How does HIV testing modality impact the cascade of care among persons diagnosed with HIV in Ethiopia?

Figures & data

Figure 1. Flowchart of inclusion of participants in the different components of the study

Abbreviations: ART – antiretroviral therapy. ANC – antenatal care. VL – viral load. Suppressed: ≥1 VL <1000 copies/ml, with no recorded VL ≥ 1000 copies/ml. Unsuppressed: ≥1 VL ≥1000 copies/ml. ¹For analysis of ART initiation, all participants were included. ²For analysis of retention in care, the following exclusion criteria were applied: diagnosed during antenatal care (ANC); transfer of care to a different clinic (transfer out); incomplete follow-up data. ³For analysis of viral load testing, participants with no registered viral load result were excluded.

Table 1. Characteristics of 2885 adults and adolescents newly diagnosed with HIV at Ethiopian health facilities with regard to type of test modality

	Total n (%^1)	VCT n (%)	Community n (%)	PICT n (%)	Other n (%)
Total n (%)	2885 (100)	561 (19)	583 (20)	1164 (40)	577 (20)
Age (years)
Median [IQR]	32 [27–40]	33 [27–40]	32 [27–38]	30 [26–40]	35 [28–40]
16–25	566 (20)	98 (18)	120 (21)	268 (24)	80 (15)
26–35	1225 (43)	249 (45)	263 (46)	482 (42)	231 (42)
≥36	1035 (37)	209 (38)	195 (34)	392 (34)	239 (44)
Missing	59 (2)	5 (1)	5 (1)	22 (2)	27 (5)
Gender
Female	1704 (59)	326 (58)	335 (57)	732 (63)	311 (54)
Male	1172 (41)	234 (42)	248 (43)	425 (37)	265 (46)
Missing	9 (0)	1 (0)	0 (0)	7 (1)	1 (0)
BMI
Median [IQR]	19.5 [17.5–22.0]	19.6 [17.9–22.2]	19.8 [17.9–22.2]	19.2 [17.2–21.7]	19.8 [17.4–22.1]
<18.5	885 (36)	173 (33)	172 (33)	377 (40)	163 (36)
≥18.5	1552 (64)	349 (67)	352 (67)	555 (60)	296 (64)
Missing	448 (16)	39 (7)	59 (10)	232 (20)	118 (21)
Concomitant TB^2
Yes	183 (7)	20 (4)	20 (4)	104 (10)	39 (8)
No	2338 (93)	503 (96)	495 (96)	906 (90)	434 (92)
Missing	364 (13)	38 (7)	68 (12)	154 (13)	104 (18)
WHO stage
I–II	1504 (59)	355 (69)	339 (64)	530 (52)	280 (59)
III–IV	1041 (41)	163 (31)	190 (36)	491 (48)	197 (41)
Missing	340 (12)	43 (8)	54 (9)	143 (12)	100 (17)
Site
Hospital	1217 (42)	187 (33)	258 (44)	538 (46)	234 (41)
Health Centre	1668 (58)	374 (67)	325 (56)	626 (54)	343 (59)
Year of diagnosis
2015	420 (15)	72 (13)	65 (11)	200 (17)	83 (14)
2016	859 (30)	115 (20)	269 (46)	318 (27)	157 (27)
2017	947 (33)	225 (40)	173 (30)	368 (32)	181 (31)
2018	659 (23)	149 (27)	76 (13)	278 (24)	156 (27)

¹Percentages calculated after exclusion of participants with missing data for the respective variables.

²Persons receiving treatment for active TB were considered to have concomitant TB.

Table 2. Uni- and multivariable analysis of factors associated with ART initiation

	ART initiation	No ART initiation	Univariate analysis			Multivariable analysis
	n (%)	n (%)	OR	95% CI	p	AOR	95% CI	p
n = 2885	2476 (86)	409 (14)
Age (years)
16–25	477 (84)	89 (16)	0.76	0.57–1.02	0.07	**
26–35	1050 (86)	175 (14)	0.85	0.67–1.09	0.21
≥36	906 (88)	129 (12)	ref
Gender
Female	1487 (87)	217 (13)	ref
Male	989 (85)	183 (16)	0.79	0.64–0.98	0.03	**
BMI
<18.5	779 (88)	106 (12)	0.86	0.66–1.11	0.24	*
≥18.5	1390 (90)	162 (10)	ref
TB
Yes	163 (89)	20 (11)	0.95	0.59–1.54	0.83	*
No	2094 (90)	244 (10)	ref
WHO stage
I–II	1372 (91)	132 (9)	ref
III–IV	910 (87)	131 (13)	0.67	0.52–0.86	0.002	0.67	0.52–0.87	0.003
Test modality
VCT	509 (91)	52 (9)	ref
Community	479 (82)	104 (18)	0.47	0.33–0.67	<0.001	0.44	0.29–0.66	<0.001
PICT	979 (84)	185 (16)	0.54	0.39–0.75	0.0002	0.65	0.44–0.97	0.035
Other	509 (88)	68 (12)	0.76	0.52–1.12	0.17	0.82	0.51–1.32	0.42

