- Category: Global Access
- Published on Thursday, 13 April 2017 00:00
- Written by Carole Leach-Lemens
Close to 60% of adults benefitting from point-of-care CD4 cell count testing at HIV testing sites, accelerated antiretroviral therapy (ART) initiation, and SMS appointment reminders were retained in care after 1 year, compared to just 44% of those receiving the standard of care in Mozambique, according to findings from the Engage4Health study presented at the recent Conference on Retroviruses and Opportunistic Infections (CROI 2017) in Seattle.
The study also found that people who received the enhanced intervention were much more likely to be linked to care within 1 month of diagnosis. Over 90% of those who received the enhanced intervention were linked to care within 1 month, compared to 63% of those who received the standard of care. People who received the enhanced intervention were 5 times more likely to link to care on the day of diagnosis (RR 5.7) and twice as likely to have linked to care within 1 week (RR 2.0), when compared to the standard of care group.
Despite the considerable success of HIV programmatic scale-up in sub-Saharan Africa, timely linkage to care after HIV diagnosis and sustained retention in care have been identified as major weaknesses across the continuum of care. Barriers at each step of the continuum persist. Identification of scalable interventions to strengthen linkage to and retention in HIV care is critical for individual and population benefits of ART.
Findings show that less than half of people with HIV in Mozambique enroll in care within a month of their diagnosis. Among those who do enroll in care, less than half are still in care 12 months later. Such low rates of linkage to and retention in care highlight the challenge of ensuring effective, long-term HIV treatment.
Led by ICAP, in partnership with the Center for Collaboration in Health and Mozambique’s Ministry of Health and funded by USAID, the Engage4Health study evaluated the effectiveness of a combination intervention strategy (CIS) compared to the standard of care (SOC) on the combined outcome of linkage to care within 1 month and retention in care at 12 months following HIV diagnosis. A subset of CIS participants received, in addition, non-cash financial incentives (CIS+FI).
The Engage4Health study was a cluster-randomized controlled trial conducted at ten health facilities from 2013 to 2016.
From April 2013 to June 2015 adults over 18 years of age who were newly diagnosed with HIV, not currently pregnant, not enrolled in HIV care or receiving ART in the prior 6 months, and willing to get HIV care at the diagnosing health facility were enrolled from clinics in Maputo and the more rural area of Inhambane Province. Participants were followed for 12 months.
Of the 2004 enrolled participants (744, 493, and 767 in the CIS, CIS+FI, and SOC arms, respectively), two-thirds were women with a mean age of 34 years, half were married, and approximately one-quarter were unemployed. Participants were referred mainly from voluntary testing and counseling sites.
The standard of care at the time comprised laboratory referral for CD4 testing, returning for results in 2 to 4 weeks, and ART counseling at a separate clinic visit.
The CIS+FI cohort received up to 3 pre-paid cell phone cards, equivalent to $5 in value, one for linkage within 1 month, the second for retention at 6 months, and the third at 12 months.
Approximately 90% of participants were interviewed at 1 month and approximately 80% at 12 months.
The primary outcome, linkage to care within 1 month and retention at 12 months, was 35%, 57%, and 55% for the SOC, CIS, and CIS+FI cohorts, respectively. The unadjusted relative risk for the primary outcome compared to the SOC arm was RR 1.6 for both the CIS and CIS+FI cohorts.
This breaks down to rates for those linked to care within 1 month as follows: 63%, 94%, and 95% for the SOC, CIS, and CIS+FI cohorts, respectively.
The CIS and CIS+FI cohorts had similar very high linkage rates. While the retention rates at 12 months remained similar for the CIS and CIS+FI cohorts, there was, nonetheless, a considerable loss to follow-up across all groups: 56%, 42%, and 45% were lost to follow-up, respectively. For the CIS cohort there was a 20% improvement in retention at 6 months and 30% at 12 months compared to the SOC group.
In a sensitivity analysis with the primary outcome expanded from clinic of diagnosis to include any clinic, the primary outcome rate was 46%, 70%, and 68% for the SOC, CIS, and CIS+FI cohorts, respectively. Increases were in the same proportion for all 3 groups. The unadjusted relative risk was similar for both cohorts and was unchanged.
Presenting findings from the study, Matthew Lamb concluded that combination strategies improved linkage within 1 month plus retention at 12 months following HIV diagnosis by 50% to 60%.
However, this improvement was due primarily to the significantly enhanced linkage to care rather than changes in retention. Financial incentives provided no additional benefit.
B Elul, MR Lamb, M Lahuerta, et al. A combination intervention strategy for HIV linkage and retention in Mozambique. Conference on Retroviruses and Opportunistic Infections. Seattle, February 13-16, 2017. Abstract 110.