Less than half of HIV-positive people identified through HBTC link to care in large community study in KwaZulu-Natal

 Access to HIV care in the context of universal test and treat: challenges within the ANRS 12249 TasP cluster-randomized trial in rural South Africa.

Plazy M, Farouki KE, Iwuji C, Okesola N, Orne-Gliemann J, Larmarange J, Lert F, Newell ML, Dabis F, Dray-Spira R. J Int AIDS Soc. 2016 Jun 1;19(1):20913. doi: 10.7448/IAS.19.1.20913. eCollection 2016.

Introduction: We aimed to quantify and identify associated factors of linkage to HIV care following home-based HIV counselling and testing (HBHCT) in the ongoing ANRS 12249 treatment-as-prevention (TasP) cluster-randomized trial in rural KwaZulu-Natal, South Africa.

Methods: Individuals ≥16 years were offered HBHCT; those who were identified HIV positive were referred to cluster-based TasP clinics and offered antiretroviral treatment (ART) immediately (five clusters) or according to national guidelines (five clusters). HIV care was also available in the local Department of Health (DoH) clinics. Linkage to HIV care was defined as TasP or DoH clinic attendance within three months of referral among adults not in HIV care at referral. Associated factors were identified using multivariable logistic regression adjusted for trial arm.

Results: Overall, 1323 HIV-positive adults (72.9% women) not in HIV care at referral were included, of whom 36.9% (n=488) linked to care <3 months of referral (similar by sex). In adjusted analyses (n=1222), individuals who had never been in HIV care before referral were significantly less likely to link to care than those who had previously been in care (<33% vs. >42%, p<0.001). Linkage to care was lower in students (adjusted odds-ratio [aOR]=0.47; 95% confidence interval [CI] 0.24-0.92) than in employed adults, in adults who completed secondary school (aOR=0.68; CI 0.49-0.96) or at least some secondary school (aOR=0.59; CI 0.41-0.84) versus ≤ primary school, in those who lived at 1 to 2 km (aOR=0.58; CI 0.44-0.78) or 2-5 km from the nearest TasP clinic (aOR=0.57; CI 0.41-0.77) versus <1 km, and in those who were referred to clinic after ≥2 contacts (aOR=0.75; CI 0.58-0.97) versus those referred at the first contact. Linkage to care was higher in adults who reported knowing an HIV-positive family member (aOR=1.45; CI 1.12-1.86) versus not, and in those who said that they would take ART as soon as possible if they were diagnosed HIV positive (aOR=2.16; CI 1.13-4.10) versus not.

Conclusions: Fewer than 40% of HIV-positive adults not in care at referral were linked to HIV care within three months of HBHCT in the TasP trial. Achieving universal test and treat coverage will require innovative interventions to support linkage to HIV care.

Abstract  Full-text [free] access 

Editor’s notes: The UNAIDS treatment target set for 2020 aims for at least 90 percent of all people living with HIV to be diagnosed, at least 90 percent of people diagnosed to receive antiretroviral therapy, and for treatment to be effective and consistent enough in at least 90 percent of people on treatment to suppress the virus. This would result in about 73% of all HIV-positive people being virally suppressed. 

This manuscript describes the linkage to care after being diagnosed HIV- positive during home based testing and counselling (HBTC) in a Treatment as Prevention trial in Kwazulu-Natal, South Africa. About 30% of consenting participants were HIV-positive. Some 43% of these participants were new diagnoses, 26% had previously been diagnosed but never accessed care, and about 31% had already accessed HIV care but dropped out of care. The authors found disappointingly low linkage proportions: fewer than 40% of participants diagnosed through HBTC accessed an HIV clinic within three months of referral. 

Although stigma is a commonly cited barrier to adherence, the authors did not find an association between perceived stigma and linkage to care. They did find that people with HIV-positive family members were more likely to access HIV care than people who did not, and suggest that this might be because they are more confident in disclosing their status and more likely to receive family support.

These findings are particularly relevant in the context of the results of the parent Treatment as Prevention trial, which were reported at the AIDS2016 conference in Durban. The trial found no effect on HIV incidence of offering immediate ART, mainly due to the low rates of linkage to care following HIV diagnosis. This underscores that while HBTC is useful to ensure that HIV-positive people know their status, further programmes are necessary to maximise the number of people linked to care and initiating ART.

South Africa
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