters). HIV care was also available in the local Department of Health (DoH) clinics. Linkage to HIV care was defined as TasP or DoH clinic attendance within three months of referral among adults not in HIV care at referral. Associated factors were identified using multivariable logistic regression adjusted for trial arm.ResultsOverall, 1323 HIV-positive adults (72.9% women) not in HIV care at referral were included, of whom 36.9% (n=488) linked to care <3 months of referral (similar by sex). In adjusted analyses (n=1222), individuals who had never been in HIV care before referral were significantly less likely to link to care than those who had previously been in care (<33% vs. >42%, p<0.001). Linkage to care was lower in students (adjusted odds-ratio [aOR]=0.47; 95% confidence interval [CI] 0.24–0.92) than in employed adults, in adults who completed secondary school (aOR=0.68; CI 0.49–0.96) or at least some secondary school (aOR=0.59; CI 0.41–0.84) versus ≤ primary school, in those who lived at 1 to 2 km (aOR=0.58; CI 0.44–0.78) or 2–5 km from the nearest TasP clinic (aOR=0.57; CI 0.41–0.77) versus <1 km, and in those who were referred to clinic after ≥2 contacts (aOR=0.75; CI 0.58–0.97) versus those referred at the first contact. Linkage to care was higher in adults who reported knowing an HIV-positive family member (aOR=1.45; CI 1.12–1.86) versus not, and in those who said that they would take ART as soon as possible if they were diagnosed HIV positive (aOR=2.16; CI 1.13–4.10) versus not.ConclusionsFewer than 40% of HIV-positive adults not in care at referral were linked to HIV care within three months of HBHCT in the TasP trial. Achieving universal test and treat coverage will require innovative interventions to support linkage to HIV care.

Brief counselling after home‐based HIV counselling and testing strongly increases linkage to care: a cluster‐randomized trial in Uganda

“…This was probably due to the already high (89%) level of linkage to care in the standard‐of‐care (referral only) arm of that trial. In contrast, linkage to care in our standard‐of‐care arm was 33%, a figure consistent with that observed after routine referral in previous studies 20, 30, 31, 38, 39, 40.…”

“…The probability of linking to care was also higher in the first month than in subsequent periods. This has been observed previously 10, 38 and may mean that persons who accept their status, and are motivated to get help, promptly link to care following HIV diagnosis 41. The finding also suggests that one month after HIV diagnosis may be the optimal time for targeting persons who are less motivated to seek care.…”

Rapid initiation of antiretroviral therapy for people living with HIV

“…We excluded several studies as they assessed the effect of ART initiation related to CD4 threshold rather than initiating ART soon after HIV diagnosis (Achhra 2017; Danel 2015; Iwuji 2017; Sabapathy 2017; Larmarange 2016; Plazy 2016; Temprano 2015). We further excluded studies that specifically assessed timing of ART in participants who had oppurtunistic infections such as cryptococcal meningitis or tuberculosis meningitis (Bisson 2013; Blanc 2011; Boulware 2014; Degu 2012; Grant 2010; Havlir 2011; Laurelliard 2013; Makadzange 2010).…”

The HIV treatment cascade and care continuum: updates, goals, and recommendations for the future

“…In these countries, it is common for PLWH to delay treatment for several years until the disease has rapidly progressed [28]. For example, the proportion of PLWH linked to care in Kenya is 42% [29] and in South Africa, 37% [30]. …”