Linkage to HIV care after home-based HIV counselling and testing in sub-Saharan Africa: a systematic review

Population impacts of conditional financial incentives and a male-targeted digital decision support application on the HIV treatment cascade in rural KwaZulu Natal: findings from the HITS cluster randomized clinical trial

INTRODUCTION

In South Africa, the HIV care cascade remains suboptimal. We investigated the impact of small conditional financial incentives (CFIs) and male-targeted HIV-specific decision-support application (EPIC-HIV) on the HIV care cascade.

METHODS

In 2018, in uMkhanyakude district, 45 communities were randomly assigned to one of four arms: (i) CFI for home-based HIV testing and linkage to care within 6 weeks (R50 [US$3] food voucher each); (ii) EPIC-HIV which are based on self-determination theory; (iii) both CFI and EPIC-HIV; and (iv) standard of care. EPIC-HIV consisted of two components: EPIC-HIV 1, provided to men through a tablet before home-based HIV testing, and EPIC-HIV 2, offered 1 month later to men who tested positive but had not yet linked to care. Linking HITS trial data to national antiretroviral treatment (ART) programme data and HIV surveillance programme data, we estimated HIV status awareness after the HITS trial implementation, ART status 3 month after the trial and viral load suppression 1 year later. Analysis included all known individuals living with HIV in the study area including those who did not participated in the HITS trial.

RESULTS

Among the 33,778 residents in the study area, 2763 men and 7266 women were identified as living with HIV by the end of the intervention period and included in the analysis. After the intervention, awareness of HIV-positive status was higher in the CFI arms compared to non-CFI arms (men: 793/908 [87.3%] vs. 1574/1855 [84.9%], RR = 1.03 [95% CI: 0.99-1.07]; women: 2259/2421 [93.3%] vs. 4439/4845 [91.6%], RR = 1.02 [95% CI: 1.00-1.04]). Three months after the intervention, no differences were found for linkage to ART between arms. One year after the intervention, only 1829 viral test results were retrieved. Viral suppression was higher but not significant in the EPIC-HIV intervention arms among men (65/99 [65.7%] vs. 182/308 [59.1%], RR = 1.11 [95% CI: 0.88-1.40]).

CONCLUSIONS

Small CFIs can contribute to achieve the first step of the HIV care cascade. However, neither CFIs nor EPIC-HIV was sufficient to increase the number of people on ART. Additional evidence is needed to confirm the impact of EPIC-HIV on viral suppression.

Understanding motivations and resilience-associated factors to promote timely linkage to HIV care: a qualitative study among people living with HIV in western Kenya

Understanding motivations and resilience-associated factors that help people newly diagnosed with HIV link to care is critical in the context of universal test and treat. We analyzed 30 in-depth interviews (IDI) among adults aged 18 and older in western Kenya diagnosed with HIV during home-based counseling and testing and who had linked to HIV care. A directed content analysis was performed, categorizing IDI quotations into a table based on linkage stages for organization and then developing and applying codes from self-determination theory and the concept of resilience. Autonomous motivations, including internalized concerns for one's health and/or to provide care for family, were salient facilitators of accessing care. Controlled forms of motivation, such as fear or external pressure, were less salient. Social support was an important resilience-associated factor fostering linkage. HIV testing and counseling programs which incorporate motivational interviewing that emphasizes motivations related to one's health or family combined with a social support/navigator approach, may promote timely linkage to care.

HIV Care Profiling and Delivery Status in the Mobile Health Clinics of eThekwini District in KwaZulu Natal, South Africa: A Descriptive Evaluation Study

Mobile health clinics (MHCs) serve as an alternative HIV care delivery method for the HIV-burdened eThekwini district. This study aimed to describe and profile the HIV care services provided by the MHCs through process evaluation. A descriptive cross-sectional quantitative evaluation study was performed on 137 MHCs using total population sampling. An online data collection method using a validated 50-item researcher-developed instrument was administered to professional nurses who are MHC team leaders, following ethical approval from the local university and departments of health. Descriptive statistics were used to analyze the data. The results described that HIV care services are offered in open spaces (43%), community buildings (37%), solid built buildings called health posts (15%), vehicles (9%), and tents (2%) with no electricity (77%), water (55%), and sanitation (64%). Adults (97%) are the main recipients of HIV care in MHCs (90%) offering antiretroviral therapy (95%). Staff, monitoring, and retaining care challenges were noted, with good linkage (91%) and referral pathways (n = 123.90%). In conclusion, the standardization and prioritization of HIV care with specific contextual practice guidelines are vital.

Prevalence of delayed antiretroviral therapy initiation among people living with HIV: A systematic review and meta-analysis

OBJECTIVE

HIV continues to be a global challenge. Key recommendations for HIV prevention and treatment are presented on rapid antiretroviral therapy (ART) initiation. However, several studies showed a high prevalence of delayed ART initiation. The aim of this systematic review and meta-analysis was to assess the prevalence of delayed ART initiation among HIV-infected patients globally.

METHODS

This review summarised eligible studies conducted between January 2015 and August 2022 on the prevalence of delayed ART initiation in HIV-infected adults (age ≥ 15). Relevant studies were systematic searched through PubMed/Medline, EMBASE, Web of Science, China National Knowledge Infrastructure, Wanfang, and Chongqing VIP databases. Random-effects models were used to calculate pooled prevalence estimates. The heterogeneity was evaluated using Cochran's Q test and I2 statistics. Moreover, potential sources of heterogeneity were explored using univariate subgroup analysis.

RESULTS

Data on the prevalence of delayed ART initiation was pooled across 29 studies involving 34,937 participants from 15 countries. The overall pooled prevalence of delayed ART initiation was 36.1% [95% confidence interval (CI), 29.7-42.5%]. In subgroup analysis, the estimated pooled prevalence decreased with age. By sex, the prevalence was higher among male patients (39.3%, 95% CI: 32.2-46.4%) than female (36.5%, 95% CI: 26.9-50.7%). Patients with high CD4 cell count were more likely to delay ART initiation than those with low CD4 cell count (>500cells/mm3: 40.3%; 201-500cells/mm3: 33.4%; and ≤200cells/mm3: 25.3%).

CONCLUSIONS

Our systematic review and meta-analysis identified a high prevalence of delayed ART initiation. The prolonged time interval between diagnosis and treatment is a prevalent and unaddressed problem that should spur initiatives from countries globally. Further research is urgently needed to identify effective strategies for promoting the early ART initiation.

Secondary distribution of HIV self-test kits by HIV index and antenatal care clients: implementation and costing results from the STAR Initiative in South Africa

BACKGROUND

Partner-delivered HIV self-testing kits has previously been highlighted as a safe, acceptable and effective approach to reach men. However, less is known about its real-world implementation in reaching partners of people living with HIV. We evaluated programmatic implementation of partner-delivered self-testing through antenatal care (ANC) attendees and people newly diagnosed with HIV by assessing use, positivity, linkage and cost per kit distributed.

METHODS

Between April 2018 and December 2019, antenatal care (ANC) clinic attendees and people or those newly diagnosed with HIV clients across twelve clinics in three cities in South Africa were given HIVST kits (OraQuick Rapid HIV-1/2 Antibody Test, OraSure Technologies) to distribute to their sexual partners. A follow-up telephonic survey was administered to all prior consenting clients who were successfully reached by telephone to assess primary outcomes. Incremental economic costs of the implementation were estimated from the provider's perspective.

RESULTS

Fourteen thousand four hundred seventy-three HIVST kits were distributed - 10,319 (71%) to ANC clients for their male partner and 29% to people newly diagnosed with HIV for their partners. Of the 4,235 ANC clients successfully followed-up, 82.1% (3,475) reportedly offered HIVST kits to their male partner with 98.1% (3,409) accepting and 97.6% (3,328) using the kit. Among ANC partners self-testing, 159 (4.8%) reported reactive HIVST results, of which 127 (79.9%) received further testing; 116 (91.3%) were diagnosed with HIV and 114 (98.3%) initiated antiretroviral therapy (ART). Of the 1,649 people newly diagnosed with HIV successfully followed-up; 1,312 (79.6%) reportedly offered HIVST kits to their partners with 95.8% (1,257) of the partners accepting and 95.9% (1,206) reported that their partners used the kit. Among these index partners, 297 (24.6%) reported reactive HIVST results of which 261 (87.9%) received further testing; 260 (99.6%) were diagnosed with HIV and 258 (99.2%) initiated ART. The average cost per HIVST distributed in the three cities was US$7.90, US$11.98, and US$14.81, respectively.

CONCLUSIONS

Partner-delivered HIVST in real world implementation was able to affordably reach many male partners of ANC attendees and index partners of people newly diagnosed with HIV in South Africa. Given recent COVID-19 related restrictions, partner-delivered HIVST provides an important strategy to maintain essential testing services.

Implementation and effectiveness of a linkage to HIV care intervention in rural South Africa (ANRS 12249 TasP trial)

BACKGROUND

Timely linkage to care and ART initiation is critical to decrease the risks of HIV-related morbidity, mortality and HIV transmission, but is often challenging. We report on the implementation and effectiveness of a linkage-to-care intervention in rural KwaZulu-Natal, South Africa.

METHODS

In the ANRS 12249 TasP trial on Universal Testing and Treatment (UTT) implemented between 2012-2016, resident individuals ≥16 years were offered home-based HIV testing every six months. Those ascertained to be HIV-positive were referred to trial clinics. Starting May 2013, a linkage-to-care intervention was implemented in both trial arms, consisting of tracking through phone calls and/or home visits to "re-refer" people who had not linked to care to trial clinics within three months of the first home-based referral. Fidelity in implementing the planned intervention was described using Kaplan-Meier estimation to compute conditional probabilities of being tracked and of being re-referred by the linkage-to-care team. Effect of the intervention on time to linkage-to-care was analysed using a Cox regression model censored for death, migration, and end of data follow-up.

