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      Linkage into care among newly diagnosed HIV-positive individuals tested through outreach and facility-based HIV testing models in Mbeya, Tanzania: a prospective mixed-method cohort study

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          Abstract

          Objective

          Linkage to care is the bridge between HIV testing and HIV treatment, care and support. In Tanzania, mobile testing aims to address historically low testing rates. Linkage to care was reported at 14% in 2009 and 28% in 2014. The study compares linkage to care of HIV-positive individuals tested at mobile/outreach versus public health facility-based services within the first 6 months of HIV diagnosis.

          Setting

          Rural communities in four districts of Mbeya Region, Tanzania.

          Participants

          A total of 1012 newly diagnosed HIV-positive adults from 16 testing facilities were enrolled into a two-armed cohort and followed for 6 months between August 2014 and July 2015. 840 (83%) participants completed the study.

          Main outcome measures

          We compared the ratios and time variance in linkage to care using the Kaplan-Meier estimator and Log rank tests. Cox proportional hazards regression models to evaluate factors associated with time variance in linkage.

          Results

          At the end of 6 months, 78% of all respondents had linked into care, with differences across testing models. 84% (CI 81% to 87%, n=512) of individuals tested at facility-based site were linked to care compared to 69% (CI 65% to 74%, n=281) of individuals tested at mobile/outreach. The median time to linkage was 1 day (IQR: 1–7.5) for facility-based site and 6 days (IQR: 3–11) for mobile/outreach sites. Participants tested at facility-based site were 78% more likely to link than those tested at mobile/outreach when other variables were controlled (AHR=1.78; 95% CI 1.52 to 2.07). HIV status disclosure to family/relatives was significantly associated with linkage to care (AHR=2.64; 95% CI 2.05 to 3.39).

          Conclusions

          Linkage to care after testing HIV positive in rural Tanzania has increased markedly since 2014, across testing models. Individuals tested at facility-based sites linked in significantly higher proportion and modestly sooner than mobile/outreach tested individuals. Mobile/outreach testing models bring HIV testing services closer to people. Strategies to improve linkage from mobile/outreach models are needed.

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          A Systematic Review of Individual and Contextual Factors Affecting ART Initiation, Adherence, and Retention for HIV-Infected Pregnant and Postpartum Women

          Ian Hodgson, Mary L. Plummer, Sarah N. Konopka … (2014)
          Background Despite progress reducing maternal mortality, HIV-related maternal deaths remain high, accounting, for example, for up to 24 percent of all pregnancy-related deaths in sub-Saharan Africa. Antiretroviral therapy (ART) is effective in improving outcomes among HIV-infected pregnant and postpartum women, yet rates of initiation, adherence, and retention remain low. This systematic literature review synthesized evidence about individual and contextual factors affecting ART use among HIV-infected pregnant and postpartum women. Methods Searches were conducted for studies addressing the population (HIV-infected pregnant and postpartum women), intervention (ART), and outcomes of interest (initiation, adherence, and retention). Quantitative and qualitative studies published in English since January 2008 were included. Individual and contextual enablers and barriers to ART use were extracted and organized thematically within a framework of individual, interpersonal, community, and structural categories. Results Thirty-four studies were included in the review. Individual-level factors included both those within and outside a woman’s awareness and control (e.g., commitment to child’s health or age). Individual-level barriers included poor understanding of HIV, ART, and prevention of mother-to-child transmission, and difficulty managing practical demands of ART. At an interpersonal level, disclosure to a spouse and spousal involvement in treatment were associated with improved initiation, adherence, and retention. Fear of negative consequences was a barrier to disclosure. At a community level, stigma was a major barrier. Key structural barriers and enablers were related to health system use and engagement, including access to services and health worker attitudes. Conclusions To be successful, programs seeking to expand access to and continued use of ART by integrating maternal health and HIV services must identify and address the relevant barriers and enablers in their own context that are described in this review. Further research on this population, including those who drop out of or never access health services, is needed to inform effective implementation.
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            Health care system and policy factors influencing engagement in HIV medical care: piecing together the fragments of a fractured health care delivery system.

