Linkage to care and antiretroviral therapy initiation by testing modality among individuals newly diagnosed with HIV in Tanzania, 2014-2017.
ABSTRACT: 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.
Project description:INTRODUCTION:HIV testing and counselling (HTC) interventions are key to controlling the HIV epidemic in East and Southern Africa where HTC is primarily delivered through voluntary counselling and testing (VCT), provider initiated testing and counselling (PITC), and home-based counselling and testing (HBVCT). Decision making processes around uptake of HTC models must be taken into account when designing new interventions. Counselling in HTC aims to reduce post-test risk taking behaviour and to link individuals to care but its efficacy is unclear. This meta-ethnography aims to understand the contexts of HTC uptake in East and Southern Africa and to analyse the perceived impacts of counselling-based interventions in relation to sexual behaviour and linkage to care. METHODS:We conducted a systematic literature review of studies investigating HTC in East and Southern Africa from 2003 -April 2014. The search and additional snowballing identified 20 studies that fit our selection criteria. These studies were synthesised through a thematic framework analysis. RESULTS:Twenty qualitative and mixed-methods studies examining impacts of HTC models in East and Southern Africa were meta-synthesised. VCT decisions were made individually while HBVCT decisions were located in family and community units. PITC was associated with coercion from healthcare providers. Low quality counselling components and multiple-intersecting barriers faced by individuals mean that counselling in HTC was not perceived to be effective in reducing post-test risk behaviour and had limited perceived effect in facilitating linkage to care. CONCLUSION:HBVCT is associated with minimal stigma and should be considered as an area of priority. Counselling components in HTC interventions were effective in transmitting information about HIV and sexual risk, but were perceived as ineffective in addressing the broader personal circumstances preventing sexual behaviour change and modulating access to care.
Project description:BACKGROUND:Male partner HIV testing and counseling (HTC) is associated with enhanced uptake of prevention of mother-to-child HIV transmission (PMTCT), yet male HTC during pregnancy remains low. Identifying settings preferred by pregnant women and their male partners may improve male involvement in PMTCT. METHODS:Participants in a randomized clinical trial (NCT01620073) to improve male partner HTC were interviewed to determine whether the preferred male partner HTC setting was the home, antenatal care (ANC) clinic or VCT center. In this nested cross sectional study, responses were evaluated at baseline and after 6 weeks. Differences between the two time points were compared using McNemar's test and correlates of preference were determined using logistic regression. RESULTS:Among 300 pregnant female participants, 54% preferred home over ANC clinic testing (34.0%) or VCT center (12.0%). Among 188 male partners, 68% preferred home-based HTC to antenatal clinic (19%) or VCT (13%). Men who desired more children and women who had less than secondary education or daily income?<?$2 USD were more likely to prefer home-based over other settings (p?<?0.05 for all comparisons). At 6 weeks, the majority of male (81%) and female (65%) participants recommended home over alternative HTC venues. Adjusting for whether or not the partner was tested during follow-up did not significantly alter preferences. CONCLUSIONS:Pregnant women and their male partners preferred home-based compared to clinic or VCT-center based male partner HTC. Home-based HTC during pregnancy appears acceptable and may improve male testing and involvement in PMTCT.
Project description:To investigate the relative effectiveness of different HIV testing and counselling (HTC) services in improving HIV diagnosis rates and increasing HTC coverage in African settings.Patient records from three HTC services [community outreach HTC during cohort study rounds (CO-HTC), walk-in HTC at the local health centre (WI-HTC) and antenatal HIV testing (ANC-HTC)] were linked to records from a community cohort study using a probabilistic record linkage algorithm. Characteristics of linked users of each HTC service were compared to those of cohort participants who did not use the HTC service using logistic regression. Data from three cohort study rounds between 2003 and 2010 were used to assess trends in the proportion of persons testing at different service types.The adjusted odds ratios for HTC use among men with increasing numbers of sexual partners in the past year, and among HIV-positive men and women compared to HIV-negative men and women, were higher at WI-HTC than at CO-HTC and ANC-HTC. Among sero-survey participants, the largest numbers of HIV-positive men and women learned their status via CO-HTC. However, we are likely to have underestimated the numbers diagnosed at WI-HTC and ANC-HTC, due to low sensitivity of the probabilistic record linkage algorithm.Compared to CO-HTC or ANC-HTC, WI-HTC was most likely to attract HIV-positive men and women, and to attract men with greater numbers of sexual partners. Further research should aim to optimise probabilistic record linkage techniques, and to investigate which types of HTC services most effectively link HIV-positive people to treatment services relative to the total cost per diagnosis made.