RESULTS

Among the 2,837 individuals (73.7% female) included in the analysis, 904 (32%) were tracked at least once, and 573 of them (63.4%) were re-referred. Probabilities of being re-referred was 17% within six months of first referral and 31% within twelve months. Compared to individuals not re-referred by the intervention, linkage-to-care was significantly higher among those with at least one re-referral through phone call (adjusted hazard ratio [aHR] = 1.82; 95% confidence interval [95% CI] = 1.47-2.25), and among those with re-referral through both phone call and home visit (aHR = 3.94; 95% CI = 2.07-7.48).

CONCLUSIONS

Phone calls and home visits following HIV testing were challenging to implement, but appeared effective in improving linkage-to-care amongst those receiving the intervention. Such patient-centred strategies should be part of UTT programs to achieve the UNAIDS 95-95-95 targets.

Early observations from the HIV self-testing program among key populations and sexual partners of pregnant mothers in Kampala, Uganda: A cross sectional study

BACKGROUND

HIV self-testing (HIVST) was adopted for key populations (KPs) and sexual partners of pregnant and lactating women (mothers) in Uganda in October 2018. We report early observations during HIVST implementation in Kampala, Uganda.

METHODS

HIVST was rolled out to reach those with unknown HIV status at 38 public health facilities, using peer-to-peer community-based distribution for female sex workers (FSW) and men who have sex with men (MSM) and secondary distribution for mothers, who gave HIVST kits to their partners. Self-testers were asked to report results within 2 days; those who did not report received a follow-up phone call from a trained health worker. Those with HIV-positive results were offered confirmatory testing at the facility using the standard HIV-testing algorithm. Data on kits distributed, testing yield, and linkage to care were analysed.

RESULTS

We distributed 9,378 HIVST kits. Mothers received 5,212 (56%) for their sexual partners while KPs received 4,166 (44%) (MSM, 2192 [53%]; FSW1, 974, [47%]). Of all kits distributed, 252 (3%) individuals had HIV-positive results; 126 (6.5%) FSW, 52 (2.3%) MSM and 74 (1.4%) partners of mothers. Out of 252 individuals who had HIV-positive results, 170 (67%) were confirmed HIV-positive; 36 (2%) were partners of mothers, 99 (58%) were FSW, and 35 (21%) were MSM. Linkage to treatment (126) was 74%.

CONCLUSIONS

HIVST efficiently reached, tested, identified and modestly linked to care HIV positive FSW, MSM, and partners of mothers. However, further barriers to confirmatory testing and linkage to care for HIV-positive self-testers remain unexplored.

Longitudinal analysis of sociodemographic, clinical and therapeutic factors of HIV-infected individuals in Kinshasa at antiretroviral therapy initiation during 2006-2017

Background

The benefits of antiretroviral therapy (ART) underpin the recommendations for the early detection of HIV infection and ART initiation. Late initiation (LI) of antiretroviral therapy compromises the benefits of ART both individually and in the community. Indeed, it promotes the transmission of infection and higher HIV-related morbidity and mortality with complicated and costly clinical management.

This study aims to analyze the evolutionary trends in the median CD4 count, the median time to initiation of ART, the proportion of patients with advanced HIV disease at the initiation of ART between 2006 and 2017 and their factors.

Methods and findings

HIV-positive adults (≥ 16 years old) who initiated ART between January 1, 2006 and December 31, 2017 in 25 HIV care facilities in Kinshasa, the capital of DRC, were eligible. The data were processed anonymously. LI is defined as CD4≤350 cells/μl and/or WHO clinical stage III or IV and advanced HIV disease (AHD), as CD4≤200 cells/μl and/or stage WHO clinic IV. Factors associated with advanced HIV disease at ART initiation were analyzed, irrespective of year of enrollment in HIV care, using logistic regression models.

A total of 7278 patients (55% admitted after 2013) with an average age of 40.9 years were included. The majority were composed of women (71%), highly educated women (68%) and married or widowed women (61%). The median CD4 was 213 cells/μl, 76.7% of patients had CD4≤350 cells/μl, 46.1% had CD4≤200 cells/μl, and 59% of patients were at WHO clinical stages 3 or 4. Men had a more advanced clinical stage (p <0.046) and immunosuppression (p<0.0007) than women.

Overall, 70% of patients started ART late, and 25% had AHD. Between 2006 and 2017, the median CD4 count increased from 190 cells/μl to 331 cells/μl (p<0.0001), and the proportions of patients with LI and AHD decreased from 76% to 47% (p< 0.0001) and from 18.7% to 8.9% (p<0.0001), respectively.

The median time to initiation of ART after screening for HIV infection decreased from 40 to zero months (p<0.0001), and the proportion of time to initiation of ART in the month increased from 39 to 93.3% (p<0.0001) in the same period.

The probability of LI of ART was higher in married couples (OR: 1.7; 95% CI: 1.3–2.3) (p<0.0007) and lower in patients with higher education (OR: 0.74; 95% CI: 0.64–0.86) (p<0.0001).

Conclusion

Despite increasingly rapid treatment, the proportions of LI and AHD remain high. New approaches to early detection, the first condition for early ART and a key to ending the HIV epidemic, such as home and work HIV testing, HIV self-testing and screening at the point of service, must be implemented.

Enthusiasm for Introducing and Integrating HIV Self-Testing but Doubts About Users: A Baseline Qualitative Analysis of Key Stakeholders' Attitudes and Perceptions in Côte d'Ivoire, Mali and Senegal

Since 2019, the ATLAS project, coordinated by Solthis in collaboration with national AIDS programs, has introduced, promoted and delivered HIV self-testing (HIVST) in Côte d'Ivoire, Mali and Senegal. Several delivery channels have been defined, including key populations: men who have sex with men, female sex workers and people who use injectable drugs. At project initiation, a qualitative study analyzing the perceptions and attitudes of key stakeholders regarding the introduction of HIVST in their countries and its integration with other testing strategies for key populations was conducted. The study was conducted from September to November 2019 within 3 months of the initiation of HIVST distribution. Individual interviews were conducted with 60 key informants involved in the project or in providing support and care to key populations: members of health ministries, national AIDS councils, international organizations, national and international non-governmental organizations, and peer educators. Semi structured interviews were recorded, translated when necessary, and transcribed. Data were coded using Dedoose© software for thematic analyses. We found that stakeholders' perceptions and attitudes are favorable to the introduction and integration of HIVST for several reasons. Some of these reasons are held in common, and some are specific to each key population and country. Overall, HIVST is considered able to reduce stigma; preserve anonymity and confidentiality; reach key populations that do not access testing via the usual strategies; remove spatial barriers; save time for users and providers; and empower users with autonomy and responsibility. It is non-invasive and easy to use. However, participants also fear, question and doubt users' autonomy regarding their ability to use HIVST kits correctly; to ensure quality secondary distribution; to accept a reactive test result; and to use confirmation testing and care services. For stakeholders, HIVST is considered an attractive strategy to improve access to HIV testing for key populations. Their doubts about users' capacities could be a matter for reflective communication with stakeholders and local adaptation before the implementation of HIVST in new countries. Those perceptions may reflect the West African HIV situation through the emphasis they place on the roles of HIV stigma and disclosure in HIVST efficiency.

Improved detection and management of advanced HIV disease through a community adult TB-contact tracing intervention with same-day provision of the WHO-recommended package of care including ART initiation in a rural district of Mozambique

INTRODUCTION

AIDS-mortality remains unacceptably high in sub-Saharan Africa, largely driven by advanced HIV disease (AHD). We nested a study in an existing tuberculosis (TB) contact-tracing intervention (Xpatial-TB). The aim was to assess the burden of AHD among high-risk people living with HIV (PLHIV) identified and to evaluate the provision of the WHO-recommended package of care to this population.

METHODS

All PLHIV ≥14 years old identified between June and December 2018 in Manhiça District by Xpatial-TB were offered to participate in the study if ART naïve or had suboptimal ART adherence. Consenting individuals were screened for AHD. Patients with AHD (CD4 < 200 cells/μL or WHO stage 3 or 4) were offered a package of interventions in a single visit, including testing for cryptococcal antigen (CrAg) and TB-lipoarabinomannan (TB-LAM), prophylaxis and treatment for opportunistic infections, adherence support or accelerated ART initiation. We collected information on follow-up visits carried out under routine programmatic conditions for six months.

RESULTS

A total of 2881 adults were identified in the Xpatial TB-contact intervention. Overall, 23% (673/2881) were HIV positive, including 351 TB index (64.2%) and 322 TB contacts (13.8%). Overall, 159/673 PLHIV (24%) were ART naïve or had suboptimal ART adherence, of whom 155 (97%, 124 TB index and 31 TB-contacts) consented to the study and were screened for AHD. Seventy percent of TB index-patients (87/124) and 16% of TB contacts (5/31) had CD4 < 200 cells/µL. Four (13%) of the TB contacts had TB, giving an overall AHD prevalence among TB contacts of 29% (9/31). Serum-CrAg was positive in 4.6% (4/87) of TB-index patients and in zero TB contacts. All ART naïve TB contacts without TB initiated ART within 48 hours of HIV diagnosis. Among TB cases, ART timing was tailored to the presence of TB and cryptococcosis. Six-month mortality was 21% among TB-index cases and zero in TB contacts.

