Linkage to HIV Care From a Mobile Testing Unit in South Africa by Different CD4 Count Strata

Abstract

Background The linkage and barriers of linkage to facility-based HIV care from a mobile HIV testing unit have not previously been described. Methods A stratified random sample (N=192) was drawn of all eligible, newly-diagnosed HIV-infected individuals with a laboratory CD4 count result on a mobile unit between August 2008 and December 2009. All individuals with CD4 counts ≤ 350 cells/μl and 30% of individuals with CD4 counts > 350 cells/μl were sampled. Linkage to care was assessed during April to June 2010 in those that received their CD4 count result. A participant who accessed HIV care at least once after testing was regarded as having linked to care. Binomial regression models were used to identify clinical and socio-demographic factors associated with receiving a CD4 count result and linking to care. Results Forty-three (27%) individuals did not receive their CD4 count result. A lower CD4 count, being female and the availability of a phone number increased the likelihood of receiving this result. Follow-up was attempted in the remaining 145 individuals. Ten refused to participate and contact was unsuccessful in 42.4%. Linkage was 100% in patients with CD4 counts ≤ 200 cells/μl, 66.7% in individuals with CD4 counts of 201-350 cells/μl and 36.4% in those with CD4 counts > 350 cells/μl. A lower CD4 count, disclosure, presence of TB symptoms and unemployment increased the likelihood of linking to care. Conclusion Linkage to care was best among those eligible for ART. Interventions designed at improving linkage among employed individuals are urgently warranted.

Health Care Utilization and Access to Human Immunodeficiency Virus (HIV) Testing and Care and Treatment Services in a Rural Area with High HIV Prevalence, Nyanza Province, Kenya, 2007

“…Thus, in our population, in which 84% of men reported a clinician or medical facility for routine medical care and 53% had received clinical services within the past 12 months, effective implementation of routine opt-out PITC through voluntary medical male circumcision programs and other outpatient clinical services could be a cost-effective strategy 35 and substantially expand male testing coverage 36 and uptake of HIV care and treatment services. 37 Consequently, the complementary implementation of nonfacility-based HIV testing strategies demonstrated to have strong linkage to care and treatment services (e.g., mVCT with point of care CD4 cell testing 38 or incentivized testing 39 ) could be more efficiently directed to male and younger populations not otherwise reached through general medical services.…”

Provision of Antiretroviral Therapy in South Africa: The Nuts and Bolts

“…The adoption of a higher CD4 + T-cell count threshold of <350 cells/µl in 2012 for initiation of ART has increased the proportion of asymptomatic PLHIV who are eligible for ART. However, predominantly health-facility-based HIV testing is a barrier to reaching these individuals and alternative pathways to care are required [47,48]. New strategies for HIV testing are being piloted; including home-based testing, self-testing, stand-alone HIV testing sites and mobile clinic testing [47][48][49] with universal testing in TB and antenatal clinics (ANC).…”

“…However, predominantly health-facility-based HIV testing is a barrier to reaching these individuals and alternative pathways to care are required [47,48]. New strategies for HIV testing are being piloted; including home-based testing, self-testing, stand-alone HIV testing sites and mobile clinic testing [47][48][49] with universal testing in TB and antenatal clinics (ANC). In 2011, the policy of provider-initiated 'opt out' testing was recommended and this has now been widely adopted in the country [50].…”

HIV point-of-care diagnostics: meeting the special needs of sub-Saharan Africa

“…Geographical, socio-economic, and skilled personnel limitations constitute barriers to accessing quality HIV care. An estimated 40% of persons diagnosed with HIV infection in sub-Saharan Africa either do not provide a blood sample for CD4 cell evaluation or do not return to obtain their CD4 count results because access routes are complex [8,77]. With the existing diagnostic platform in subSaharan Africa, it becomes difficult to recruit more patients into care while effectively monitoring patients already in care.…”

“…In addition, the leveraging of mobile smart phones and the development of telemedicine can help address challenges of POC implementation in regions where access to computing systems is limited [23,77]. For example, telephonic counseling has been shown to improve outcomes of HIV in-home testing [23].…”