Abstract
BackgroundConcerning gaps in the HIV care continuum compromise individual and population health. We evaluated a combination intervention strategy (CIS) targeting prevalent barriers to timely linkage and sustained retention in HIV care in Mozambique.Methods and findingsIn this cluster-randomized trial, 10 primary health facilities in the city of Maputo and Inhambane Province were randomly assigned to provide the CIS or the standard of care (SOC). The CIS included point-of-care CD4 testing at the time of diagnosis, accelerated ART initiation, and short message service (SMS) health messages and appointment reminders. A pre–post intervention 2-sample design was nested within the CIS arm to assess the effectiveness of CIS+, an enhanced version of the CIS that additionally included conditional non-cash financial incentives for linkage and retention. The primary outcome was a combined outcome of linkage to care within 1 month and retention at 12 months after diagnosis. From April 22, 2013, to June 30, 2015, we enrolled 2,004 out of 5,327 adults ≥18 years of age diagnosed with HIV in the voluntary counseling and testing clinics of participating health facilities: 744 (37%) in the CIS group, 493 (25%) in the CIS+ group, and 767 (38%) in the SOC group. Fifty-seven percent of the CIS group achieved the primary outcome versus 35% in the SOC group (relative risk [RR]CIS vs SOC = 1.58, 95% CI 1.05–2.39). Eighty-nine percent of the CIS group linked to care on the day of diagnosis versus 16% of the SOC group (RRCIS vs SOC = 9.13, 95% CI 1.65–50.40). There was no significant benefit of adding financial incentives to the CIS in terms of the combined outcome (55% of the CIS+ group achieved the primary outcome, RRCIS+ vs CIS = 0.96, 95% CI 0.81–1.16). Key limitations include the use of existing medical records to assess outcomes, the inability to isolate the effect of each component of the CIS, non-concurrent enrollment of the CIS+ group, and exclusion of many patients newly diagnosed with HIV.ConclusionsThe CIS showed promise for making much needed gains in the HIV care continuum in our study, particularly in the critical first step of timely linkage to care following diagnosis.Trial registrationClinicalTrials.gov NCT01930084
Highlights
The extraordinary scale-up of HIV testing, care, and treatment programs in subSaharan Africa over the past decade has resulted in more than 19 million persons accessing antiretroviral therapy (ART) [1], the effectiveness of these programs has been significantly hindered by high levels of attrition across the HIV care continuum
We designed a combination intervention strategy (CIS) composed of several scalable evidence-based interventions targeting prevalent health system, structural, and behavioral barriers across the HIV care continuum, and determined its effect on a combined outcome of linkage to and retention in HIV care among adults newly diagnosed with HIV in Mozambique, while collecting information on its implementation and potential for broader scale-up [20]
We focused on individuals newly diagnosed in voluntary counseling and testing (VCT) clinics, as opposed to those diagnosed in antenatal clinics and tuberculosis clinics, because the latter groups of patients typically follow a modified clinic flow
Summary
The extraordinary scale-up of HIV testing, care, and treatment programs in subSaharan Africa over the past decade has resulted in more than 19 million persons accessing antiretroviral therapy (ART) [1], the effectiveness of these programs has been significantly hindered by high levels of attrition across the HIV care continuum. Implementation science research that evaluates proposed multi-component approaches in real-world settings is needed to assess effectiveness, and implementation outcomes including reach, adoption, and sustainability [19]. To this end, we designed a combination intervention strategy (CIS) composed of several scalable evidence-based interventions targeting prevalent health system, structural, and behavioral barriers across the HIV care continuum, and determined its effect on a combined outcome of linkage to and retention in HIV care among adults newly diagnosed with HIV in Mozambique, while collecting information on its implementation and potential for broader scale-up [20]. Because the interventions included in the CIS are expected to be implemented at the facility level, as opposed to targeted at specific individuals, should they be scaled up, we evaluated effectiveness using a cluster design, which best mirrors this implementation approach
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