            Michael Saag, Angela W Norton, Michael Mugavero (2011)
            Grounded in a socio-ecological framework, we describe salient health care system and policy factors that influence engagement in human immunodeficiency virus (HIV) clinical care. The discussion emphasizes successful programs and models of service delivery and highlights the limitations of current, fragmented health care system components in supporting effective, efficient, and sustained patient engagement across a continuum of care. A fundamental need exists for improved synergies between funding and service agencies that provide HIV testing, prevention, treatment, and supportive services. We propose a feedback loop whereby actionable, patient-level surveillance of HIV testing and engagement in care activities inform educational outreach and resource allocation to support integrated "testing and linkage to care plus" service delivery. Ongoing surveillance of programmatic performance in achieving defined benchmarks for linkage of patients who have newly diagnosed HIV infection and retention of those patients in care is imperative to iteratively inform further educational efforts, resource allocation, and refinement of service delivery.
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              A conceptual model of HIV/AIDS stigma from five African countries.

              William L Holzemer, Leana Uys, Lucy Makoae … (2007)
              This paper is a report on the development of a conceptual model delineating contexts and processes of HIV/AIDS stigma as reported by persons living with HIV/AIDS and nurses from African countries. It is part of a larger study to increase understanding of HIV/AIDS stigma. Researchers have defined stigma, explored determinants and outcomes of stigma and attempted to measure its multiple dimensions. This literature is difficult to synthesize, and often does not distinguish adequately between experiences of stigma and its causes and outcomes. Forty-three focus groups were held with persons living with HIV/AIDS and nurses in five African countries in 2004. Focus group recordings were transcribed and coded. The data were organized into a conceptual model of HIV/AIDS stigma. Two components were identified in the data: contextual factors--environment, healthcare system, agents--that influence and affect stigma and the stigma process itself. The stigma process included four dimensions: triggers of stigma, stigmatizing behaviours, types of stigma and the outcomes of stigma. A conceptual model is presented that delineates the dynamic nature of stigma as reported by study participants. The model may be used to identify areas appropriate for the design and testing of stigma reduction interventions that have a goal of reducing the burden of HIV/AIDS stigma.
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                Author and article information

                Journal
                Journal ID (nlm-ta): BMJ Open
                Journal ID (iso-abbrev): BMJ Open
                Journal ID (hwp): bmjopen
                Journal ID (publisher-id): bmjopen
                Title: BMJ Open
                Publisher: BMJ Publishing Group (BMA House, Tavistock Square, London, WC1H 9JR )
                ISSN (Electronic): 2044-6055
                Publication date Collection: 2017
                Publication date (Electronic): 12 April 2017
                Volume: 7
                Issue: 4
                Electronic Location Identifier: e013733
                Affiliations
                [1 ]NIMR-Mbeya Medical Research Centre (MMRC) , Mbeya, Tanzania
                [2 ]School of Public Health, University of Western Cape , Cape Town, South Africa
                [3 ]School of Public Health, Mekelle University , Mekelle, Ethiopia
                [4 ]National Institute for Medical Research (NIMR) , Dar es Salaam, Tanzania
                [5 ]Division of Infectious Diseases and Tropical Medicine, Medical Centre of the University of Munich (LMU) , Munich, Germany
                [6 ]University of Montreal Hospital Research Centre and School of Public Health, Université de Montréal , Montreal, Quebec, Canada
                Author notes
                [Correspondence to ] Erica Samson Sanga; esanga@ 123456nimr-mmrc.org
                Article
                Publisher ID: bmjopen-2016-013733
                DOI: 10.1136/bmjopen-2016-013733
                PMC ID: 5541440
                PubMed ID: 28404611
                SO-VID: e1e1e0ed-a9ce-4956-854d-3456b44bf6ea
                Copyright © Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/
                License:

                This is an Open Access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/

                History
                Date received : 20 August 2016
                Date revision received : 18 February 2017
                Date accepted : 27 February 2017
                Categories
                Subject: HIV/AIDS
                Subject: Research
                Subject: 1506
                Subject: 1842
                Subject: 1704

                ScienceOpen disciplines: Medicine
                Keywords: hiv,linkage to care,facility-based hiv testing,mobile and outreach hiv testing,mbeya-tanzania
                Data availability:
                ScienceOpen disciplines: Medicine
                Keywords: hiv, linkage to care, facility-based hiv testing, mobile and outreach hiv testing, mbeya-tanzania

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