Brief counselling after home‐based HIV counselling and testing strongly increases linkage to care: a cluster‐randomized trial in Uganda

Abstract

IntroductionThe aim of this study was to determine whether counselling provided subsequent to HIV testing and referral for care increases linkage to care among HIV‐positive persons identified through home‐based HIV counselling and testing (HBHCT) in Masaka, Uganda.MethodsThe study was an open‐label cluster‐randomized trial. 28 rural communities were randomly allocated (1:1) to intervention (HBHCT, referral and counselling at one and two months) or control (HBHCT and referral only). HIV‐positive care‐naïve adults (≥18 years) were enrolled. To conceal participants’ HIV status, one HIV‐negative person was recruited for every three HIV‐positive participants. Primary outcomes were linkage to care (clinic‐verified registration for care) status at six months, and time to linkage. Primary analyses were intention‐to‐treat using random effects logistic regression or Cox regression with shared frailty, as appropriate.ResultsThree hundred and two(intervention, n = 149; control, n = 153) HIV‐positive participants were enrolled. Except for travel time to the nearest HIV clinic, baseline participant characteristics were generally balanced between trial arms. Retention was similar across trial arms (92% overall). One hundred and twenty‐seven (42.1%) participants linked to care: 76 (51.0%) in the intervention arm versus 51 (33.3%) in the control arm [odds ratio = 2.18, 95% confidence interval (CI) = 1.26–3.78; p = 0.008)]. There was evidence of interaction between trial arm and follow‐up time (p = 0.009). The probability of linkage to care, did not differ between arms in the first two months of follow‐up, but was subsequently higher in the intervention arm versus the control arm [hazard ratio = 4.87, 95% CI = 1.79–13.27, p = 0.002].ConclusionsCounselling substantially increases linkage to care among HIV‐positive adults identified through HBHCT and may enhance efforts to increase antiretroviral therapy coverage in sub‐Saharan Africa.

Factors associated with uptake of home-based HIV counselling and testing and HIV care services among identified HIV-positive persons in Masaka, Uganda

“…As reported previously (Ruzagira, Grosskurth, Kamali, & Baisley, 2017 ) individuals in our trial who received follow-up counselling in addition to referral (intervention arm) after HBHCT were more likely to link to HIV care services than those who were referred only (control arm). Follow-up counselling may improve care seeking behaviour by providing specific information on how to access services (Ware et al., 2016 ), enhancing personal motivation (Knight, Van Rooyen, Humphries, Barnabas, & Celum, 2015 ), and reducing psychosocial barriers that inhibit linkage to care (Knight et al., 2015 ).…”

“…The trial primary outcomes were linkage to care (clinic-verified registration for HIV care) determined six months after HIV diagnosis, and time to linkage. As reported previously, the trial intervention significantly increased linkage to HIV care and uptake of HIV care services (Ruzagira, Grosskurth, Kamali, & Baisley, 2017 ). This paper investigates factors associated with HBHCT uptake (i.e., the proportion who consented to an HIV test and received the result at home) among persons who were offered HBHCT.…”

“…Three to seven days later, study counsellors visited all the households in a community, enumerated resident adults, and conducted HBHCT for those who consented. HIV testing was done using rapid test kits as reported elsewhere (Ruzagira, Grosskurth, Kamali, & Baisley, 2017 ). Age, sex, HBHCT uptake, and reasons for non-uptake, and HIV test result data were recorded on a questionnaire.…”

A Cascade of Interventions to Promote Adherence to Antiretroviral Therapy in African Countries

“…For those not already on ART, 73% were linked to care and initiated on ART within 12 months [ 16 ]. Other studies, like one in Uganda, have found only modest benefit from home visits to encourage ART initiation after home-based testing (34% intervention versus 26% control; HR = 1.31; 95% CI = 0.85–2.04) [ 17 ]. In South Africa, standard of care (SoC) mobile HIV counselling and testing units were compared with point-of-care (POC) CD4 alone, POC CD4 plus up to five care facilitation counselling sessions and POC CD4 plus transport reimbursement [ 18 ].…”

“Vital”: HIV counselling and testing staff’s views of addressing mental health with HIV in Uganda

“…registered with a facility providing treatment) within 1 month of their HIV counselling and testing (HCT) session [ 17 ]. Using home-based testing with augmented counselling in Uganda, another study achieved 44% linkage into care [ 18 ].…”