Linkage to and engagement in HIV care in western Kenya: an observational study using population-based estimates from home-based counselling and testing

Abstract

Summary Background There is limited research characterizing the HIV care continuum with population-based data in sub-Saharan Africa. The objectives of this study were to: 1) describe engagement in care among all known HIV-positive adults in one sub-county of western Kenya; and 2) determine the time to and predictors of linkage and engagement among adults newly diagnosed via home-based counseling and testing (HBCT). Methods AMPATH (Academic Model Providing Access to Healthcare) has provided HIV care in western Kenya since 2001 and HBCT since 2007. Following a widespread HBCT program in Bunyala sub-county, electronic medical records (EMR) were reviewed to identify uptake of care among individuals with previously known (self-reported) infection and new (identified by HBCT) HIV diagnoses as of June 2014. Engagement in HIV care was defined as an initial encounter with an HIV care provider. Cox regression analysis was used to examine the predictors of engagement among those newly diagnosed. Findings Of the 3,482 infected adults identified, 61% had previously known infections, among whom 84% (n = 1778/2122) had ever had at least one clinical encounter within AMPATH. While 73% were registered in the EMR, only 15% (n = 209/1360) of the newly diagnosed had seen a clinician over a median of 3·4 years. The median time to engagement among the newly diagnosed was 60 days (interquartile range: 10–411 days). Interpretation Engagement in care was high among those who at the time of HBCT were already known HIV-positive, but few who were newly diagnosed in HBCT saw an HIV care provider. Funding This research was supported by the President’s Emergency Plan for AIDS Relief (PEPFAR) through USAID under the terms of Cooperative Agreement No. AID-623-A-12-0001. The HBCT program was supported by grants from Abbott Laboratories, the Purple ville Foundation, and the Global Business Coalition. Abbott Laboratories provided test kits and logistical support. Further support was provided by the National Institute of Mental Health (K01MH099966, PI: Genberg) and the Bill and Melinda Gates Foundation. The contents of this study are the sole responsibility of the authors and do not necessarily reflect the views of USAID, NIMH, BMGF, or the United States Government.

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.…”

“…On the basis of findings from HBHCT studies in which only referral was provided following HIV diagnosis 30, 31, 32, 33 and those in which counselling was provided after referral 6, 7, we assumed linkage of 35% in the control arm and that this would increase to 60% in the intervention arm. We aimed to have 80% power to detect this increase at a significance level of 5%.…”

Factors associated with HIV status awareness and Linkage to Care following home based testing in rural Malawi

“…These linkage-to-care results (49% at 3 months) are in line with other studies conducted in sub-Saharan Africa using home-based [26,27] and other testing strategies [6]. Our study adds to the evidence base that home-based testing strategies are effective to diagnose and link to care remaining undiagnosed individuals in a population where an already high proportion is diagnosed, but also underscores that more attention is needed to support timely linkage to care.…”

“…Similar to other studies, we found that young HIVpositive adolescents and young adults (age [15][16][17][18][19][20][21][22][23][24][25][26][27][28][29] were less likely to be diagnosed and to link to care once diagnosed. Survey data collected from sub-Saharan Africa indicate that only 10% of young men and 15% of young women (15-24 years) were aware of their HIV status [34].…”

Home testing and counselling with linkage to care

“…9 Our work in the Academic Model Providing Access to Healthcare (AMPATH) programme in western Kenya shows high levels of HTC coverage, but suggests linkage rates might be low if not actively facilitated. 10 Ying and colleagues write about an encouraging intervention in a catchment area where HTC had very high coverage and linkage to care was strong because of the geographical proximity of care facilities. 1,11 Although frequency of HTC plays a part, the main focus of the analysis by Ying and colleagues is a comparison of ART initiation thresholds under an assumption of high rates of linkage to care.…”