Title

Factors affecting linkage to HIV care and ART initiation following referral for ART by a mobile health clinic in South Africa: Evidence from a mixed-methods study

Presenter

Brendan Maughan-Brown

Authors

B. Maughan-Brown¹, A. Harrison², O. Galárraga³, C. Kuo², P. Smith⁴, L.-G. Bekker⁴, M. Lurie⁵

Institutions

¹Southern Africa Labour and Development Research Unit, University of Cape Town, Cape Town, South Africa, ²Brown University School of Public Health, Department of Behavioral and Social Sciences, Providence, United States, ³Brown University School of Public Health, Department of Health Services, Policy & Practice, Providence, United States, ⁴The Desmond Tutu HIV Centre, Cape Town, South Africa, ⁵Brown University School of Public Health, Department of Epidemiology, Cape Town, South Africa

Background: Community-based HIV-testing is effective at diagnosing asymptomatic people living with HIV, but subsequent linkage to care is often poor and inadequately understood. This mixed-methods study assessed factors that both improved and hindered linkage to care and antiretroviral therapy (ART) uptake following ART-referral by a mobile health clinic in Cape Town, South Africa.
Methods: From April 2015 to August 2016, longitudinal data were collected among individuals (N=86) referred for ART by a mobile health clinic: face-to-face survey data were collected immediately after ART referral, and data on subsequent clinic visits and ART initiation were obtained from clinic records. Multiple logistic regression analyses were used to assess factors associated with visiting a clinic within three months, and with ART-initiation within three months. Follow-up in-depth interviews (N=41) were conducted to examine challenges to, and factors motivating ART initiation.
Results: Among people living with HIV (N=86), 67% linked to care and 42% initiated ART within three months. Linkage to care was more likely among individuals expressing intentions to disclose their HIV-status (aOR: 2.99, 95%CI: 1.13-7.91), and among those who were classified as treatment ready (aOR: 2.97, 95%CI: 1.05-8.34); and less likely among individuals in good health (aOR: 0.35, 95%CI: 0.13-0.99), those who drank alcohol at least once weekly (aOR: 0.35, 95%CI: 0.12-0.98), and those reporting internalised stigma (aOR: 0.32, 95%CI: 0.11-0.91). ART initiation was more likely among individuals reporting greater treatment readiness (aOR: 3.20, 95%CI: 1.09- 9.39); and less likely among individuals who drank alcohol at least once weekly (aOR: 0.24, 95%CI: 0.08-0.73); who reported internalised stigma (aOR: 0.44, 95%CI: 0.17-1.12); and who reported any perceived stigma (aOR: 0.38, 95%CI: 0.14-1.02). In-depth interviews elucidated fears about ART side-effects, HIV-status denial, and lack of money for food as barriers to ART initiation. Factors motivating treatment uptake included awareness of a positive ART-effect, follow-up telephone counselling, familial ties and responsibilities, and maintaining health to avoid involuntary disclosure.
Conclusions: Results provide evidence that an array of interventions are required to encourage rapid ART initiation among individuals diagnosed HIV-positive by mobile health clinic HIV-testing services. This is especially the case among healthier populations.