CONCLUSIONS

A TB contact-tracing outreach intervention identified undiagnosed HIV and AHD in TB patients and their contacts, undiagnosed cryptococcosis among TB patients, and resulted in an adequate provision of the WHO-recommended package of care in this rural Mozambican population. Same-day and accelerated ART initiation was feasible and safe in this population including among those with AHD.

Evidence on the effectiveness of community-based primary health care in improving HIV/AIDS outcomes for mothers and children in low- and middle-income countries: Findings from a systematic review

BACKGROUND

The effectiveness of community-based primary health care (CBPHC) interventions in low- and middle-income countries (LMICs), especially for maternal, neonatal and child health, is well established. However, there has not been a systematic review of the literature on the effectiveness of CBPHC on HIV outcomes derived from rigorous assessments of primary studies. Using peer-reviewed studies of randomized interventions or those containing a specified control group and directly measuring clinical HIV outcomes, we provide evidence for the effectiveness of CBPHC on HIV outcomes for mothers and children in low- and middle-income countries (LMICs).

METHODS

Eligibility criteria included studies assessing the effectiveness of community-based HIV interventions with or without a facility-based component, or multiple integrated projects, with outcome measures defining an aspect of HIV health status such as the utilization of prevention or health care services, nutritional status, serious morbidity (including clinical measures of HIV progression) or mortality of children aged five or younger and pregnant women. Articles published through June 3, 2020 were identified by searching four databases. The type of community-based projects implemented, the implementors, and the implementation strategies of each program were identified and the impact on HIV-related outcomes assessed.

RESULTS

The search yielded 10 537 articles; 4881 underwent title and abstract screening after removing duplicates. Of these, 117 studies qualified for full-text screening; only 22 were included in the final analysis. Most studies showed that community-based interventions improved HIV prevention and treatment outcomes compared to facility-based approaches alone. Each study had at least one statistically significant HIV-related outcome; the non-significant outcomes found in six of the 22 studies were mostly not related to HIV programming. Most interventions were implemented by community health workers; other implementers were government workers, community members, or research staff. Strategies used included peer-to-peer education, psychosocial support, training of community champions, community-based follow-up care, home-based care, and integrated care.

CONCLUSIONS

CBPHC strategies are effective in improving population-based, HIV-related health outcomes for mothers and children, especially in combination with facility-based approaches. However, there is a need to assess the scalability of such interventions and integrate them into existing health systems to assess their impact on the HIV pandemic in more routine settings.

Costs of implementing community-based intervention for HIV testing in sub-Saharan Africa: a systematic review

BACKGROUND

Community-based interventions (CBIs) are interventions aimed at improving the well-being of people in a community. CBIs for HIV testing seek to increase the availability of testing services to populations that have been identified as at high risk by reaching them in homes, schools, or community centers. However, evidence for a detailed cost analysis of these community-based interventions in sub-Saharan Africa (SSA) is limited. We conducted a systematic review of the cost analysis of HIV testing interventions in SSA.

METHODS

Keyword search was conducted on SCOPUS, CINAHL, MEDLINE, PsycINFO, Web of Science, and Global Health databases. Three categories of key terms used were cost (implementation cost OR cost-effectiveness OR cost analysis OR cost-benefit OR marginal cost), intervention (HIV testing), and region (sub-Saharan Africa OR sub-Saharan Africa OR SSA). CBI studies were included if they primarily focused on HIV testing, was implemented in SSA, and used micro-costing or ingredients approach.

RESULTS

We identified 1533 citations. After screening, ten studies were included in the review: five from East Africa and five from Southern Africa. Two studies conducted cost-effectiveness analysis, and one study was a cost-utility analysis. The remainder seven studies were cost analyses. Four intervention types were identified: HIV self-testing (HIVST), home-based, mobile, and Provider Initiated Testing and Counseling. Commonly costed resources included personnel (n = 9), materials and equipment (n = 6), and training (n = 5). Cost outcomes reported included total intervention cost (n = 9), cost per HIV test (n = 9), cost per diagnosis (n = 5), and cost per linkage to care (n = 3). Overall, interventions were implemented at a higher cost than controls, with the largest cost difference with HIVST compared to facility-based testing.

CONCLUSION

To better inform policy, there is an urgent need to evaluate the costs associated with implementing CBIs in SSA. It is important for cost reports to be detailed, uniform, and informed by economic evaluation guidelines. This approach minimizes biases that may lead decision-makers to underestimate the resources required to scale up, sustain, or reproduce successful interventions in other settings. In an evolving field of implementation research, this review contributes to current resources on implementation cost studies.

Increasing the Uptake of HIV Testing among Men in Tanzania: A Novel Intervention for Bar Patrons

We investigated a novel community-based HIV testing and counseling (HTC) strategy by recruiting men from bars in northern Tanzania in order to identify new HIV infections. All bars in the town of Boma Ng'ombe were identified and male patrons were systematically invited to participate in a health study. HIV testing was offered to all enrolled participants. Outputs included HIV test yield, cost per diagnosis, and comparison of our observed test yield to that among male patients contemporaneously tested at five local facility-based HTC. We enrolled 366 participants and identified 17 new infections - providing a test yield of 5.3% (95% Confidence interval [CI] 3.3-8.4). The test yield among men contemporaneously tested at five local HTC centers was 2.1% (95% CI 1.6-2.8). The cost-per-diagnosis was $634. Our results suggest that recruiting male bar patrons for HIV testing is efficient for identifying new HIV infections. The scalability of this intervention warrants further evaluation.

Annual home-based HIV testing in the Chókwè Health Demographic Surveillance System, Mozambique, 2014 to 2019: serial population-based survey evaluation

INTRODUCTION

WHO recommends implementing a mix of community and facility testing strategies to diagnose 95% of persons living with HIV (PLHIV). In Mozambique, a country with an estimated 506,000 undiagnosed PLHIV, use of home-based HIV testing services (HBHTS) to help achieve the 95% target has not been evaluated.

METHODS

HBHTS was provided at 20,000 households in the Chókwè Health Demographic Surveillance System (CHDSS), Mozambique, in annual rounds (R) during 2014 to 2019. Trends in prevalence of HIV infection, prior HIV diagnosis among PLHIV (diagnostic coverage), and undiagnosed HIV infection were assessed with three population-based surveys conducted in R1 (04/2014 to 04/2015), R3 (03/2016 to 12/2016), and R5 (04/2018 to 03/2019) of residents aged 15 to 59 years. Counts of patients aged ≥15 years tested for HIV in CHDSS healthcare facilities were obtained from routine reports.

RESULTS

During 2014 to 2019, counsellors conducted 92,512 home-based HIV tests and newly diagnosed 3711 residents aged 15 to 59 years. Prevalence of HIV infection was stable (R1, 25.1%; R3 23.6%; R5 22.9%; p-value, 0.19). After the first two rounds (44,825 home-based tests; 31,717 facility-based tests), diagnostic coverage increased from 73.8% (95% CI 70.3 to 77.2) in R1 to 93.0% (95% CI 91.3 to 94.7) in R3, and prevalence of undiagnosed HIV infection decreased from 6.6% (95% CI 5.6 to 7.5) in R1 to 1.7% (95% CI 1.2 to 2.1) in R3. After two more rounds (32,226 home-based tests; 46,003 facility-based tests), diagnostic coverage was 95.4% (95% CI 93.7 to 97.1) and prevalence of undiagnosed HIV infection was 1.1% (95% CI 0.7 to 1.5) in R5. Prevalence of having last tested at home was 12.7% (95% CI 11.3 to 14.0) in R1, 45.2% (95% CI 43.4 to 47.0) in R3, and 41.4% (95% CI 39.5 to 43.2) in R5, and prevalence of having last tested at a healthcare facility was 45.3% (95% CI 43.3 to 47.3) in R1, 40.1% (95% CI 38.4 to 41.8) in R3, and 45.2% (95% CI 43.3 to 47.0) in R5.

CONCLUSIONS

HBHTS successfully augmented facility-based testing to achieve HIV diagnostic coverage in a high-burden community of Mozambique. HBHTS should be considered in sub-Saharan Africa communities striving to diagnose 95% of persons living with HIV.

Overcoming Barriers to HIV Care: Findings from a Peer-Delivered, Community-Based, Linkage Case Management Program (CommLink), Eswatini, 2015-2018

To help persons living with HIV (PLHIV) in Eswatini initiate antiretroviral therapy (ART), the CommLink case-management program provided a comprehensive package of linkage services delivered by HIV-positive, peer counselors. Of 1250 PLHIV participants aged ≥ 15 years diagnosed in community settings, 75% reported one or more barriers to care (e.g., fearing stigmatization). Peer counselors helped resolve 1405 (65%) of 2166 identified barriers. During Test and Treat (October 2016-September 2018), the percentage of participants who initiated ART and returned for ≥ 1 antiretroviral refills was 92% overall (759/824); 99% (155/156) among participants without any identified barriers; 96% (544/564) among participants whose counselors helped resolve all or all but one barrier; and 58% (59/102) among participants who had ≥ 2 unresolved barriers to care. The success of CommLink is attributed, at least in part, to peer counselors who helped their clients avoid or at least temporarily resolve many well-known barriers to HIV care.

Engagement in Care, Viral Suppression, Drug Resistance, and Reasons for Nonengagement After Home-Based Same-Day Antiretroviral Therapy Initiation in Lesotho: A Two-Year Follow-up of the CASCADE Trial

Background

The CASCADE trial showed that compared with usual care (UC), offering same-day (SD) antiretroviral therapy (ART) during home-based human immunodeficiency virus testing improved engagement in care and viral suppression 12 months after diagnosis. However, questions remain regarding long-term outcomes and the risk of propagating drug resistance.

