Linkage to and retention in care for people living with HIV in South Africa needs improvement, says SAMRC scientist

A study led by Dr Edward Nicol, a specialist scientist from the South African Medical Research Council (SAMRC)’s Burden of Disease Research Unit has revealed substantial gaps in South Africa’s linkage to and retention in care for people living with HIV (PLHIV) and recommended interventions for improvement.

The study, which explored the linkage to and retention in care rates among adults with a new HIV diagnosis in a high-HIV prevalent district in KwaZulu Natal, brought together researchers from the SAMRC, Stellenbosch University (SU), University of the Western Cape UWC), University of Cape Town (UCT) and Centers for Disease Control and Prevention (CDC) Pretoria – this collaborative effort was funded by the CDC Atlanta, USA.

This observational prospective cohort study comprised of a patient-level survey with clinical data being collected from 18 primary healthcare facilities and triangulated between HIV and laboratory databases and registered deaths from Department of Home Affairs. The study was conducted over 12 months, between December 2017 to November 2018, with 5,637 participants enrolled. Adults greater than 18 years seeking HIV testing in different facilities were approached to enroll and requested to complete a self-administered questionnaire.

Results and significance of findings

The study found an initial high linkage to care rates of 83% at 3 months, with less than 50% remaining in care at 12 months after initiating antiretroviral therapy (ART) – the treatment for HIV. More men were linked to care at 3 months, however, significantly more women remained in care after 12 months. It was found that young women test for HIV more often compared to young males, which may be attributed to the fact that they have more opportunities for testing, through accessing family planning or maternal and child health (MCH) services. However, despite integrated family planning or MCH services improving testing for women of reproductive age, there is still a definite need to improve testing for older women as well as younger men.

Furthermore, a considerable amount of effort is required to retain PLHIV in care, especially during the first year of ART initiation. Several, socio-demographic characteristics such as sex, education, access to cash, place of residence (urban or rural), access to health facility, need to be considered when designing HIV prevention and care interventions since these pose a challenge and a direct threat to accessing chronic care.

According to Dr Nicol, the study findings suggest that patients generally access HIV testing services that are situated in towns (urban areas) and this may be due to HIV stigma that is still pervading rural communities as opposed to towns, or it may be too limited staff at the rural facilities and the time taken to be seen.

“While integrated family planning or antenatal services may have improved testing for women of reproductive age, interventions could target women aged 18–34 years and younger men. More research is needed to understand barriers to care linkage and retention for men,” he said.

The road to ending AIDS by 2030

It has been suggested that ending AIDS by 2030 depends on how successfully healthcare systems are in linking people living with HIV (PLHIV) to care, which includes the completion of a first medical clinic visit for HIV testing and to achieve early/same day initiation on ART and lifelong retention in care.

The World Health Organization (WHO) has recommended the ‘Universal Test-and-Treat’ (UTT), which initiates all individuals testing HIV positive onto ART irrespective of their CD4 count and clinical staging as a fast-track strategy to achieving the UNAIDS ’95-95-95’ goals, where 95% of PLHIV know their HIV status, 95% of those who know their status should commence treatment within 14 days (of initial positive diagnosis), with the aim of reaching 95% viral suppression for those on treatment.

Dr Nicol highlighted that due to the drop in HIV incidence and HIV-related deaths in South Africa, the general impression is that the country is making progress in the fight against the HIV epidemic. “However, despite this, HIV care linkage and retention are key weaknesses in South Africa’s ART programme. Additionally, evidence related to the impact of UTT and whether it has improved the efficiency and quality of HIV care at the population-level is still scarce, “said Dr Nicol.

He added that while the linkage to care and retention in care rates of PLHIV before the UTT era is well documented with previous findings showing a national linkage rate of 56.9% and that the greatest loss of patients in the HIV treatment pathway occurred before ART initiation, to date, very few studies have investigated the proportions of people newly diagnosed with HIV linked to care and who are retained in care in the UTT era.

Where to from here?

As a result of this study, the team received additional funding from CDC to conduct two further studies:

  1. Identifying effective and feasible Pre-Exposure Prophylaxis (PrEP) models of care for improving PrEP uptake, continuation, and adherence among Adolescent girls and young women (AGYW) and adolescent boys and young men (ABYM).
  2. Monitoring the HIV testing and treatment services in PEPFAR-supported districts in Kwa-Zulu Natal and to generate knowledge that can be used to strengthen the HIV services and increase linkage to, and retention in HIV care among AGYW aged 15-24 years and ABYM aged 15-35 years.

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