*Not included in multivariable analysis due to p > 0.2 in univariate analysis.

**Excluded in multivariate analysis with forward removal.

Table 3. Uni- and multivariable analysis of factors associated with retention in care

	Retention	Lack of retention	Univariate analysis			Multivariable analysis
	n (%)	n (%)	OR	95% CI	p	AOR	95% CI	p
n = 2043	1422 (70)	621 (30)
Age
16–25	203 (64)	112 (36)	0.72	0.54–0.94	0.02	0.62	0.45–0.85	0.003
26–35	598 (69)	265 (31)	0.89	0.72–1.10	0.29	0.81	0.64–1.03	0.09
≥36	594 (72)	235 (28)	ref			ref
Gender
Female	814 (71)	331 (29)	ref			ref
Male	608 (68)	290 (32)	0.80	0.66–0.97	0.02	0.77	0.62–0.96	0.02
BMI
<18.5	468 (67)	229 (33)	0.71	0.58–0.87	0.001	0.75	0.61–0.94	0.01
≥18.5	861 (74)	300 (26)	ref			ref
TB
Yes	98 (65)	52 (35)	0.77	0.54–1.09	0.14	*
No	1234 (71)	504 (29)	ref
WHO stage
I–II	778 (72)	297 (28)	ref
III–IV	556 (68)	266 (32)	0.80	0.65–0.97	0.03	*
Test modality
VCT	348 (75)	119 (25)	ref
Community	291 (68)	134 (32)	0.74	0.55–0.99	0.05	*
PICT	474 (68)	227 (32)	0.71	0.55–0.93	0.01
Other	309 (69)	141 (31)	0.75	0.56–1.00	0.05

*Excluded in multivariable analysis with forward removal.

Table 4. Viral load result available, among those eligible for testing (ie in care at time points for routine viral load testing, at 6 and 12 months after ART initiation)

	No viral load result	Viral load result
Total N (%)	760	1046
Age (years)
16–25	139 (46)	164 (54)
26–35	338 (44)	432 (56)
≥36	275 (39)	425 (61)
Gender
Female	445 (42)	622 (58)
Male	315 (43)	424 (57)
BMI
<18.5	248 (44)	316 (56)
≥18.5	435 (40)	640 (60)
Clinical stage
I–II	384 (38)	627 (62)
III–IV	323 (48)	348 (52)
TB treatment
Yes	657 (42)	900 (58)
No	52 (43)	69 (57)
Site
Hospital	359 (49)	369 (50)
Health centre	401 (37)	677 (63)
Year of diagnosis
2015	142 (60)	93 (40)
2016	268 (50)	273 (50)
2017	233 (37)	398 (63)
2018	117 (29)	282 (71)
Test modality
VCT	148 (36)	259 (64)
Community	172 (48)	188 (52)
PICT	289 (44)	370 (56)
Other	151 (40)	299 (60)

Table 5. Uni- and multivariable analysis of factors associated with viral suppression

	Suppressed	Unsuppressed	Univariate analysis			Multivariable analysis
	n (%)	n (%)	OR	95% CI	p	AOR	95% CI	p
n = 1046	953 (91)	93 (9)
Age
16–25	145 (88)	19 (11)	0.64	0.35–1.17	0.15	**
26–35	393 (91)	39 (9)	0.85	0.52–1.38	0.51
≥36	392 (92)	33 (8)	ref
Gender
Female	574 (92)	48 (8)	ref
Male	379 (89)	45 (11)	0.70	0.46–1.08	0.11	**
BMI
<18.5	287 (91)	29 (9)	0.91	0.57–1.46	0.70	*
≥18.5	586 (92)	54 (8)	ref
TB
Yes	61 (88)	8 (12)	0.71	0.33–1.55	0.39	*
No	823 (91)	77 (9)	ref
WHO stage
I–II	579 (92)	48 (8)	ref
III–IV	309 (89)	39 (11)	0.66	0.42–1.02	0.06	**
Test modality
VCT	241 (93)	18 (7)	ref
Community	173 (92)	15 (8)	0.86	0.42–1.76	0.68	**
PICT	329 (89)	41 (11)	0.60	0.34–1.07	0.08
Other	210 (92)	19 (8)	0.82	0.42–1.61	0.58

Suppressed: ≥1 VL <1000 copies/ml, with no recorded VL ≥ 1000 copies/ml. Unsuppressed: ≥1 VL ≥1000 copies/ml.