Methods

After completion of the primary endpoint at 12 months, participants not in care in both arms were traced and encouraged to access care. At 24 months, the following outcomes were assessed in both arms: engagement in care, viral suppression, and reasons for nonengagement. Furthermore, we explored the acquisition of drug resistance mutations (DRMs) among SD arm nonlinkers.

Results

At 24 months, 64% (88/137) in the SD arm vs 59% (81/137) in the UC arm were in care (absolute difference [AD], 5%; 95% confidence interval [CI], −6 to16; P = .38) and 57% (78/137) vs 54% (74/137) had documented viral suppression (AD, 3%; 95% CI, −9 to 15; P = .28). Among 36 participants alive and not in care at 24 months with ascertained status, the majority rejected contact with the health system or were unwilling to take ART. Among 8 interviewed SD arm nonlinkers, 6 had not initiated ART upon enrollment, and no acquired DRMs were detected. Two had taken the initial 30-day ART supply and acquired DRMs.

Conclusions

SD ART resulted in higher rates of engagement in care and viral suppression at 12 months but not at 24 months. Leveling off between both arms was driven by linkage beyond 12 months in the UC arm. We did not observe compensatory long-term disengagement in the SD arm. These long-term results endorse SD ART initiation policies.

Clinical Trials Registration

NCT02692027.

Finding, treating and retaining persons with HIV in a high HIV prevalence and high treatment coverage country: Results from the Botswana Combination Prevention Project

INTRODUCTION

The scale-up of Universal Test and Treat has resulted in reductions in HIV morbidity, mortality and incidence. However, healthcare system and personal challenges have impacted the levels of treatment coverage achieved. We implemented interventions to improve linkage to care, retention, viral load (VL) coverage and service delivery, and describe the HIV care cascade over the course of the Botswana Combination Prevention Project (BCPP) study.

METHODS

BCPP was designed to evaluate the impact of prevention interventions on HIV incidence in 30 communities in Botswana. We followed a longitudinal cohort of newly identified and known HIV-positive persons not on antiretroviral therapy (ART) identified through community-based testing activities through BCPP and referred with appointments to local HIV clinics in 15 intervention communities. Those who did not keep the first or follow-up appointments were tracked and traced through phone and home contacts. Improvements to service delivery models in the intervention clinics were also implemented.

RESULTS

A total of 3,657 newly identified or HIV-positive persons not on ART were identified and referred to their local HIV clinic; 90% (3,282/3,657) linked to care and of those, 93% (3,066/3,282) initiated treatment. Near the end of the study, 221 persons remained >90 days late for appointments or missing. Tracing efforts identified 54/3,066 (2%) persons who initiated treatment but died, and 106/3,066 (3%) persons were located and returned to treatment. At study end, 61/3,066 (2%) persons remained missing and were never reached. Overall, 2,951 (98%) persons living with HIV (PLHIV) who initiated treatment were still alive, retained in care and still receiving ART out of the 3,001 persons alive at the end of the study. Of those on ART, 2,854 (97%) had current VL results and 2,784 (98%) of those were virally suppressed at study end.

CONCLUSIONS

This study achieved high rates of linkage, treatment initiation, retention and VL coverage and suppression in a cohort of newly identified and known PLHIV not on ART. Tracking and tracing interventions effectively identified those persons who needed more resource intensive follow-up. The interventions implemented to improve service delivery and data quality may have also contributed to high linkage and retention rates. Clinical trial number: NCT01965470.

Home- and Clinic-Based Pediatric HIV Index Case Testing in Kenya: Uptake, HIV Prevalence, Linkage to Care, and Missed Opportunities

INTRODUCTION

Gaps in HIV testing of children persist, particularly among older children born before the expansion of the prevention of mother-to-child transmission of HIV programs.

METHODS

The Counseling and Testing for Children at Home study evaluated an index-case pediatric HIV testing approach. Caregivers receiving HIV care at 7 health facilities in Kenya (index cases), who had children of unknown HIV status aged 0-12 years, were offered the choice of clinic-based testing (CBT) or home-based testing (HBT). Testing uptake and HIV prevalence were compared between groups choosing HBT and CBT; linkage to care, missed opportunities, and predictors of HIV-positive diagnosis were identified.

RESULTS

Among 493 caregivers, 70% completed HIV testing for ≥1 child. Most caregivers who tested children chose CBT (266/347, 77%), with 103 (30%) agreeing to same-day testing of an untested accompanying child. Overall HIV prevalence among 521 tested children was 5.8% (CBT 6.8% vs HBT 2.4%; P = 0.07). Within 1 month of diagnosis, 88% of 30 HIV-positive children had linked to care, and 54% had started antiretroviral treatment. For 851 children eligible for testing, the most common reason for having an unknown HIV status was that the child's mother was not tested for HIV or had tested HIV negative during pregnancy (82%).

CONCLUSION

Testing uptake and HIV prevalence were moderate with nonsignificant differences between HBT and CBT. Standardized offer to test children accompanying caregivers is feasible to scale-up with little additional investment. Linkage to care for HIV-positive children was suboptimal. Lack of peripartum maternal testing contributed to gaps in pediatric testing.

High Coverage of Antiretroviral Treatment With Annual Home-Based HIV Testing, Follow-up Linkage Services, and Implementation of Test and Start: Findings From the Chókwè Health Demographic Surveillance System, Mozambique, 2014-2019

BACKGROUND

Early antiretroviral therapy (ART) is necessary for HIV epidemic control and depends on early diagnosis and successful linkage to care. Since 2014, annual household-based HIV testing and counseling and linkage services have been provided through the Chókwè Health and Demographic Surveillance System for residents testing HIV positive in this high HIV-burden district.

METHODS

District-wide Test and Start [T&S, ART for all people living with HIV (PLHIV)] began in August 2016, supported by systematic interventions to improve linkage to care and treatment. Annual rounds (R) of random household surveys were conducted to assess trends in population prevalence of ART use and viral load suppression (<1000 viral RNA copies/mL).

RESULTS

Between R1 (April 2014-April 2015) and R5 (April 2018-Mar 2019), 46,090 (67.2%) of 68,620 residents aged 15-59 years were tested for HIV at home at least once, and 3711 were newly diagnosed with HIV and provided linkage services. Population prevalence of current ART use among PLHIV increased from 65.0% to 87.5% between R1 and R5. ART population prevalence was lowest among men aged 25-34 years (67.8%) and women aged 15-24 (78.0%), and highest among women aged 35-44 years (93.6%) and 45-59 years (93.7%) in R5. Viral load suppression prevalence increased among all PLHIV aged 15-59 years from 52.0% in R1 to 78.3% in R5.

DISCUSSION

Between 2014 and 2019, Chókwè Health and Demographic Surveillance System residents surpassed the UNAIDS targets of ≥81% of PLHIV on ART and ≥73% virally suppressed. This achievement supports the combination of efforts from household-based HIV testing and counseling, support for linkage to care and treatment, and continued investments in T&S implementation.

Implementation planning for community-based point-of-care HIV testing for infants: Recommendations from community leaders in Kenya

Background

Early infant diagnosis (EID) establishes the presence of HIV infection in HIV-exposed infants and children younger than 18 months of age. EID services are hospital-based, and thus fail to capture HIV-exposed infants who are not brought to the hospital for care. Point-of-care (POC) diagnostic systems deployed in the community could increase the proportion tested and linked to treatment, but little feasibility and acceptability data is available.

Methods

Semi-structured interviews (n = 74) were conducted by a Kenyan team with community members (Community Health Workers/Volunteers [CHW/CHV], Traditional Birth Attendants [TBAs], community leaders) and parents of HIV-exposed infants at four study sites in Kenya to elicit feedback on the acceptability and feasibility of community-based POC HIV testing.

Results

Participants described existing community health resources that could be leveraged to support integration of community-based POC HIV testing; however, the added demand placed on CHW/CHV could pose a challenge. Participants indicated that other potential barriers (concerns about confidentiality, disclosure, and HIV stigma) could be overcome with strong engagement from trusted community leaders and health providers, community sensitization, and strategic location and timing of testing. These steps were seen to improve acceptability and maximize the recognized benefits (rapid results, improved reach) of community-based testing.

Conclusion

Community members felt that with strategic planning and engagement, community-based POC HIV testing could be a feasible and acceptable strategy to overcome the existing barriers of hospital-based EID.

Overview of systematic reviews on strategies to improve treatment initiation, adherence to antiretroviral therapy and retention in care for people living with HIV: part 1

OBJECTIVES

We sought to map the evidence and identify interventions that increase initiation of antiretroviral therapy, adherence to antiretroviral therapy and retention in care for people living with HIV at high risk for poor engagement in care.

METHODS

We conducted an overview of systematic reviews and sought for evidence on vulnerable populations (men who have sex with men (MSM), African, Caribbean and Black (ACB) people, sex workers (SWs), people who inject drugs (PWID) and indigenous people). We searched PubMed, Excerpta Medica dataBASE, Cumulative Index to Nursing and Allied Health Literature, PsycINFO, Web of Science and the Cochrane Library in November 2018. We screened, extracted data and assessed methodological quality in duplicate and present a narrative synthesis.

