Improving HIV service linkage and retention in Mozambique and South Africa

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Providing immune cell testing and HIV treatment counseling immediately after a positive HIV test was the first in a series of measures that increased rapid linkage to care and retention at ten clinic sites in Mozambique, data presented at the the Conference on Retroviruses and Opportunistic Infections (CROI 2017) showed.

Measures in a randomised trial of interventions in Maputo and Inhambane Province also included accelerated access to antiretroviral treatment and text message appointment reminders. Findings from the trial were presented by Matthew Lamb from ICAP at Columbia University.

Abstract 1
Identifying scalable interventions to strengthen linkage to and retention in HIV care is essential to ensuring individual and population benefits of ART.
Engage4Health, a cluster-randomized controlled trial implemented at 10 health facilities in Mozambique, evaluated the effectiveness of a combination intervention strategy (CIS) vs the standard of care (SOC) on the combined outcome of linkage to care within 1 month and retention in care at 12 months following HIV diagnosis. CIS included: (1) point-of-care CD4+ count at HIV testing sites; (2) accelerated ART initiation for eligible patients; and (3) SMS appointment reminders. A subset of CIS participants additionally received non-cash financial incentives (CIS+FI). Adults >18 years newly diagnosed with HIV and willing to receive HIV care at the diagnosing health facility were enrolled from 4/13-6/15 and followed for 12 months. Main analyses assessed outcomes at the diagnosing facility using medical record abstraction, while sensitivity analyses examined outcomes at any health facility using self-reports collected during follow-up interviews. Log-Poisson models were used to estimate the relative risk (RR) of outcomes in intent-to-treat analyses, with additional models adjusting for clustering within sites and patient characteristics using propensity score matching.
Among 2004 participants (N=744 CIS, 493 CIS+FI, 767 SOC), 64% were women and the mean age was 34 years (standard deviation = 10). As shown in the table, 57% receiving CIS and 55% receiving CIS+FI achieved the primary outcome versus 35% receiving SOC (RR vs SOC: 1.63 [95%CI:1.45-1.83] for CIS; 1.56 [95%CI:1.37-1.76] for CIS+FI). Participants in the CIS (94%, RR vs SOC 1.50 [95%CI:1.42-1.49]) and CIS+FI (94%, RR 1.49 vs SOC [95%CI:1.41-1.58]) groups had higher linkage to care at 1 month versus those in the SOC (63%) group; and higher 12-month retention (CIS 59%, RR vs SOC 1.31 [95%CI:1.19-1.45], and CIS+FI 55%, RR vs SOC 1.24 [95%CI:1.11-1.38]) relative to those in SOC (45%). In sensitivity analyses considering self-reported linkage and retention at any health facility, 73% in CIS, 72% in CIS+FI, and 47% in SOC achieved the primary outcome (RR vs SOC: 1.55 [95%CI: 1.35-1.77] for CIS; 1.53 [95%CI: 1.32-1.77] for CIS+FI).
The CIS offers a feasible approach for enhancing outcomes across the HIV care continuum, particularly linkage to care following diagnosis. No additional benefit of non-cash financial incentives was observed.

Batya Elul, Matthew R Lamb, Maria Lahuerta, Fatima Abacassamo, Laurence Ahoua, Stephanie Kujawski, Maria Tomo, Ilesh Jani


In the same session, Wayne Steward from University of California – San Francisco reported on two interventions aiming to improve patient retention tested in the I-CARE Trial in North West Province, South Africa.

That trial compared the impact of text messages, and the use of peer navigators to the standard of care in 18 primary care clinics.

Abstract 2
Engagement in care is critical to meeting UNAIDS 90-90-90 goals. South Africa has improved access to antiretroviral therapy (ART) through expanded ART initiation and monitoring at primary health clinics, however nearly half of HIV-positive clients are still lost to care. To improve retention in care, we designed and implemented short message service (SMS) reminders and peer navigation (PN) to address barriers to HIV care.
The I-Care Trial (registration: NCT02417233) used a cluster randomized design to assign primary health clinics in North West Province, South Africa, to: 1) SMS check-in messages, along with appointment and healthy living reminders (6 clinics); 2) SMS reminders plus PN services (SMS+PN) to address personal barriers to care (7 clinics); and 3) standard of care (SOC; 4 clinics). From October, 2014, to April, 2015, we enrolled 752 recently HIV-diagnosed, consenting adults (292 men, 460 women) in SMS, SMS+PN, or SOC assigned clinics and followed them for up to 1 year. We extracted clinical record data and conducted intention-to-treat analyses of 12-month retention outcomes using generalized estimating equations (GEE). Retention in care was defined as: 1) an average of at least 1 clinic visit every 3 months for participants on ART, which corresponded to the minimum frequency with which ART was dispensed at the facilities; or 2) an average of at least 1 clinic visit every 6 months for pre-ART participants (those not yet eligible for ART at the time of the study). The trial is complete and results are final.
Participants receiving SMS+PN services had nearly 3 times the odds of being retained in care compared to SOC participants (Table 1). SMS services alone did not significantly improve outcomes relative to SOC, although SMS demonstrated protective trends for those on ART. When analyzed by gender, men (OR=3.34, 95% CI: 1.37-8.14) and women (OR=2.64, 95% CI: 1.60-4.37) had greater odds of being retained in care when receiving SMS+PN services than when receiving SOC. There were no differences between SMS and SOC conditions for men or women in stratified analyses.
Peer navigation paired with SMS reminders substantially improves retention in HIV care at South African primary health clinics. The intervention offers a valuable strategy for meeting 90-90-90 campaign targets. Efforts are now needed to identify feasible strategies for wider-scale implementation in resource-constrained clinics.

Wayne T Steward, Emily Agnew, Julia DeKadt, Hailey Gilmore, Mary-Jane Ratlhagana, Jessica Grignon, Starley B Shade, John Tumbo, Scott Barnhart, Sheri A Lippman

Science Speaks blog
CROI 2017 abstract 1 (110)
CROI 2017 abstract 2 (111)

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