*Not included in multivariable analysis due to p > 0.2 in univariate analysis.

**Excluded in multivariate analysis with forward removal.

Table 6. Uni- and multivariable analysis of factors associated with each step of the cascade of care

	ART initiation	No ART initiation	Univariate analysis			Multivariable analysis
	n (%)	n (%)	OR	95% CI	p	AOR	95% CI	p
n = 1704 Age (years)	1487 (87)	217 (13)
16–25	402 (86)	67 (14)	0.60	0.40–0.91	0.02	**
26–35	656 (86)	103 (14)	0.64	0.43–0.94	0.02
≥36	400 (91)	40 (9)	ref		ref
BMI
<18.5	428 (90)	46 (10)	1.05	0.72–1.52	0.8	*
≥18.5	836 (90)	94 (10)	ref		ref
TB
Yes	61 (84)	12 (16)	0.49	0.26–0.94	0.03	0.39	0.20–0.76	0.01
No	1286 (91)	125 (9)	ref		ref
WHO stage
I–II	895 (92)	75 (8)	ref		ref	**
III–IV	477 (88)	68 (13)	0.59	0.42–0.83	0.003
Test modality
VCT	296 (91)	30 (9)	ref		ref	ref
Community	274 (82)	61 (18)	0.45	0.29–0.73	0.001	0.47	0.27–0.82	0.01
PICT	643 (88)	89 (12)	0.73	0.47–1.13	0.16	0.95	0.55–1.65	0.87
Other	274 (88)	37 (12)	0.75	0.45–1.25	0.26	0.93	0.48–1.81	0.93
	Retention	Lack of retention	Univariate analysis			Multivariable analysis
	n (%)	n (%)	OR	95% CI	p	AOR	95% CI	p
n = 1145	814 (71)	331 (29)
Age (years)
16–25	164 (65)	89 (35)	0.65	0.46–0.93	0.02	0.59	0.40–0.86	0.01
26–35	364 (72)	140 (28)	0.92	0.68–1.26	0.63	0.91	0.66–1.28	0.60
≥36	269 (74)	96 (26)	ref		ref
BMI
<18.5	261 (69)	115 (31)	0.75	0.56–0.99	0.04	**
≥18.5	494 (75)	163 (25)	ref		ref
TB
Yes	39 (68)	18 (32)	0.83	0.47–1.47	0.52	*
No	725 (72)	277 (28)	ref		ref
WHO stage
I–II	468 (74)	167 (26)	ref		ref	**
III–IV	302 (70)	130 (30)	0.83	0.63–1.09	0.18
Test modality
VCT	207 (76)	67 (25)	ref		ref	**
Community	175 (72)	69 (28)	0.82	0.55–1.21	0.32
PICT	273 (70)	117 (30)	0.75	0.53–1.07	0.12
Other	159 (67)	78 (33)	0.65	0.45–0.97	0.03
	Suppressed	Unsuppressed	Univariate analysis			Multivariable analysis
	n (%)	n (%)	OR	95% CI	p	AOR	95% CI	p
n = 622	574 (92)	48 (8)
Age (years)
16–25	122 (91)	12 (9)	0.76	0.34–1.71	0.51	*
26–35	251 (92)	21 (8)	0.89	0.45–1.82	0.77
≥36	186 (93)	14 (7)	ref		ref
BMI
<18.5	166 (93)	12 (7)	1.09	0.54–2.21	0.8	*
≥18.5	354 (93)	28 (7)	ref		ref
TB
Yes	21 (84)	4 (16)	0.41	0.13–1.25	0.12	**
No	513 (93)	40 (7)	ref		ref
WHO stage
I–II	366 (93)	26 (7)	ref		ref	*
III–IV	172 (91)	18 (10)	0.68	0.36–1.27	0.23
Test modality
VCT	150 (96)	6 (4)	ref		ref	**
Community	99 (93)	8 (8)	0.50	1.17–1.47	0.21
PICT	219 (89)	26 (11)	0.34	1.14–0.84	0.02
Other	115 (94)	8 (7)	0.57	0.19–1.70	0.3

*Not included due to univariate p > 0.2.

