Title

Poor rates of linkage to HIV care and treatment uptake after home-based HIV testing among 15-49 year-old men and women in a high HIV prevalence setting in South Africa

Presenter

Brendan Maughan-Brown

Authors

B. Maughan-Brown¹, S. Beckett², A.B.M. Kharsany³, C. Cawood⁴, D. Khanyile⁴, L. Lewis³, A. Venkataramani⁵, G. George²

Institutions

¹Southern Africa Labour and Development Research Unit, University of Cape Town, Cape Town, South Africa, ²Health Economics and HIV and AIDS Research Division, University of KwaZulu-Natal, Durban, South Africa, ³Centre for the AIDS Programme of Research in South Africa, University of KwaZulu-Natal, Durban, South Africa, ⁴Epicentre AIDS Risk Management (Pty) Limited, Paarl, South Africa, ⁵University of Pennsylvania, Department of Medical Ethics and Health Policy, Perelman School of Medicine, Philadelphia, United States

Background: Early antiretroviral therapy (ART) initiation is essential to obtain the full therapeutic and prevention benefits from ART, but linkage to care following community-based testing services is often poor, and inadequately understood. This study examined demographic, socioeconomic and psychosocial factors influencing linkage to care following home-based HIV-testing services (HBHTS) in a hyper-endemic epidemic setting in South Africa.
Methods: HBHTS was offered to all participants (N=10,236) in the 2015-2016 cross-sectional survey of the HIV Incidence Provincial Surveillance System, KwaZulu-Natal, South Africa. Fieldworkers collected venous blood samples for health screening, including CD4 counts. Follow-up telephone surveys (N=194) collected data on clinic visits and ART initiation among individuals diagnosed HIV-positive through HBHTS. Factors associated with linkage to care (defined as a clinic visit within 12 weeks of receiving an HIV-positive diagnosis) were assessed using multivariable logistic regression models.
Results: Fifty-four percent of men and women linked to care, and 21% of ART-eligible participants started treatment within 12 weeks (men:25%, women:19%). The median CD4 count was 416 cells/µL (IQR:268-608) and 418 (IQR:254-612) among those that did, and did not, link to care respectively. Few men (11%) or women (13%) linked to care within 4 weeks. Linkage to care was less likely among participants who had doubted their HIV-diagnosis (aOR:0.54,95%CI:0.27-1.06, p=0.072), and who reported being unafraid of contracting HIV due to the effectiveness of ART (aOR:0.53,95%CI:0.28-1.01, p=0.054). Linkage to care was more likely among participants who had disclosed their HIV status (aOR:2.28,95%CI:1.07-4.86, p=0.033), and who had recently engaged in an HIV-related activity (aOR:1.91,95%CI:0.93-3.94, p=0.079). Self-reported reasons for not linking to care included no time (men:75%, women:57%); only wanting to start treatment when sick (men:58%, women:39%); being afraid of side-effects (men:29%, women:35%); and not believing the HIV-diagnosis (men:4%, women:22%).
Conclusions: HBHTS needs to be paired with targeted interventions to facilitate early linkage to care. Interventions are required to counter denial of HIV status, and encourage early ART initiation among individuals inclined to delay treatment until falling ill. Further research is needed to better understand the interplay between perceptions of ART and HIV, and how perceptions of HIV affect the uptake of HIV care and treatment services.