New approaches needed to improve HIV testing and subsequent linkage to care

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Investigators at the 19th Conference on Retroviruses and Opportunistic Infections Wednesday reviewed studies looking to improve linkage to care rates after HIV diagnosis in sub-Saharan Africa.

Dr. Gabriel Chamie of the University of California at San Francisco discussed outcomes in a routine linkage-to-care strategy versus and an enhanced strategy for accelerated antiretroviral therapy (ART) start in rural Uganda.

Investigators offered HIV voluntary counseling and testing at a five-day, multi-disease health campaign in a rural community of 6,300 people. They conducted point-of-care CD4 and rapid tuberculosis (TB) testing with the GeneXpert for those found to be HIV positive, and tracked subsequent successful linkage to care defined as a clinic visit within three months of the campaign.

Those with a CD4 cell count greater than 100 received the routine referral to the clinic within three months; but those with CD4 counts less than 100 received the enhanced rapid-referral strategy in less than two weeks from testing time, plus expedited pre-ART counseling and immediate treatment initiation at the first visit. Investigators offered a small payment to cover transportation costs to follow up care, and were introduced to a clinic nurse, in both arms.

The study team tested 73 percent of the adult population and found HIV prevalence of 7.8 percent, with 139 HIV-infected adults accepting referrals to HIV care. The enhanced linkage approach led to rapid ART initiation in adults with advanced HIV – but for those with higher CD4 cell counts, even with robust measures to promote linkage, routine efforts were insufficient, with only 57 percent of them linking to care within three months. Seven adults with advanced AIDS and one pregnant woman received enhanced referrals – six of whom linked to care within ten days of the campaign and immediately started ART. All six of these tested negative for TB and were still in treatment four weeks later. Chamie highlighted the need for enhanced linkage to care efforts for patients at all CD4 cell counts.

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