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Linkage to HIV care still challenging for young men, Botswana study finds
Keith Alcorn, 2017-03-16 07:10:00

Almost one in five people newly diagnosed with HIV in a study employing active methods to link people to care and treatment had still not linked to care a year after diagnosis, a large study in Botswana has found. The problem was most acute in young men and those in employment, leading the investigators to suggest that despite high rates of linkage to care in the rest of the population, alternative treatment delivery models may be needed for these groups.

The findings were presented last month at the Conference on Retroviruses and Opportunistic Infections (CROI 2017) in Seattle.

Achieving linkage to care of people diagnosed with HIV has emerged as a major obstacle to achieving the UNAIDS 90-90-90 goals, which call for 90% of people diagnosed with HIV to be on treatment and 90% of people on treatment to have undetectable viral load by 2020.

A recently published study conducted in South Africa showed good retention in care but very slow linkage to care among people diagnosed with HIV in a large population study in KwaZulu-Natal. Active approaches that link people to care, whether through personal or telephone follow-up, peer support, accompaniment to health facilities, or even antiretroviral therapy (ART) initiation at home, are being tested in sub-Saharan Africa in order to identify what can be done to improve linkage to care.

The Botswana Combination Prevention Project is a community-randomised trial comparing the impact of standard of care or an aggressive combination prevention package on HIV incidence in selected communities in Botswana. The intervention includes home-based or mobile testing and point-of-care CD4 test, next-day clinic appointments for people who test positive. Text message appointment reminders and active tracing by phone or home visits are used to ensure retention in care.

The investigators of the Botswana Combination Prevention Project reported on linkage to care and ART initiation among people in intervention communities in two poster presentations at CROI 2017.

The first round of HIV testing campaigns began in September 2013. The study has randomised 30 communities to receive the intervention package or the standard of care, and the intervention has been rolled out in three phases, each to five pairs of villages. An intensive local HIV testing campaign lasting six to eight weeks and linkage to care is followed by an analysis of linkage to care, treatment initiation and retention in care during the subsequent year.

In 2016 results of a survey of 20% of households in 24 of the villages in the study were presented at CROI. The results presented at CROI 2017 consist of the linkage to care outcomes of the 15 communities receiving the combination prevention package, after the first round of testing campaigns and one-year follow-up, and the treatment initiation outcomes of all those in the intervention communities who tested positive and who were not on treatment at the time they were enrolled into the study.