Abstract
BackgroundGaps in the HIV care continuum contribute to suboptimal individual health outcomes and increased risk of HIV transmission at the population level. Implementation science studies are needed to evaluate clinic-based interventions aimed at improving retention of patients across the continuum.Methods/designLink4Health uses an unblended cluster site-randomized design to evaluate the effectiveness of a combination intervention strategy (CIS) as compared to standard of care on linkage to and retention in care among HIV-diagnosed adults in Swaziland. The CIS intervention targets a multiplicity of structural, behavioral, and biomedical barriers through five interventions: (1) point-of-care CD4 testing at time of HIV testing, (2) accelerated antiretroviral therapy (ART) initiation for eligible patients, (3) mobile phone appointment reminders, (4) care and prevention packages, and (5) non-cash financial incentives for linkage and retention. The unit of randomization is a network of HIV clinics inclusive of a secondary facility coupled with an affiliated primary facility. Ten study units were randomized based on implementing partner, geographic location, and historic volume of HIV patients. Target enrollment was 2200 individuals, each to be followed for 12 months. Eligibility criteria includes HIV-positive test, age >18 years, willing to receive HIV care at a clinic in the study unit and consent to study procedures. Exclusion criteria included previous HIV care in the past 6 months, planning to leave the community, and current pregnancy.The primary study outcome is linkage within 1 month and retention at 12 months after testing HIV positive. Secondary outcomes include viral load suppression at 12 months, time to ART eligibility and initiation, participant acceptability, and cost-effectiveness. The trial status is that study enrollment is complete and follow-up procedures are ongoing.DiscussionLink4Health evaluates a novel and pragmatic combination intervention strategy to improve linkage to and retention in care among adults with HIV in Swaziland. If the strategy is found to be effective, this study has the potential to inform HIV service delivery in resource-limited settings.Trial registrationClinicaltrials.gov NCT01904994
Highlights
Gaps in the HIV care continuum contribute to suboptimal individual health outcomes and increased risk of HIV transmission at the population level
We describe the design of Link4Health, an implementation science study that aims to assess the effectiveness of a combination strategy comprised of five evidencebased interventions designed to improve linkage to and retention in care among adults newly tested HIV positive in Swaziland
The effectiveness of combination intervention strategy (CIS) compared to Standard of care (SOC) will be assessed on secondary outcomes including the following: linkage to care within 1 month; retention 12 months after HIV diagnosis; and time from antiretroviral therapy (ART) eligibility to ART initiation, viral load suppression 12 months after HIV diagnosis, disease progression, and cost-effectiveness
Summary
Gaps in the HIV care continuum contribute to suboptimal individual health outcomes and increased risk of HIV transmission at the population level. Implementation science studies are needed to evaluate clinic-based interventions aimed at improving retention of patients across the continuum. Patient engagement and retention in the HIV care continuum is essential to optimize health outcomes for the individual and to reduce HIV transmission to others [1–3]. Multiple studies conducted in sub-Saharan Africa report high attrition from testing to linkage to care and suboptimal retention in ongoing care [9–18]. While several studies have evaluated the effect of an individual intervention on one step in the HIV care continuum, few have evaluated a combination approach that includes multiple interventions bundled into a coherent strategy that would target numerous barriers along the continuum [19]. There is the need for implementation science research to evaluate proposed combination approaches in a “real-life” context to provide pragmatic information on uptake of interventions, feasibility, and acceptability [31, 32]
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