Does provider‐initiated counselling and testing (PITC) strengthen early diagnosis and treatment initiation? Results from an analysis of an urban cohort of HIV‐positive patients in Lusaka, Zambia

Abstract

IntroductionBuilding on earlier works demonstrating the effectiveness and acceptability of provider-initiated counselling and testing (PITC) services in integrated outpatient departments of urban primary healthcare clinics (PHCs), this study seeks to understand the relative utility of PITC services for identifying clients with early-stage HIV-related disease compared to traditional voluntary testing and counselling (VCT) services. We additionally seek to determine whether there are any significant differences in the clinical and demographic profile of PITC and VCT clients.MethodsRoutinely collected, de-identified data were collated from two cohorts of HIV-positive patients referred for HIV treatment, either from PITC or VCT in seven urban-integrated PHCs. Univariate and multivariate analyses were conducted to compare the two cohorts across demographic and clinical characteristics at enrolment.ResultsForty-five per cent of clients diagnosed via PITC had CD4<200, and more than 70% (i.e. two thirds) had CD4<350 at enrolment, with significantly lower CD4 counts than that of VCT clients (p<0.001). PITC clients were more likely to be male (p=0.0005) and less likely to have secondary or tertiary education (p<0.0001). Among those who were initiated on antiretroviral therapy (ART), PITC clients had lower odds of initiating treatment within four weeks of enrolment into HIV care (adjusted odds ratio, or AOR: 0.86; 95% confidence interval, or CI: 0.75–0.99; p=0.035) and significantly lower odds of retention in care at six months (AOR: 0.84; CI: 0.77–0.99; p=0.004).ConclusionsIn Lusaka, Zambia, large numbers of individuals with late-stage HIV are being incidentally diagnosed in outpatient settings. Our findings suggest that PITC in this setting does not facilitate more timely diagnosis and referral to care but rather act as a “safety net” for individuals who are unwilling or unable to seek testing independently. Further work is needed to document the way provision of clinic-based services can be strengthened and linked to community-based interventions and to address socio-cultural norms and socio-economic status that underpin healthcare-seeking behaviour.

Gender-Specific Risk Factors for Virologic Failure in KwaZulu-Natal: Automobile Ownership and Financial Insecurity

“…Existing literature has demonstrated that financial insecurity is a barrier to care and is associated with poor adherence and VF, yet no studies have assessed differences in this association between genders (25, 26, 56–58). The association between financial dependency indicators and VF among women but not men in this cohort may indicate that personal financial insecurity is a risk factor for VF more specific to women in this context, as has been suggested by some findings in countries where women are often dependent upon men (16, 59, 60). …”

Systematic review and meta-analysis of community and facility-based HIV testing to address linkage to care gaps in sub-Saharan Africa

“…Coverage was reported in 19 home HTC studies 15,18,29–45 , one mobile 13 , two campaign 46,47 , three index partner/family member 48–50 , five facility VCT 51–55 , and five facility PITC studies 56–61 . Overall, community HTC modalities achieved higher coverage than facility, with home (70%, 95% CI = 58–79) and campaign (76%, 95% CI = 49–95%) having the highest population coverage (Fig.…”

“…The percentage of men out of total persons tested was reported in 25 home HTC studies 5,14,18,29,31,32,37,38,41–45,63,64,66,68–72,88–90 , two home with self-testing 11,75 , 10 mobile 10,13,68,72,91–99 , 3 index partner 47,49,88 , 3 campaign 46,47,76 , 2 workplace 100,101 , 20 facility VCT 52,54,61,64,81,88,89,92,93,95,96,98,102–107 , and 13 facility PITC 58,60,82–84,86,99,108–113 (Fig. 2).…”

“…The proportion of individuals with CD4 count of less than 350 cells μL −1 at HIV diagnosis was reported in 7 home 14,38,42,43,65,72,73 , 3 mobile 91,94,114 , 3 campaign 46,47,76 , 8 facility VCT 60,81,107,126,127,129–131 and 5 facility PITC studies 61,81,99,126,130 . Community-based strategies identified HIV-positive individuals at higher CD4 counts than facility HTC, with campaign having the lowest proportion with CD4 count less than 350 cells μL −1 (26%, 95% CI = 22–30%) (Fig.…”

“…ART initiation rates after home HTC with facilitated linkage were similar to those achieved through facility HTC. Initiation among those eligible was 64% (95% CI = 54–72%) in facility VCT and 70% (95% CI = 61–78%) in facility PITC with three studies reporting initiation rates for VCT 61,126,130 and four for facility PITC 60,81,84,87,111 . Self-testing showed an ART initiation rate of 29% (95% CI = 17–45%), although this number is among all HIV-positive individuals and is not restricted to those who are ART eligible since POC CD4 counts were not conducted 11 (Supplementary Figure S55).…”