Project description:In recent years children and adolescents have emerged as a priority for HIV prevention and care services. We conducted a systematic review to investigate the acceptability, yield and prevalence of HIV testing and counselling (HTC) strategies in children and adolescents (5 to 19 years) in sub-Saharan Africa.An electronic search was conducted in MEDLINE, EMBASE, Global Health and conference abstract databases. Studies reporting on HTC acceptability, yield and prevalence and published between January 2004 and September 2014 were included. Pooled proportions for these three outcomes were estimated using a random effects model. A quality assessment was conducted on included studies.A total of 16,380 potential citations were identified, of which 21 studies (23 entries) were included. Most studies were conducted in Kenya (n=5) and Uganda (n=5) and judged to provide moderate (n=15) to low quality (n=7) evidence, with data not disaggregated by age. Seven studies reported on provider-initiated testing and counselling (PITC), with the remainder reporting on family-centred (n=5), home-based (n=5), outreach (n=5) and school-linked HTC among primary schoolchildren (n=1). PITC among inpatients had the highest acceptability (86.3%; 95% confidence interval [CI]: 65.5 to 100%), yield (12.2%; 95% CI: 6.1 to 18.3%) and prevalence (15.4%; 95% CI: 5.0 to 25.7%). Family-centred HTC had lower acceptance compared to home-based HTC (51.7%; 95% CI: 10.4 to 92.9% vs. 84.9%; 95% CI: 74.4 to 95.4%) yet higher prevalence (8.4%; 95% CI: 3.4 to 13.5% vs. 3.0%; 95% CI: 1.0 to 4.9%). School-linked HTC showed poor acceptance and low prevalence.While PITC may have high test acceptability priority should be given to evaluating strategies beyond healthcare settings (e.g. home-based HTC among families) to identify individuals earlier in their disease progression. Data on linkage to care and cost-effectiveness of HTC strategies are needed to strengthen policies.
Project description:Research indicates that individuals tested for HIV have higher socio-economic status than those not tested, but less is known about how socio-economic status is associated with modes of testing. We compared individuals tested through provider-initiated testing and counselling (PITC), those tested through voluntary counselling and testing (VCT) and those never tested.Cross-sectional surveys were conducted at health facilities in Burkina Faso, Kenya, Malawi and Uganda, as part of the Multi-country African Testing and Counselling for HIV (MATCH) study. A total of 3659 clients were asked about testing status, type of facility of most recent test and socio-economic status. Two outcome measures were analysed: ever tested for HIV and mode of testing. We compared VCT at stand-alone facilities and PITC, which includes integrated facilities where testing is provided with medical care, and prevention of mother-to-child transmission (PMTCT) facilities. The determinants of ever testing and of using a particular mode of testing were analysed using modified Poisson regression and multinomial logistic analyses.Higher socio-economic status was associated with the likelihood of testing at VCT rather than other facilities or not testing. There were no significant differences in socio-economic characteristics between those tested through PITC (integrated and PMTCT facilities) and those not tested.Provider-initiated modes of testing make testing accessible to individuals from lower socio-economic groups to a greater extent than traditional VCT. Expanding testing through PMTCT reduces socio-economic obstacles, especially for women. Continued efforts are needed to encourage testing and counselling among men and the less affluent.