RESULTS

We identified 2420 records of which only 98 systematic reviews were eligible. Overall, 65/98 (66.3%) were at low risk of bias. Systematic reviews focused on ACB (66/98; 67.3%), MSM (32/98; 32.7%), PWID (6/98; 6.1%), SWs and prisoners (both 4/98; 4.1%). Interventions were: mixed (37/98; 37.8%), digital (22/98; 22.4%), behavioural or educational (9/98; 9.2%), peer or community based (8/98; 8.2%), health system (7/98; 7.1%), medication modification (6/98; 6.1%), economic (4/98; 4.1%), pharmacy based (3/98; 3.1%) or task-shifting (2/98; 2.0%). Most of the reviews concluded that the interventions effective (69/98; 70.4%), 17.3% (17/98) were neutral or were indeterminate 12.2% (12/98). Knowledge gaps were the types of participants included in primary studies (vulnerable populations not included), poor research quality of primary studies and poorly tailored interventions (not designed for vulnerable populations). Digital, mixed and peer/community-based interventions were reported to be effective across the continuum of care.

CONCLUSIONS

Interventions along the care cascade are mostly focused on adherence and do not sufficiently address all vulnerable populations.

Towards achieving the 90-90-90 HIV targets: results from the south African 2017 national HIV survey

Background

Measuring progress towards the Joint United Nations Programme on HIV/AIDS (UNAIDS) 90–90–90 treatment targets is key to assessing progress towards turning the HIV epidemic tide. In 2017, the UNAIDS model estimated that 75% of people living with HIV (PLHIV) globally knew their HIV positive status, 79% of those who knew their status were on antiretroviral therapy (ART), and 81% of those who knew their HIV status and were on ART had a suppressed viral load. The fifth South African national HIV sero-behavioural survey collected nationally representative data that enabled the empirical estimation of these 90–90–90 targets for the country stratified by a variety of key factors.

Methods

To evaluate progress towards achievement of the 90–90–90 targets for South Africa, data obtained from a national, representative, cross-sectional population-based multi-stage stratified cluster random survey conducted in 2017 were analysed. The Fifth South African National HIV Prevalence, Incidence, Behaviour and Communication Survey (SABSSM V), collected behavioural and biomarker data from individuals residing in households from 1000 randomly selected Small Area Layers (SALs), across all nine provinces of the country. Structured questionnaires were used to collect socio-demographic data, knowledge and perceptions about HIV, and related risk behaviours. Blood samples were collected to test for HIV infection, antiretroviral use, and viral suppression (defined as < 1000 copies/ml). Weighted proportions of study participants aged 15 years and older who tested HIV positive were computed for those who reported awareness of their status (1st 90), and among these, those who were currently on ART (2nd 90) and of these, those who were virally suppressed (3rd 90).

Results

Among persons 15 years and older who were HIV positive, 84.8% were aware of their HIV positive status, of whom 70.7% were currently on ART, with 87.4% of these estimated to have suppressed viral load at the time of the survey. These estimates varied by sex, age, and geo-location type. Relatively higher percentages across all three indicators for women compared to men were observed: 88.7% versus 78.2% for those aware of their status, 72.3% versus 67.7% for on ART, and 89.8% versus 82.3% for viral suppression. Knowing one’s positive HIV status increased with age: 74.0, 85.8, and 88.1% for age groups 15–24 years old, 25–49 years old and 50–64 years old, although for those 65 years and older, 78.7% knew their HIV positive status. A similar pattern was observed for the 2nd 90, among those who knew their HIV positive status, 51.7% of 15 to 24 year olds, 70.5% of those aged 25–49 years old, 82.9% of those aged 50–64 years old and 82.4% of those aged 65 years or older were currently on ART. Viral suppression for the above mentioned aged groups, among those who were on ART was 85.2, 87.2, 89.5, and 84.6% respectively. The 90–90–90 indicators for urban areas were 87.7, 66.5, and 87.2%, for rural settings was 85.8, 79.8, and 88.4%, while in commercial farming communities it was 56.2, 67.6 and 81.4%.

Conclusions

South Africa appears to be on track to achieve the first 90 indicator by 2020. However, it is behind on the second 90 indicator with ART coverage that was ~ 20-percentage points below the target among people who knew their HIV status, this indicates deficiencies around linkage to and retention on ART. Overall viral suppression among those on ART is approaching the target at 87.4%, but this must be interpreted in the context of low reported ART coverage as well as with variation by age and sex. Targeted diagnosis, awareness, and treatment programs for men, young people aged 15–24 years old, people who reside in farming communities, and in specific provinces are needed. More nuanced 90–90–90 estimates within provinces, specifically looking at more granular sub-national level (e.g. districts), are needed to identify gaps in specific regions and to inform provincial interventions.

Male Partner Linkage to Clinic-Based Services for Sexually Transmitted Infections and Human Immunodeficiency Virus Services Following Couple Home-Based Education and Testing

BACKGROUND

Home-based human immunodeficiency virus (HIV) testing and education has increased HIV test uptake and access to health services among men. We studied how a home-based antenatal intervention influenced male partner utilization of clinic-based HIV and sexually transmitted infection (STI) services, linkage to HIV care and medical circumcision.

METHODS

We conducted a secondary analysis within a randomized controlled trial of pregnant women attending antenatal care in Kenya. Women and their male partners received either a home-based couple intervention or an invitation letter for clinic-based couple HIV testing. The home-based intervention included education on STI symptoms, STI and HIV treatment and male circumcision for HIV prevention. Male self-reported outcomes were compared using relative risks at 6 months postpartum.

RESULTS

Among 525 women, we reached 487 (93%) of their male partners; 247 men in the intervention arm and 240 men in the control arm. Men who received the intervention were more likely to report an STI consultation (n = 47 vs. 16; relative risk, 1.59; 95% confidence interval, 1.33-1.89). Among 23 men with newly diagnosed HIV, linkage to HIV care was reported by 4 of 15 in the intervention (3 men had missing linkage data) and 3 of 5 men in the control arms (relative risk, 0.66; 95% confidence interval, 0.34-1.29). Although the intervention identified 3 times more men with new HIV infection, the study lacked power to find significant differences in linkage to HIV care. Few eligible men sought medical circumcision (4 of 72 intervention and 2 of 88 control).

CONCLUSIONS

Home-based couple education and testing increased STI consultations among male partners of pregnant women, but appeared insufficient to overcome the barriers involved in linkage to HIV care and medical circumcision.

HIV prevalence and the cascade of care in five South African correctional facilities

Background

South Africa is home to the world’s largest HIV epidemic. Throughout the world, incarcerated individuals have a higher prevalence of HIV than the general public, and South Africa has one of the highest rates of incarceration in sub-Saharan Africa. In spite of this, little has been published about the burden of HIV and how care is delivered in South African correctional facilities.

Objective

To estimate the prevalence of people living with HIV and identify initiation and retention in the HIV cascade of care across five correctional facilities.

Methods

Cross-sectional retrospective analysis of 30,571 adult inmates who participated in a tuberculosis screening and HIV counseling and testing campaign in South African correctional facilities (January 1, 2014—January 31, 2015). Descriptive statistics were used to estimate the proportion and 95% confidence intervals of HIV. Proportions of persons retained and lost at each step in the HIV cascade of care under this intervention were calculated. Poisson regression with robust variance estimates were used, and clustering by facility was accounted for in all analyses.

Results

Results of the screening campaign found previously undiagnosed HIV among 13.0% of those consenting to screening, with a total estimated HIV prevalence of 17.7% (n = 3,184, 95% CI: 17.2–18.3%) in the sample. When examining the overall cascade of care, 48.3% of those with HIV initiated care, and overall 45.6% of persons who entered care qualified for ART initiated treatment. A Poisson regression accounting for clustering by facility found HIV high risk groups within the population such as women (aRR = 1.72, 95% CI: 1.57, 1.89), those over 35 years of age (aRR = 2.43, 95% CI: 1.53, 3.85), and people incarcerated less than one year (aRR = 1.41, 95% CI: 1.19, 1.67).

Conclusion

In this setting, routine screening is recommended, and measures are needed to ensure that persons diagnosed are adequately linked to and retained in care.

Emerging priorities for HIV service delivery

Nathan Ford and co-authors discuss global priorities in the provision of HIV prevention and treatment services.

Point of Diagnosis and Patient Retention in HIV Care in Western Kenya

BACKGROUND

Home-based counseling and testing (HBCT) achieves earlier HIV diagnosis than other testing modalities; however, retention in care for these healthier patients is unknown. The objective of this study was to determine the association between point of HIV testing and retention in care and mortality.

SETTING

Academic Model Providing Access to Healthcare (AMPATH) has provided HIV care in western Kenya since 2001.

METHODS

AMPATH initiated HBCT in 2007. This retrospective analysis included individuals 13 years and older, enrolled in care between January 2008 and September 2016, with data on point of testing. Discrete-time multistate models were used to estimate the probability of transition between the following states: engaged, disengaged, transfer, and death, and the association between point of diagnosis and transition probabilities.

RESULTS

Among 77,358 patients, 67% women, median age: 35 years and median baseline CD4: 248 cells/mm. Adjusted results demonstrated that patients from HBCT were less likely to disengage [relative risk ratio (RRR) = 0.87, 95% CI: 0.83 to 0.91] and die (RRR = 0.65, 95% CI: 0.55 to 0.75), whereas those diagnosed through provider-initiated counseling and testing were more likely to disengage (RRR = 1.09, 95% CI: 1.07 to 1.12) and die (RRR = 1.13, 95% CI: 1.06 to 1.20), compared with patients from voluntary counseling and testing. Once disengaged, patients from HBCT were less likely to remain disengaged, compared with patients from voluntary counseling and testing.