**Excluded in multivariable analysis.

Table 7. Male participants: uni- and multivariable analysis of factors associated with each step of the cascade of careresult available, among those eligible

	ART initiation	No ART initiation	Univariate analysis			Multivariable analysis
	n (%)	n (%)	OR	95% CI	p	AOR	95% CI	p
n = 1172	1487 (87)	217 (13)
Age (years)
16–25	75 (77)	22 (23)	0.60	0.35–1.01	0.05	0.45	0.24–0.83	0.01
26–35	394 (85)	71 (15)	0.98	0.70–1.37	0.89	0.98	0.64–1.50	0.92
≥36	506 (85)	89 (15)	ref		ref
BMI
<18.5	351 (86)	58 (14)	0.73	0.50–1.07	0.1	**
≥18.5	554 (89)	67 (11)	ref		ref
TB
Yes	102 (94)	7 (6)	2.13	0.96–4.69	0.06	**
No	808 (87)	118 (13)	ref		ref
WHO stage
I–II	477 (90)	56 (11)	ref		ref	*
III–IV	433 (89)	62 (13)	0.82	0.56–1.20	0.31
Test modality
VCT	213 (91)	21 (9)	ref		ref	ref
Community	205 (83)	43 (17)	0.47	0.27–0.82	0.01	0.39	0.19–0.78	0.01
PICT	336 (79)	89 (21)	0.37	0.22–0.62	0.0001	0.34	0.17–0.65	0.001
Other	235 (89)	30 (11)	0.77	0.43–1.39	0.39	0.56	0.26–1.17	0.12
	Retention	Lack of retention	Univariate analysis			Multivariable analysis
	n (%)	n (%)	OR	95% CI	p	AOR	95% CI	p
n = 898	608 (68)	290 (32)
Age (years)
16–25	39 (63)	23 (37)	0.73	0.42–1.26	0.25	**
26–35	234 (65)	125 (35)	0.89	0.59–1.07	0.14
≥36	325 (70)	139 (30)	ref		ref
BMI
<18.5	207 (65)	114 (36)	0.68	0.50–0.92	0.01	0.68	0.50–0.92	0.01
≥18.5	367 (73)	137 (27)	ref		ref
TB
Yes	59 (63)	34 (37)	0.77	0.49–1.21	0.26	*
No	509 (69)	227 (31)	ref		ref
WHO stage
I–II	310 (71)	130 (30)	ref		ref	**
III–IV	254 (65)	136 (35)	0.78	0.58–1.05	0.10
Test modality
VCT	141 (73)	52 (27)	ref		ref	**
Community	116 (64)	65 (36)	0.65	0.42–1.02	0.06
PICT	201 (65)	119 (35)	0.62	0.42–0.92	0.02
Other	150 (70)	63 (30)	0.88	0.57–1.35	0.56
	Suppression	Unsuppressed	Univariate analysis			Multivariable analysis
	n (%)	n (%)	OR	95% CI	p	AOR	95% CI	p
Age (years)
16–25	23 (77)	7 (23)	0.30	0.12–0.80	0.02	0.30	0.12–0.80	0.02
26–35	142 (89)	18 (11)	0.72	0.36–1.44	0.36	0.73	0.37–1.44	0.36
≥36	206 (92)	19 (8)	ref		ref
BMI
<18.5	121 (88)	17 (23)	0.80	0.41–1.53	0.50	*
≥18.5	232 (90)	26 (10)	ref		ref
TB
Yes	40 (91)	4 (9)	1.19	0.40–3.52	0.75	*
No	310 (89)	37 (11)	ref		ref
WHO stage
I–II	213 (91)	22 (9)	ref		ref	*
III–IV	137 (87)	21 (13)	0.67	0.36–1.27	0.22
Test modality
VCT	91 (88)	12 (12)	ref		ref	*
Community	74 (91)	7 (9)	1.39	0.52–3.72	0.51
PICT	119 (89)	15 (11)	1.04	0.47–2.34	0.91
Other	95 (90)	11 (10)	1.14	0.48–2.71	0.77

*Not included due to univariate p > 0.2.

**Excluded in multivariable analysis.

Figure 2. Cascade of HIV care for the overall population and disaggregated by test modality

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