Project description:BACKGROUND: We examined linkage to care for patients with sexually transmitted infection who were diagnosed HIV-positive via the provider-initiated HIV testing and counselling (PITC) approach, as compared to the voluntary counselling and testing (VCT) approach, as little is known about the impact of expanded testing strategies on linkage to care. METHODS: In a controlled trial on PITC (Cape Town, 2007), we compared HIV follow-up care for a nested cohort of 930 HIV-positive patients. We cross-referenced HIV testing and laboratory records to determine access to CD4 and viral load testing as primary outcomes. Secondary outcomes were HIV immune status and time taken to be linked to HIV care. Logistic regression was performed to analyse the difference between arms. RESULTS: There was no difference in the main outcomes of patients with a record of CD4 testing (69.9% in the intervention, 65.2% in control sites, OR 0.82 (CI: 0.44-1.51; p?=?0.526) and viral load testing (14.9% intervention versus 10.9% control arm; OR 0.69 (CI: 0.42-1.12; p?=?0.131). In the intervention arm, ART-eligible patients (based on low CD4 test result), accessed viral load testing approximately 2.5 months sooner than those in the control arm (214 days vs. 288 days, HR: 0.417, 95% CI: 0.221-0.784; p?=?0.007). CONCLUSION: The PITC intervention did not improve linkage to CD4 testing, but shortened the time to viral load testing for ART-eligible patients. Major gaps found in follow-up care across both arms, indicate the need for more effective linkage-to-HIV care strategies. TRIAL REGISTRATION: Current Controlled Trials ISRCTN93692532.
Project description:To diagnose ?90% HIV-infected residents (diagnostic coverage), the Bukoba Combination Prevention Evaluation (BCPE) implemented provider-initiated (PITC), home- (HBHTC), and venue-based (VBHTC) HIV testing and counseling (HTC) intervention in Bukoba Municipal Council, a mixed urban and rural lake zone community of 150,000 residents in Tanzania. This paper describes the methods, outcomes, and incremental costs of these HTC interventions. PITC was implemented in outpatient department clinics in all eight public and three faith-based health facilities. In clinics, lay counselors routinely screened and referred eligible patients for HIV testing conducted by HTC-dedicated healthcare workers. In all 14 wards, community teams offered HTC to eligible persons encountered at 31,293 home visits and at 79 male- and youth-frequented venues. HTC was recommended for persons who were not in HIV care or had not tested in the prior 90 days. BCPE conducted 133,695 HIV tests during the 2.5 year intervention (PITC: 88,813, 66%; HBHTC: 27,407, 21%; VBHTC: 17,475, 13%). Compared with other strategies, PITC conducted proportionally more tests among females (65%), and VBHTC conducted proportionally more tests among males (69%) and young-adults aged 15-24 years (42%). Of 5,550 (4.2% of all tests) HIV-positive tests, 4,143 (75%) clients were newly HIV diagnosed, including 1,583 males and 881 young adults aged 15-24 years. Of HIV tests conducted 3.7%, 1.8%, and 2.1% of PITC, HBHTC, and VBHTC clients, respectively, were newly HIV diagnosed; PITC accounted for 79% of all new diagnoses. Cost per test (per new diagnosis) was $4.55 ($123.66), $6.45 ($354.44), and $7.98 ($372.67) for PITC, HBHTC, and VBHTC, respectively. In a task-shifting analysis in which lay counselors replaced healthcare workers, estimated costs per test (per new diagnosis) would have been $3.06 ($83.15), $ 4.81 ($264.04), and $5.45 ($254.52), for PITC, HBHTC, and VBHTC, respectively. BCPE models reached different target groups, including men and young adults, two groups with consistently low coverage. Implementation of multiple models is likely necessary to achieve ?90% diagnostic coverage.
Project description:BACKGROUND: Approaches to HIV counselling and testing (HCT) within low-resource high HIV prevalence settings have shifted over the years from primarily client-initiated approaches to provider initiated. As part of an ongoing programme science research agenda, we examine the relative costs of provider-initiated testing and counselling (PITC) services compared with voluntary counselling and testing (VCT) services in the same health facilities in two low-resource settings: Kenya and Swaziland. METHODS: Annual financial and economic costs and output measures were collected retrospectively from 28 health facilities. Total annual costs and average costs per client counselled and tested (C&T), and HIV-positive clients identified, were estimated. RESULTS: VCT remains the predominant mode of HCT service delivery across both countries. However, unit cost per client C&T and per person testing HIV positive is lower for PITC than VCT across all facility types in Kenya, but the picture is mixed in Swaziland. Average cost per client C&T ranged from US $4.81 to US $6.11 in Kenya, US $6.92 to US $13.51 in Swaziland for PITC, and from US $5.05 to US $16.05 and US $8.68 to US $19.32 for VCT in Kenya and Swaziland, respectively. CONCLUSIONS: In the context of significant policy interest in optimising scarce HIV resources, this study demonstrates that there may be potential for substantial gains in efficiency in the provision of HCT services in both Kenya and Swaziland. However, considerations of how to deliver services efficiently need to be informed by local contextual factors, such as prevalence, service demand and availability of human resources.