CONCLUSIONS

Patients entering care from different HIV-testing programs demonstrate differences in retention in HIV care over time beyond disease severity. Additional research is needed to understand the patient and system level factors that may explain the associations between testing program, retention, and mortality.

Population-based estimates of engagement in HIV care and mortality using double-sampling methods following home-based counseling and testing in western Kenya

Introduction

Data on engagement in HIV care from population-based samples in sub-Saharan Africa are limited. The objective of this study was to use double-sampling methods to estimate linkage to HIV care, ART initiation, and mortality among all adults diagnosed with HIV by a comprehensive home-based counseling and testing (HBCT) program in western Kenya.

Methods

HBCT was conducted door-to-door from December 2009 to April 2011 in three sub-counties of western Kenya by AMPATH (Academic Model Providing Access to Healthcare). For those identified as HIV-positive, data were merged with electronic medical records to determine engagement with HIV care. A randomly-drawn follow-up sample of 120 adults identified via HBCT who had not linked to care as of June 2015 in Bunyala sub-county were visited by trained fieldworkers to ascertain HIV care engagement and vital status. Double-sampled data were used to generate, via multinomial regression, predicted probabilities of engagement in care and mortality among those whose status could not be ascertained by matching with the electronic medical records in the three catchments.

Results

Incorporating information from the double-sampling yielded estimates of prospective linkage to HIV care that ranged from 40–45%. Mortality estimates of those who did not engage in care following HBCT ranged from 12–16%. Among those who linked to care following HBCT, between 72–81% initiated ART.

Discussion

In settings without universal national identifiers, rates of linkage to care from community-based programs may be subject to substantial underestimation. Follow-up samples of those with missing information can be used to partially correct this bias, as has been demonstrated previously for mortality among those who were lost-to-care programs. There is a need for harmonized data systems across health systems and programs.

Factors affecting linkage to HIV care and ART initiation following referral for ART by a mobile health clinic in South Africa: evidence from a multimethod study

Linkage to care from mobile clinics is often poor and inadequately understood. This multimethod study assessed linkage to care and antiretroviral therapy (ART) uptake following ART-referral by a mobile clinic in Cape Town (2015/2016). Clinic record data (N = 86) indicated that 67% linked to care (i.e., attended a clinic) and 42% initiated ART within 3 months. Linkage to care was positively associated with HIV-status disclosure intentions (aOR: 2.99, 95% CI 1.13-7.91), and treatment readiness (aOR: 2.97, 95% CI 1.05-8.34); and negatively with good health (aOR: 0.35, 95% CI 0.13-0.99), weekly alcohol consumption (aOR: 0.35, 95% CI 0.12-0.98), and internalised stigma (aOR: 0.32, 95% CI 0.11-0.91). Following linkage, perceived stigma negatively affected ART-initiation. In-depth interviews (N = 41) elucidated fears about ART side-effects, HIV-status denial, and food insecurity as barriers to ART initiation; while awareness of positive ART-effects, follow-up telephone counselling, familial responsibilities, and maintaining health to avoid involuntary disclosure were motivating factors. Results indicate that an array of interventions are required to encourage rapid ART-initiation following mobile clinic HIV-testing services.

Continuum of HIV Care in Rural Mozambique: The Implications of HIV Testing Modality on Linkage and Retention

Supplemental Digital Content is Available in the Text.

Introduction:

Context-specific improvements in the continuum of HIV care are needed to achieve the UNAIDS target of 90-90-90. This study aimed to assess the linkage to and retention in HIV care according to different testing modalities in rural southern Mozambique.

Methods:

Adults newly diagnosed with HIV from voluntary counseling and testing, provider-initiated counseling and testing, and home-based HIV testing services were prospectively enrolled between 2014 and 2015 at the Manhiça District. Patients were passively followed up through chart examination. Tracing was performed at 12 months to ascertain causes of loss to follow-up. Fine and Gray competing risk analysis was performed to determine factors associated with the each step of the cascade.

Results:

Overall linkage to care as defined by having a CD4 count at 3 months was 43.7% [95% confidence interval (CI): 40.8 to 46.6] and 25.2% of all participants initiated antiretroviral therapy. Factors associated with increased linkage in multivariable analysis included testing at voluntary counseling and testing, older age, having been previously tested for HIV, owning a cell phone, presenting with WHO clinical stages III/IV, self-reported illness-associated disability in the previous month, and later calendar month of participant recruitment. Ascertaining deaths and transfers allowed for adjustment of the rate of 12-month retention in treatment from 75.6% (95% CI: 70.2 to 80.5) to 84.2% (95% CI: 79.2 to 88.5).

Conclusions:

Home-based HIV testing reached a sociodemographically distinct population from that of clinic-based testing modalities but low linkage to care points to a need for facilitated linkage interventions. Distinguishing between true treatment defaulting and other causes of loss to follow-up can significantly change indicators of retention in care.

Findings from home-based HIV testing and facilitated linkage after scale-up of test and treat in rural South Africa: young people still missing

OBJECTIVES

The aim of the study was to estimate rates of linkage to HIV care and antiretroviral treatment (ART) initiation after the introduction of home-based HIV counselling and testing (HBHCT) and telephone-facilitated support for linkage in rural South Africa.

METHODS

A population-based prospective cohort study was carried out in KwaZulu Natal, South Africa. All residents aged ≥ 15 years were eligible for HBHCT. Those who tested positive and were not in care were referred for ART at one of 11 public-sector clinics. Individuals who did not attend the clinic within 2 weeks were sent a short message service (SMS) reminder; those who had not attended after a further 2 weeks were telephoned by a nurse counsellor, to discuss concerns and encourage linkage. Kaplan-Meier methods were used to estimate the proportion of newly diagnosed individuals linking to care and initiating ART.

RESULTS

Among 38 827 individuals visited, 26% accepted HBHCT. Uptake was higher in women than in men (30% versus 20%, respectively), but similar in people aged < 30 years and ≥ 30 years (28% versus 26%, respectively). A total of 784 (8%) tested HIV positive, of whom 427 (54%) were newly diagnosed. Within 6 months, 31% of women and 18% of men < 30 years old had linked to care, and 29% and 16%, respectively, had started ART. Among those ≥ 30 years, 41% of women and 38% of men had linked to care within 6 months, and 41% and 35%, respectively, had started ART.

CONCLUSIONS

Despite facilitated linkage, rates of timely linkage to care and ART initiation after HBHCT were very low, particularly among young men. Innovations are needed to provide effective HIV care and prevention interventions to young people, and thus maximize the benefits of universal test and treat.

VIBRA trial - Effect of village-based refill of ART following home-based same-day ART initiation vs clinic-based ART refill on viral suppression among individuals living with HIV: protocol of a cluster-randomized clinical trial in rural Lesotho

BACKGROUND

There is a need for evaluating community-based antiretroviral therapy (ART) delivery models to improve overall performance of HIV programs, specifically in populations that may have difficulties to access continuous care. This cluster-randomized clinical trial aims to evaluate the effectiveness of a multicomponent differentiated ART delivery model (VIBRA model) after home-based same-day ART initiation in remote villages in Lesotho, southern Africa.

METHODS/DESIGN

The VIBRA trial (VIllage-Based Refill of ART) is a cluster-randomized parallel-group superiority clinical trial conducted in two districts in Lesotho, southern Africa. Clusters (i.e., villages) are randomly assigned to either the VIBRA model or standard care. The clusters are stratified by district, village size, and village access to the nearest health facility. Eligible individuals (HIV-positive, aged 10 years or older, and not taking ART) identified during community-based HIV testing campaigns are offered same-day home-based ART initiation. The intervention clusters offer a differentiated ART delivery package with two features: (1) drug refills and follow-ups by trained and supervised village health workers (VHWs) and (2) the option of receiving individually tailored adherence reminders and notifications of viral load results via SMS. The control clusters will continue to receive standard care, i.e., collecting ART refills from a clinic and no SMS notifications. The primary endpoint is viral suppression 12 months after enrolment. Secondary endpoints include linkage to and engagement in care. Furthermore, safety and cost-effectiveness analyses plus qualitative research are planned. The minimum target sample size is 262 participants. The statistical analyses will follow the CONSORT guidelines. The VIBRA trial is linked to another trial, the HOSENG (HOme-based SElf-testiNG) trial, both of which are within the GET ON (GETing tOwards Ninety) research project.

DISCUSSION

The VIBRA trial is among the first to evaluate the delivery of ART by VHWs immediately after ART initiation. It assesses the entire HIV care cascade from testing to viral suppression. As most countries in sub-Saharan Africa have cadres like the VHW program in Lesotho, this model-if shown to be effective-has the potential to be scaled up. The system impact evaluation will provide valuable cost estimations, and the qualitative research will suggest how the model could be further modified to optimize its impact.

TRIAL REGISTRATION

Clinicaltrials.gov, NCT03630549 . Registered on 15 August 2018.

Interventions to Improve Linkage to HIV Care in the Era of "Treat All" in Sub-Saharan Africa: a Systematic Review

PURPOSE OF THE REVIEW

In 2015, antiretroviral therapy (ART) was recommended for all people living with HIV (PLHIV) regardless of CD4 count ("Treat All"). To better understand how to improve linkage to care under these new guidelines, we conducted a systematic review of studies evaluating linkage interventions in Sub-Saharan Africa under Treat All.

RECENT FINDINGS

We identified 14 eligible articles and qualitatively analyzed the effectiveness of the interventions. Increases in linkage were reported by supply-side and counseling interventions. Mobile testing and economic incentives did not increase linkage. Given the lag time between adoption and implementation, only two of the studies were conducted in a Treat All setting. None of the interventions specifically focused on re-linking PLHIV who had disengaged from care. Future studies must design interventions that target not only newly diagnosed or treatment naïve PLHIV, but should explicitly focus on PLHIV who have disengaged from care.

