Linkage into care among newly diagnosed HIV-positive individuals tested through outreach and facility-based HIV testing models in Mbeya, Tanzania: a prospective mixed-method cohort study

Abstract

ObjectiveLinkage to care is the bridge between HIV testing and HIV treatment, care and support. In Tanzania, mobile testing aims to address historically low testing rates. Linkage to care was reported at 14% in 2009 and 28% in 2014. The study compares linkage to care of HIV-positive individuals tested at mobile/outreach versus public health facility-based services within the first 6 months of HIV diagnosis.SettingRural communities in four districts of Mbeya Region, Tanzania.ParticipantsA total of 1012 newly diagnosed HIV-positive adults from 16 testing facilities were enrolled into a two-armed cohort and followed for 6 months between August 2014 and July 2015. 840 (83%) participants completed the study.Main outcome measuresWe compared the ratios and time variance in linkage to care using the Kaplan-Meier estimator and Log rank tests. Cox proportional hazards regression models to evaluate factors associated with time variance in linkage.ResultsAt the end of 6 months, 78% of all respondents had linked into care, with differences across testing models. 84% (CI 81% to 87%, n=512) of individuals tested at facility-based site were linked to care compared to 69% (CI 65% to 74%, n=281) of individuals tested at mobile/outreach. The median time to linkage was 1 day (IQR: 1–7.5) for facility-based site and 6 days (IQR: 3–11) for mobile/outreach sites. Participants tested at facility-based site were 78% more likely to link than those tested at mobile/outreach when other variables were controlled (AHR=1.78; 95% CI 1.52 to 2.07). HIV status disclosure to family/relatives was significantly associated with linkage to care (AHR=2.64; 95% CI 2.05 to 3.39).ConclusionsLinkage to care after testing HIV positive in rural Tanzania has increased markedly since 2014, across testing models. Individuals tested at facility-based sites linked in significantly higher proportion and modestly sooner than mobile/outreach tested individuals. Mobile/outreach testing models bring HIV testing services closer to people. Strategies to improve linkage from mobile/outreach models are needed.

Research priorities to inform “Treat All” policy implementation for people living with HIV in sub‐Saharan Africa: a consensus statement from the International epidemiology Databases to Evaluate AIDS (IeDEA)

“…In addition, in some settings, routine HIV viral load monitoring is infrequent, and pre‐ART CD4 count monitoring is declining in frequency with Treat All implementation , which limits opportunities to evaluate individual and public health impacts of HIV programming. Four key metrics for assessing the timeliness of continuum milestones include: (1) median CD4 count at diagnosis , care enrollment , and ART initiation ; (2) time between diagnosis, enrollment ; (3) time between enrollment and ART initiation ; and (4) time to first HIV viral suppression and sustained HIV viral suppression. Research approaches : Metrics for this research priority could be generated from routinely collected, patient‐level, programmatic data. Where CD4 count and viral load data are not readily available for a large enough proportion of clinics and patients, it may be possible to produce estimates from a systematic sample of sites.…”

Characterizing a Leak in the HIV Care Cascade: Assessing Linkage Between HIV Testing and Care in Tanzania

“…Our finding that approximately a quarter of cases did not link to care during the pilot, is similar to the findings of other studies in Tanzania. The study in the Kilimanjaro region found that only 70% had presented to for HIV care within 6 months after receiving a positive HIV test result (10), and in the Mbeya region study, 78% linked to care within 6 months (7). Linkage to care rates vary throughout sub-Saharan Africa.…”

“…Other studies conducted in Tanzania have found similar associations. A study conducted in the Mbeya region found that people testing positive at a facility with a CTC, were 78% more likely to link to care compared to people testing at mobile/outreach sites (7). Another study in the Tanga region found a significant association between early entry in care and point of diagnosis, level of education and CD4 count (9).…”

“…Timely linkage to care remains an issue in sub-Saharan Africa, including Tanzania (6)(7)(8)(9)(10). The prevalence of HIV in Tanzania among adults aged 15-49 years is 5.1% (11), with an estimated 1.4 million people living with HIV (12).…”

Facilitators and Barriers to Linkage to HIV Care and Treatment among Female Sex Workers in a Community-based HIV Prevention Intervention in Tanzania: a qualitative study

“…We employ a social-ecological perspective to explore more precisely what factors prevented or facilitated FSWs testing positive in the Sauti Project services to initiate HIV care, with the aim of adapting programs to increase initiation rates. Indeed, a study conducted in Mbeya found that about a third (31%) of individuals testing HIV positive did not link to care for a period of six months (13). An exploration of the barriers and facilitators of linkage to care among FSWs is critical for designing effective interventions to reach national and global goals for HIV control.…”