Project description:Home HIV counselling and testing (HTC) achieves high coverage of testing and linkage to care compared with existing facility-based approaches, particularly among asymptomatic individuals. In a modelling analysis we aimed to assess the effect on population-level health and cost-effectiveness of a community-based package of home HTC in KwaZulu-Natal, South Africa.We parameterised an individual-based model with data from home HTC and linkage field studies that achieved high coverage (91%) and linkage to antiretroviral therapy (80%) in rural KwaZulu-Natal, South Africa. Costs were derived from a linked microcosting study. The model simulated 10,000 individuals over 10 years and incremental cost-effectiveness ratios were calculated for the intervention relative to the existing status quo of facility-based testing, with costs discounted at 3% annually.The model predicted implementation of home HTC in addition to current practice to decrease HIV-associated morbidity by 10–22% and HIV infections by 9–48% with increasing CD4 cell count thresholds for antiretroviral therapy initiation. Incremental programme costs were US$2·7 million to $4·4 million higher in the intervention scenarios than at baseline, and costs increased with higher CD4 cell count thresholds for antiretroviral therapy initiation; antiretroviral therapy accounted for 48–87% of total costs. Incremental cost-effectiveness ratios per disability-adjusted life-year averted were $1340 at an antiretroviral therapy threshold of CD4 count lower than 200 cells per ?L, $1090 at lower than 350 cells per ?L, $1150 at lower than 500 cells per ?L, and $1360 at universal access to antiretroviral therapy.Community-based HTC with enhanced linkage to care can result in increased HIV testing coverage and treatment uptake, decreasing the population burden of HIV-associated morbidity and mortality. The incremental cost-effectiveness ratios are less than 20% of South Africa's gross domestic product per person, and are therefore classed as very cost effective. Home HTC can be a viable means to achieve UNAIDS' ambitious new targets for HIV treatment coverage.National Institutes of Health, Bill & Melinda Gates Foundation, Wellcome Trust.
Project description:Provider-initiated HIV testing and counselling (PITC) is promoted as a means to increase HIV case finding. We assessed the effectiveness of PITC to increase HIV testing rate and HIV case finding among outpatients in Rwandan health facilities (HF).PITC was introduced in six HFs in 2009-2010. HIV testing rate and case finding were compared between phase 1 (pre-PITC) and phase 3 (PITC period) for outpatient-department (OPD) attendees only, and for OPD and voluntary counseling & testing (VCT) departments combined.Out of 26,367 adult OPD attendees in phase 1, 4.7% were tested and out of 29,864 attendees in phase 3, 17.0% were tested (p < 0.001). The proportion of HIV cases diagnosed was 0.25% (67/26,367) in phase 1 and 0.46% (136/29864) in phase 3 (p < 0.001). In multivariable analysis, both testing rate and case finding were significantly higher in phase 3 for OPD attendees. In phase 1 most of the HIV testing was done in VCT departments rather than at the OPD (78.6% vs 21.4% respectively); in phase 3 this was reversed (40.0% vs 60.0%; p < 0.001). In a combined analysis of VCT and OPD attendees, testing rate increased from 18.7% in phase 1 to 25.4% in phase 3, but case finding did not increase. In multivariable analysis, testing rate was significantly higher in phase 3 (OR 1.67; 95% CI 1.60-1.73), but case finding remained stable (OR 1.09; 95% CI 0.93-1.27).PITC led to a shift of HIV testing from VCT department to the OPD, a higher testing rate, but no additional HIV case finding.