Examining engagement in care of women living with HIV in South India

HIV seropositive adherence-challenged women, who reported being on ART for at least four months were interviewed. Data on healthcare history, anti-retroviral therapy, clinic visits, doctor communication, disclosure and fear of stigma were collected. Better engagement in care was significantly more likely among older women, ≥ 10 years of education, higher income, HIV status disclosure to family, with higher community stigma fears and fewer healthcare access barriers. To promote retention, women may be encouraged to consider disclosing their HIV serostatus to supportive household members. A variety of possible interventions to overcome the prevalent barriers to care are provided.

Immune Activation, Inflammation, and Non-AIDS Co-Morbidities in HIV-Infected Patients under Long-Term ART

Despite effective antiretroviral therapy (ART), people living with HIV (PLWH) still present persistent chronic immune activation and inflammation. This condition is the result of several factors including thymic dysfunction, persistent antigen stimulation due to low residual viremia, microbial translocation and dysbiosis, caused by the disruption of the gut mucosa, co-infections, and cumulative ART toxicity. All of these factors can create a vicious cycle that does not allow the full control of immune activation and inflammation, leading to an increased risk of developing non-AIDS co-morbidities such as metabolic syndrome and cardiovascular diseases. This review aims to provide an overview of the most recent data about HIV-associated inflammation and chronic immune exhaustion in PLWH under effective ART. Furthermore, we discuss new therapy approaches that are currently being tested to reduce the risk of developing inflammation, ART toxicity, and non-AIDS co-morbidities.

Brief Report: "Give Me Some Time": Facilitators of and Barriers to Uptake of Home-Based HIV Testing During Household Contact Investigation for Tuberculosis in Kampala, Uganda

BACKGROUND

Integrating home-based HIV counseling and testing (HCT) with tuberculosis (TB) evaluation could improve the uptake of HIV testing among household contacts of patients with active TB. We sought to identify the facilitators of and barriers to HCT during household contact investigation for TB in Kampala, Uganda.

METHODS

We nested semi-structured interviews with 28 household contacts who were offered home-based HCT in a household-randomized trial of home-based strategies for TB contact investigation. Respondents reflected on their experiences of the home visit, the social context of the household, and their decision to accept or decline HIV testing. We used content analysis to identify and evaluate facilitators of and barriers to testing, then categorized the emergent themes using the Capability, Opportunity, Motivation, and Behavior (COM-B) model.

RESULTS

Facilitators included a preexisting desire to confirm HIV status or to show support for the index TB patient; a perception that home-based services are convenient; and positive perceptions of lay health workers. Key barriers included fear of results and feeling psychologically unprepared to receive results. The social influence of other household members operated as both a facilitator and a barrier.

CONCLUSIONS

Preexisting motivation, psychological readiness to test, and the social context of the household are major contributors to the decision to test for HIV at home. Uptake might be improved by providing normalizing information about HCT before the visit, by offering a second HCT opportunity, by offering self-tests with follow-up counseling, or by introducing HCT using "opt-out" language.

The use of home-based HIV testing and counseling in low-and-middle income countries: a scoping review

BACKGROUND

Knowledge of HIV status is crucial for both prevention and treatment of HIV infection. However, according to the Joint United Nations Programme on HIV/AIDS in low-and-middle-income countries (LMICs), only 10% of the population has access to HIV testing services. Home-based HIV testing and counseling (HTC) is one of the approaches which have been shown to be effective in improving access to HIV testing in LMICs. The objective of this review was to map evidence on the use of home-based HTC in LMICs.

METHODS

We searched PubMed, EBSCOhost, Google Scholar, Science Direct, World Health Organization library database and UNAIDS databases from January 2013 to October 2017. Eligibility criteria included articles pertaining to the use of home-based HTC in LMICs. Two reviewers independently reviewed the articles for eligibility. The following themes were extracted from the included studies: use, feasibility and effectiveness of home-based HTC on patient-centered outcomes in LMICs. The risk of bias for the included studies was assessed using mixed methods appraisal tool -version 2011.

RESULTS

A total of 855,117 articles were identified from all the databases searched. Of this, only 17 studies met the inclusion criteria after full article screening and were included for data extraction. All included studies presented evidence on the use of Home-based HTC by most age groups (18 months to 70 years) comprising of both males and females. The included studies were conducted in the following countries: Zambia, Uganda, South Africa, Kenya, Ethiopia, Malawi, Swaziland, Pakistan, and Botswana. This study demonstrated that home-based HTC was used in LMICs alongside supervised HTC intervention using different types of HTC tests kits produced by different manufacturers. This study also showed that home-based HTC was feasible, highly effective, and increased uptake of HIV testing and counseling. This study further demonstrated a highly successful usage of supervised home-based HTC by most age groups in LMICs, with majority of users being females (89.1%).

CONCLUSION

We therefore recommend primary studies in other LMICs to determine the feasibility and use of HTC to help achieve the UNAIDS 90:90:90 targets. Interventions to improve the use of home-based HTC by males are also recommended.

TRIAL REGISTRATION

PROSPERO registration number: CRD42017056478.

Linkage to care and antiretroviral therapy initiation by testing modality among individuals newly diagnosed with HIV in Tanzania, 2014-2017

OBJECTIVE

To measure linkage to care and antiretroviral therapy (ART) initiation among newly diagnosed individuals with HIV in a rural Tanzanian community.

METHODS

We included all new HIV diagnoses of adults made between 2014 and 2017 during community- or facility-based HIV testing and counselling (HTC) in a rural ward in northwest Tanzania. Community-based HTC included population-level HIV serological testing (sero-survey), and facility-based HTC included a stationary, voluntary HTC clinic (VCT) and an antenatal clinic (ANC) offering provider-initiated HTC (ANC-PITC). Cox regression models were used to compare linkage to care rates by testing modality and identify associated factors. Among those in care, we compared initial CD4 cell counts and ART initiation rates by testing modality.

RESULTS

A total of 411 adults were newly diagnosed, of whom 10% (27/265 sero-survey), 18% (3/14 facility-based ANC-PITC) and 53% (68/129 facility-based VCT) linked to care within 90 days. Individuals diagnosed using facility-based VCT were seven times (95% CI: 4.5-11.0) more likely to link to care than those diagnosed in the sero-survey. We found no difference in linkage rates between those diagnosed using facility-based ANC-PITC and sero-survey (P = 0.26). Among individuals in care, 63% of those in the sero-survey had an initial CD4 count >350 cells/mm³ vs. 29% of those using facility-based VCT (P = 0.02). The proportion who initiated ART within 1 year of linkage to care was similar for both groups (94% sero-survey vs. 85% facility-based VCT; P = 0.16).

CONCLUSIONS

Community-based sero-surveys are important for earlier diagnosis of HIV-positive individuals; however, interventions are essential to facilitate linkage to care.

The cascade of care following community-based detection of HIV in sub-Saharan Africa - A systematic review with 90-90-90 targets in sight

Introduction

We aimed to establish how effective community-based HIV testing services (HTS), including home and community location based (non-health facility) HIV testing services (HB-/CLB-HTS), are in improving care in sub-Saharan Africa (SSA), with a view to achieving the 90-90-90 targets.

Methods

We conducted a systematic review of published literature from 2007–17 which reported on the proportion of individuals who link-to-care and/or initiate ART after detection with HIV through community-based testing. A meta-analysis was deemed inappropriate due to heterogeneity in reporting.

Results and discussion

Twenty-five care cascades from 6 SSA countries were examined in the final review– 15 HB-HTS, 8 CLB-HTS, 2 combined HB-/CLB-HTS. Proportions linked-to-care over 1–12 months ranged from 14–96% for HB-HTS and 10–79% for CLB-HTS, with most studies reporting outcomes over short periods (3 months). Fewer studies reported ART-related outcomes following community-based testing and most of these studies included <50 HIV-positive individuals. Proportions initiating ART ranged from 23–93%. One study reported retention on ART (76% 6 months after initiation). Viral suppression 3–12 months following ART initiation was 77–85% in three studies which reported this.

There was variability in definitions of outcomes, numerators/denominators and observation periods. Outcomes varied between studies even for similar time-points since HTS. The methodological inconsistencies hamper comparisons. Previously diagnosed individuals appear more likely to link-to-care than those who reported being newly-diagnosed. It appears that individuals diagnosed in the community need time before they are ready to link-to-care/initiate ART. Point-of-care (POC) CD4-counts at the time of HTS did not achieve higher proportions linking-to-care or initiating ART. Similarly, follow-up visits to HIV-positive individuals did not appear to enhance linkage to care overall.

Conclusion

This systematic review summarises the available data on linkage to care/ART initiation following community-based detection of HIV, to help researchers and policy makers evaluate findings. The available evidence suggests that different approaches to community-based HTS including HB-HTS and CLB-HTS, are equally effective in achieving linkage to care and ART initiation among those detected. Engagement and support for newly diagnosed individuals may be key to achieving all three UNAIDS 90-90-90 targets. We also recommend that standardised measures of reporting of steps on the cascade of care are needed, to measure progress against targets and compare across settings.

Optimal timing of HIV home-based counselling and testing rounds in Western Kenya

INTRODUCTION

Weaknesses in care programmes providing anti-retroviral therapy (ART) persist and are often instigated by late HIV diagnosis and poor linkage to care. We investigated the potential for a home-based counselling and testing (HBCT) campaign to be improved through the optimal timing and enhancement of testing rounds to generate greater health outcomes at minimum cost.

