Findings from home-based HIV testing and facilitated linkage after scale-up of test and treat in rural South Africa: young people still missing.

Abstract

The aim of the study was to estimate rates of linkage to HIV care and antiretroviral treatment (ART) initiation after the introduction of home-based HIV counselling and testing (HBHCT) and telephone-facilitated support for linkage in rural South Africa. A population-based prospective cohort study was carried out in KwaZulu Natal, South Africa. All residents aged ≥ 15years were eligible for HBHCT. Those who tested positive and were not in care were referred for ART at one of 11 public-sector clinics. Individuals who did not attend the clinic within 2weeks were sent a short message service (SMS) reminder; those who had not attended after a further 2weeks were telephoned by a nurse counsellor, to discuss concerns and encourage linkage. Kaplan-Meier methods were used to estimate the proportion of newly diagnosed individuals linking to care and initiating ART. Among 38827 individuals visited, 26% accepted HBHCT. Uptake was higher in women than in men (30% versus 20%, respectively), but similar in people aged <30years and ≥ 30years (28% versus 26%, respectively). A total of 784 (8%) tested HIV positive, of whom 427 (54%) were newly diagnosed. Within 6months, 31% of women and 18% of men <30years old had linked to care, and 29% and 16%, respectively, had started ART. Among those ≥ 30years, 41% of women and 38% of men had linked to care within 6months, and 41% and 35%, respectively, had started ART. Despite facilitated linkage, rates of timely linkage to care and ART initiation after HBHCT were very low, particularly among young men. Innovations are needed to provide effective HIV care and prevention interventions to young people, and thus maximize the benefits of universal test and treat.