Linkage to care following a home‐based HIV counselling and testing intervention in rural South Africa

Abstract

IntroductionEfforts to increase awareness of HIV status have led to growing interest in community-based models of HIV testing. Maximizing the benefits of such programmes requires timely linkage to care and treatment. Thus, an understanding of linkage and its potential barriers is imperative for scale-up.MethodsThis study was conducted in rural South Africa. HIV-positive clients (n=492) identified through home-based HIV counselling and testing (HBHCT) were followed up to assess linkage to care, defined as obtaining a CD4 count. Among 359 eligible clients, we calculated the proportion that linked to care within three months. For 226 clients with available data, we calculated the median CD4. To determine factors associated with the rate of linkage, Cox regression was performed on a subsample of 196 clients with additional data on socio-demographic factors and personal characteristics.ResultsWe found that 62.1% (95% CI: 55.7 to 68.5%) of clients from the primary sample (n=359) linked to care within three months of HBHCT. Among those who linked, the median CD4 count was 341 cells/mm3 (interquartile range [IQR] 224 to 542 cells/mm3). In the subsample of 196 clients, factors predictive of increased linkage included the following: believing that drugs/supplies were available at the health facility (adjusted hazard ratio [aHR] 1.78; 95% CI: 1.07 to 2.96); experiencing three or more depression symptoms (aHR 2.09; 95% CI: 1.24 to 3.53); being a caregiver for four or more people (aHR 1.93; 95% CI: 1.07 to 3.47); and knowing someone who died of HIV/AIDS (aHR 1.68; 95% CI: 1.13 to 2.49). Factors predictive of decreased linkage included the following: younger age – 15 to 24 years (aHR 0.50; 95% CI: 0.28 to 0.91); living with two or more adults (aHR 0.52; 95% CI: 0.35 to 0.77); not believing or being unsure about the test results (aHR 0.48; 95% CI: 0.30 to 0.77); difficulty finding time to seek health care (aHR 0.40; 95% CI: 0.24 to 0.67); believing that antiretroviral treatment can make you sick (aHR 0.56; 95% CI: 0.35 to 0.89); and drinking alcohol (aHR 0.52; 95% CI: 0.34 to 0.80).ConclusionsThe findings highlight barriers to linkage following an increasingly popular model of HIV testing. Further, they draw attention to ways in which practical interventions and health education strategies could be used to improve linkage to care.

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].…”

“…Adolescents may be undiagnosed in part because they have been infected for a shorter time [20,32]. The lower probability of linkage once diagnosed, which was also found in other studies, highlights the need of specific interventions targeting youth and adolescents [26,[34][35][36]. This study was based on a large and representative population sample.…”

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

“…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.…”

“…Results from observational studies suggest that counselling provided after referral could increase linkage to care among HIV‐positive persons identified through HBHCT in SSA 6, 7, 8, 9, 10. A major limitation of observational studies, however, is that it is difficult to account for the effects of confounding factors.…”