METHODS

Using a mathematical model of HIV care calibrated to longitudinal data from The Academic Model Providing Access To Healthcare (AMPATH) in Kenya, we simulated HBCT campaigns between 2016 and 2036, assessing the impact and total cost of care for each, for a further 20 years.

RESULTS

We find that simulating five equally spaced rounds averts 1.53 million disability-adjusted life-years (DALYs) at a cost of $1617 million. By altering the timing of HBCT rounds, a four-round campaign can produce greater impact for lower cost. With "front-loaded" rounds, the cost per DALY averted is reduced by 12% as fewer rounds are required ($937 vs. $1060). Furthermore, improvements to HBCT coverage and linkage to care avert over two million DALYs at a cost per DALY averted of $621 (41% less than the reference scenario).

CONCLUSIONS

Countries implementing HBCT can reduce costs by optimally timing rounds and generate greater health outcomes through improving linkage, coverage, and retention. Tailoring HBCT campaigns to individual settings can enhance patient outcomes for minimal cost.

Assessing linkage to and retention in care among HIV patients in Uganda and identifying opportunities for health systems strengthening: a descriptive study

Background

While antiretroviral therapy (ART) availability for HIV patients has increased dramatically in Uganda, patient linkage to and retention in care remains a challenge. We assessed patterns of engagement in care in 20 Ugandan health facilities with low retention based on national reporting.

Methods

We assessed patient linkage to care (defined as registering for pre-ART or ART care at the facility within 1 month of HIV diagnosis) and 6-month retention in care (having a visit 3-6 months after ART initiation) and associations with patient−/facility-level factors using multivariate logistic regression.

Results

Among 928 newly HIV-diagnosed patients, only 53.0% linked to care within 1 month. Of these, 83.7% linked within 1 week. Among 678 newly initiated ART patients, 14.5% never returned for a follow-up visit at the facility. Retention was 71.7% according to our primary definition but much lower if stricter definitions were used. Most patients were already falling behind appointment schedules at their first ART follow-up (median: 28 days post-initiation vs. recommended 14 days). 27.3% of newly-initiated patients had follow-up appointments scheduled 45+ days apart rather than monthly per national guidelines. Linkage and retention were not strongly correlated with each other within facilities (r_s = 0.06; p = 0.82). Females, adolescents, and patients in rural settings tended to have lower linkage and retention in multivariable-adjusted models.

Conclusions

Linkage support may be most critical immediately after testing positive, as patients are less likely to link over time. More information is needed on reasons for appointment schedules by clinicians and implications on retention.

Trial registration

This study was registered in the Pan African Clinical Trial Registry database (#PACTR201611001756166).

Electronic supplementary material

The online version of this article (10.1186/s12879-018-3042-8) contains supplementary material, which is available to authorized users.

Effect of Offering Same-Day ART vs Usual Health Facility Referral During Home-Based HIV Testing on Linkage to Care and Viral Suppression Among Adults With HIV in Lesotho: The CASCADE Randomized Clinical Trial

IMPORTANCE

Home-based HIV testing is a frequently used strategy to increase awareness of HIV status in sub-Saharan Africa. However, with referral to health facilities, less than half of those who test HIV positive link to care and initiate antiretroviral therapy (ART).

OBJECTIVE

To determine whether offering same-day home-based ART to patients with HIV improves linkage to care and viral suppression in a rural, high-prevalence setting in sub-Saharan Africa.

DESIGN, SETTING, AND PARTICIPANTS

Open-label, 2-group, randomized clinical trial (February 22, 2016-September 17, 2017), involving 6 health care facilities in northern Lesotho. During home-based HIV testing in 6655 households from 60 rural villages and 17 urban areas, 278 individuals aged 18 years or older who tested HIV positive and were ART naive from 268 households consented and enrolled. Individuals from the same household were randomized into the same group.

INTERVENTIONS

Participants were randomly assigned to be offered same-day home-based ART initiation (n = 138) and subsequent follow-up intervals of 1.5, 3, 6, 9, and 12 months after treatment initiation at the health facility or to receive usual care (n = 140) with referral to the nearest health facility for preparatory counseling followed by ART initiation and monthly follow-up visits thereafter.

MAIN OUTCOMES AND MEASURES

Primary end points were rates of linkage to care within 3 months (presenting at the health facility within 90 days after the home visit) and viral suppression at 12 months, defined as a viral load of less than 100 copies/mL from 11 through 14 months after enrollment.

RESULTS

Among 278 randomized individuals (median age, 39 years [interquartile range, 28.0-52.0]; 180 women [65.7%]), 274 (98.6%) were included in the analysis (137 in the same-day group and 137 in the usual care group). In the same-day group, 134 (97.8%) indicated readiness to start ART that day and 2 (1.5%) within the next few days and were given a 1-month supply of ART. At 3 months, 68.6% (94) in same-day group vs 43.1% (59) in usual care group had linked to care (absolute difference, 25.6%; 95% CI, 13.8% to 36.3%; P < .001). At 12 months, 50.4% (69) in the same-day group vs 34.3% (47) in usual care group achieved viral suppression (absolute difference, 16.0%; 4.4%-27.2%; P = .007). Two deaths (1.5%) were reported in the same-day group, none in usual care group.

CONCLUSIONS AND RELEVANCE

Among adults in rural Lesotho, a setting of high HIV prevalence, offering same-day home-based ART initiation to individuals who tested positive during home-based HIV testing, compared with usual care and standard clinic referral, significantly increased linkage to care at 3 months and HIV viral suppression at 12 months. These findings support the practice of offering same-day ART initiation during home-based HIV testing.

TRIAL REGISTRATION

clinicaltrials.gov Identifier: NCT02692027.

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

Introduction

The aim of this study was to determine whether counselling provided subsequent to HIV testing and referral for care increases linkage to care among HIV‐positive persons identified through home‐based HIV counselling and testing (HBHCT) in Masaka, Uganda.

Methods

The study was an open‐label cluster‐randomized trial. 28 rural communities were randomly allocated (1:1) to intervention (HBHCT, referral and counselling at one and two months) or control (HBHCT and referral only). HIV‐positive care‐naïve adults (≥18 years) were enrolled. To conceal participants’ HIV status, one HIV‐negative person was recruited for every three HIV‐positive participants. Primary outcomes were linkage to care (clinic‐verified registration for care) status at six months, and time to linkage. Primary analyses were intention‐to‐treat using random effects logistic regression or Cox regression with shared frailty, as appropriate.

Results

Three hundred and two(intervention, n = 149; control, n = 153) HIV‐positive participants were enrolled. Except for travel time to the nearest HIV clinic, baseline participant characteristics were generally balanced between trial arms. Retention was similar across trial arms (92% overall). One hundred and twenty‐seven (42.1%) participants linked to care: 76 (51.0%) in the intervention arm versus 51 (33.3%) in the control arm [odds ratio = 2.18, 95% confidence interval (CI) = 1.26–3.78; p = 0.008)]. There was evidence of interaction between trial arm and follow‐up time (p = 0.009). The probability of linkage to care, did not differ between arms in the first two months of follow‐up, but was subsequently higher in the intervention arm versus the control arm [hazard ratio = 4.87, 95% CI = 1.79–13.27, p = 0.002].

Conclusions

Counselling substantially increases linkage to care among HIV‐positive adults identified through HBHCT and may enhance efforts to increase antiretroviral therapy coverage in sub‐Saharan Africa.

Factors associated with uptake of home-based HIV counselling and testing and HIV care services among identified HIV-positive persons in Masaka, Uganda

We investigated uptake of home-based HIV counselling and testing (HBHCT) and HIV care services post-HBHCT in order to inform the design of future HBHCT programmes. We used data from an open-label cluster-randomised controlled trial which had demonstrated the effectiveness of a post-HBHCT counselling intervention in increasing linkage to HIV care. HBHCT was offered to adults (≥18 years) from 28 rural communities in Masaka, Uganda; consenting HIV-positive care naïve individuals were enrolled and referred for care. The trial's primary outcome was linkage to HIV care (clinic-verified registration for care) six months post-HBHCT. Random effects logistic regression was used to investigate factors associated with HBHCT uptake, linkage to care, CD4 count receipt, and antiretroviral therapy (ART) initiation; all analyses of uptake of post-HBHCT services were adjusted for trial arm allocation. Of 13,455 adults offered HBHCT, 12,100 (89.9%) accepted. HBHCT uptake was higher among men [adjusted odds ratio (aOR) 1.20, 95% confidence interval (CI) = 1.07-1.36] than women, and decreased with increasing age. Of 551 (4.6%) persons who tested HIV-positive, 205 (37.2%) were in care. Of those not in care, 302 (87.3%) were enrolled in the trial and of these, 42.1% linked to care, 35.4% received CD4 counts, and 29.8% initiated ART at 6 months post-HBHCT. None of the investigated factors was associated with linkage to care. CD4 count receipt was lower in individuals who lived ≥30 min from an HIV clinic (aOR 0.60, 95%CI = 0.34-1.06) versus those who lived closer. ART initiation was higher in older individuals (≥45 years versus <25 years, aOR 2.14, 95% CI = 0.98-4.65), and lower in single (aOR 0.60, 95% CI = 0.28-1.31) or divorced/separated/widowed (aOR 0.47, 95% CI = 0.23-0.93) individuals versus those married/cohabiting. HBHCT was highly acceptable but uptake of post-HBHCT care was low. Other than post-HBHCT counselling, this study did not identify specific issues that require addressing to further improve linkage to care.