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Innovative approaches to linkage to care boost clinic visits, HIV treatment uptake in African study
Keith Alcorn, 2015-07-21 07:20:00

A systematic effort to promote HIV testing, linkage to care for people diagnosed with HIV and circumcision for those testing negative can result in high levels of diagnosis, linkage to care and viral suppression in rural communities, a randomised study of combination HIV prevention conducted in South Africa and Uganda has shown.

The findings were presented  by Dr Ruanne Barnabas of the University of Washington Department of Global Health on Monday at the Eighth International AIDS Society Conference on HIV Pathogenesis, Treatment and Prevention in Vancouver, Canada.

Combination HIV prevention has been promoted by UNAIDS as essential in high-prevalence settings, but there have been remarkably few studies which assess the efficacy of a combination of approaches, especially in multifactorial designs. Combination HIV prevention studies are needed to test how different approaches work together and how limited resources can be used efficiently to maximise diagnosis, linkage to care and uptake of prevention services.

Efforts to maximise HIV diagnosis through community-based testing provide an important opportunity both for diagnosing people with HIV infection and linking them to care, and identifying people who are HIV-negative and in need of prevention services. Reaching younger men who might benefit from circumcision has been a particular challenge

Several large community-based studies have previously examined how to maximise the uptake of HIV testing and achieve linkage to HIV care for those diagnosed with HIV. Two large multi-disease prevention campaigns, in Kenya and Uganda, showed that it was possible to achieve very high uptake of HIV testing through running time-limited campaigns in a locality, during which people were offered commodities such as water filters or screening for a range of health problems such as diabetes in addition to HIV testing. These studies also examined linkage to care, but did not compare methods of linkage to care.

The Project ACCEPT randomised study showed that widespread community mobilisation and the provision of mobile testing services were sufficient to result in a 14% fall in HIV incidence in the communities which received the intervention, when compared to the provision of standard voluntary counselling and testing services.

But there is still a big gap between HIV diagnosis and starting antiretroviral therapy. Large numbers of people diagnosed with HIV either never make it to the clinic to be assessed for ART eligibility, or else don’t return when told that they are not yet eligible. Efforts to improve linkage to care after diagnosis are critical for preventing a situation where people stay away from medical care until they are sick, and for maximising the number of people who are able to benefit from antiretroviral therapy. Numerous speakers at the conference agreed that improving linkage to care is now one of the most critical challenges facing HIV programmes as they work to achieve the UNAIDS 90-90-90 target.

The Linkages study, developed by the University of Washington’s Department of Global Health, was designed to test a number of different approaches to maximising linkage to care, initiation of antiretroviral therapy and uptake of voluntary medical male circumcision. HIV testing was offered in two communities in rural Kwazulu Natal, South Africa, and rural Sheema district, Uganda.

750 uncircumcised men who tested negative were randomised to one of three interventions promoting medical male circumcision:

  • Standard of care promotion at point of HIV testing,

  • SMS follow-up with motivating, unidentifiable messages at months 1,2 and 3

  • Lay-counsellor follow-up visits at months 1, 2 and 3

The primary study outcomes in this study arm were the proportion of HIV-uninfected men who visited a male circumcision clinic or outreach venue for information about circumcision, and the proportion who reported being circumcised by months 3 and 9 in the lay-counsellor arm compared to the SMS follow-up arm, and to the male circumcision promotion at HIV testing arm.

The study found that both innovative methods of promoting circumcision resulted in an increase in uptake of approximately 70% when compared to standard of care, with the greatest impact in the first three months after testing.

Source:1