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

ABSTRACT

Early antiretroviral therapy (ART) initiation is essential, but linkage to care following community-based services is often poor, and inadequately understood. This study examined factors influencing linkage to care following home-based HIV-testing services (HBHTS) in a hyper-endemic setting in South Africa. HBHTS was offered to participants (N = 10,236) enrolled in the second HIV Incidence Provincial Surveillance System survey (2015–2016), KwaZulu-Natal. Follow-up telephone surveys with 196 of the 313 individuals diagnosed HIV-positive through HBHTS were used to measure linkage to care (i.e., a clinic visit within 12 weeks) and ART-initiation. Among newly diagnosed individuals (N = 183), 55% linked to care, and 21% of those who were ART-eligible started treatment within 12 weeks. Linkage to care was less likely among participants who had doubted their HIV-diagnosis (aOR:0.46, 95%CI: 0.23–0.93) and more likely among participants who had disclosed their HIV-status (aOR:2.31, 95%CI: 1.07–4.97). Reasons for not linking to care included no time (61%), only wanting to start treatment when sick (48%), fear of side-effects (33%), and not believing the HIV-diagnosis (16%). Results indicate that HBHTS needs to be paired with targeted interventions to facilitate early linkage to care. Interventions are required to counter denial of HIV status and facilitate early linkage to care among healthier individuals.

KEYWORDS:

• Community-based HIV testing services
• home-based HIV testing services
• linkage to care
• antiretroviral therapy
• HIV treatment cascade
• Southern Africa

Acknowledgements

We thank all the participants of HIV Incidence Provincial Surveillance System (HIPSS), as well as HIPSS co-investigators and members of the HIPSS study team from the following organisations: Epicentre, CAPRISA, HEARD, NICD and CDC. We thank the HIPSS collaborating partners: The National Department of Health, Provincial KwaZulu-Natal Department of Health, uMgungundlovu Health District, the uMgungundlovu District AIDS Council, local municipal and traditional leaders, and community members for all their support throughout the HIPSS study. We are extremely grateful to Kassahun Ayalew, Ehimario Igumbor and Mary Glenshaw for valuable feedback on previous versions of this manuscript.

Disclosure statement

No potential conflict of interest was reported by the author(s).

Additional information

Funding

HIV Incidence Provincial Surveillance System (HIPSS) is funded by a cooperative agreement (3U2GGH000372) between Epicentre and the Centers for Disease Control and Prevention (CDC). Support was provided to BMB by the National Research Foundation, South Africa, through the Research Career Advancement Fellowship. ABMK is supported by a joint South Africa–U.S. Program for Collaborative Biomedical Research, National Institutes of Health grant (R01HD083343). The findings and conclusions in this paper are those of the author(s) and do not necessarily represent the official views of any of the funders in this study.