Continuum of HIV Care in Rural Mozambique: The Implications of HIV Testing Modality on Linkage and Retention

INTRODUCTION: Context-specific improvements in the continuum of HIV care are needed in order to achieve the UNAIDS target of 90-90-90. This study aimed to assess the linkage to and retention in HIV care according to different testing modalities in rural southern Mozambique. METHODS: Adults newly diagnosed with HIV from voluntary counseling and testing (VCT), provider-initiated (PICT) and home-based HIV testing (HBT) services were prospectively enrolled between 2014- 2015 at the Manhica District. Patients were passively followed-up through chart examination .Tracing was performed at 12-months to ascertain causes of loss to follow-up. Fine and Grey competing risk analysis was performed to determine factors associated with the each step of the cascade. RESULTS: Overall linkage to care as defined by having a CD4 count at 3 months, was 43.7% (95CI% 40.8-46.6) and 25.2% of all participants initiated ART. Factors associated with increased linkage in multivariable analysis included testing at VCT, older age, having been previously tested for HIV, owning a cell phone, presenting with WHO clinical stages III/IV, self-reported illness-associated disability in the previous month , and later calendar month of participant recruitment. Ascertaining deaths and transfers allowed adjustment of the rate of 12-month retention in treatment from 75.6% (95% CI 70.2-80.5) to 84.2% (95% CI 79.2-88.5). CONCLUSIONS: HBT reached a socio-demographically distinct population from that of clinic based testing modalities but low linkage to care points to a need for facilitated linkage interventions. Distinguishing between true treatment defaulting and other causes of loss-to-follow-up can significantly change indicators of retention in care

Loss to follow-up and opportunities for reengagement in HIV care in rural Mozambique: A prospective cohort study.

"Patients lost to follow-up (LTFU) over the human immunodeficiency virus (HIV) cascade have poor clinical outcomes and contribute to onward HIV transmission. We assessed true care outcomes and factors associated with successful reengagement in patients LTFU in southern Mozambique.Newly diagnosed HIV-positive adults were consecutively recruited in the Manhi\xC3\xA7a District. Patients LTFU within 12 months after HIV diagnosis were visited at home from June 2015 to July 2016 and interviewed for ascertainment of outcomes and reasons for LTFU. Factors associated with reengagement in care within 90 days after the home visit were analyzed by Cox proportional hazards model.Among 1122 newly HIV-diagnosed adults, 691 (61.6%) were identified as LTFU. Of those, 557 (80.6%) were approached at their homes and 321 (57.6%) found at home. Over 50% had died or migrated, 10% had been misclassified as LTFU, and 252 (78.5%) were interviewed. Following the visit, 79 (31.3%) reengaged in care. Having registered in care and a shorter time between LTFU and visit were associated with reengagement in multivariate analyses: adjusted hazards ratio of 3.54 [95% confidence interval (CI): 1.81-6.92; P\xE2\x80\x8A<\xE2\x80\x8A.001] and 0.93 (95% CI: 0.87-1.00; P\xE2\x80\x8A=\xE2\x80\x8A.045), respectively. The most frequently reported barriers were the lack of trust in the HIV-diagnosis, the perception of being in good health, and fear of being badly treated by health personnel and differed by type of LTFU.Estimates of LTFU in rural areas of sub-Saharan Africa are likely to be overestimated in the absence of active tracing strategies. Home visits are resource-intensive but useful strategies for reengagement for at least one-third of LTFU patients when applied in the context of differentiated care for those LTFU individuals who had already enrolled in HIV care at some point.

Continuum of HIV Care in Rural Mozambique: The Implications of HIV Testing Modality on Linkage and Retention

INTRODUCTION: Context-specific improvements in the continuum of HIV care are needed in order to achieve the UNAIDS target of 90-90-90. This study aimed to assess the linkage to and retention in HIV care according to different testing modalities in rural southern Mozambique. METHODS: Adults newly diagnosed with HIV from voluntary counseling and testing (VCT), provider-initiated (PICT) and home-based HIV testing (HBT) services were prospectively enrolled between 2014- 2015 at the Manhica District. Patients were passively followed-up through chart examination .Tracing was performed at 12-months to ascertain causes of loss to follow-up. Fine and Grey competing risk analysis was performed to determine factors associated with the each step of the cascade. RESULTS: Overall linkage to care as defined by having a CD4 count at 3 months, was 43.7% (95CI% 40.8-46.6) and 25.2% of all participants initiated ART. Factors associated with increased linkage in multivariable analysis included testing at VCT, older age, having been previously tested for HIV, owning a cell phone, presenting with WHO clinical stages III/IV, self-reported illness-associated disability in the previous month , and later calendar month of participant recruitment. Ascertaining deaths and transfers allowed adjustment of the rate of 12-month retention in treatment from 75.6% (95% CI 70.2-80.5) to 84.2% (95% CI 79.2-88.5). CONCLUSIONS: HBT reached a socio-demographically distinct population from that of clinic based testing modalities but low linkage to care points to a need for facilitated linkage interventions. Distinguishing between true treatment defaulting and other causes of loss-to-follow-up can significantly change indicators of retention in care

Quantifying the gender gap in the HIV care cascade in southern Mozambique: We are missing the men.

BackgroundHIV-infected men have higher rates of delayed diagnosis, reduced antiretroviral treatment (ART) retention and mortality than women. We aimed to assess, by gender, the first two UNAIDS 90 targets in rural southern Mozambique.MethodsThis analysis was embedded in a larger prospective cohort enrolling individuals with new HIV diagnosis between May 2014-June 2015 from clinic and home-based testing (HBT). We assessed gender differences between steps of the HIV-cascade. Adjusted HIV-community prevalence was estimated using multiple imputation (MI).ResultsAmong 11,773 adults randomized in HBT (7084 female and 4689 male), the response rate before HIV testing was 48.7% among eligible men and 62.0% among women (pConclusionThe contribution of missing HIV-serostatus data differentially impacted indicators of HIV prevalence and of achievement of UNAIDS targets by age and gender and men were missing long before the second 90. Increased efforts to characterize missing men and their needs will and their needs will allow us to urgently address the barriers to men accessing care and ensure men are not left behind in the UNAIDS 90-90-90 targets achievement

Monitoring progress towards the first UNAIDS target: understanding the impact of people living with HIV who re-test during HIV-testing campaigns in rural Mozambique

INTRODUCTION: Awareness of HIV-infection goes beyond diagnosis, and encompasses understanding, acceptance, disclosure and initiation of the HIV-care. We aimed to characterize the HIV-positive population that underwent repeat HIV-testing without disclosing their serostatus and the impact on estimates of the first UNAIDS 90 target. METHODS: This analysis was nested in a prospective cohort established in southern Mozambique which conducted three HIV-testing modalities: voluntary counselling and testing (VCT), provider-initiated counselling and testing (PICT) and home-based testing (HBT). Participants were given the opportunity to self-report their status to lay counsellors and HIV-positive diagnoses were verified for previous enrolment in care. This study included 1955 individuals diagnosed with HIV through VCT/PICT and 11,746 participants of a HBT campaign. Those who did not report their serostatus prior to testing, and were found to have a previous HIV-diagnosis, were defined as non-disclosures. Venue-stratified descriptive analyses were performed and factors associated with non-disclosure were estimated through log-binomial regression. RESULTS: In the first round of 2500 adults randomized for HBT, 1725 were eligible for testing and 18.7% self-reported their HIV-positivity. Of those tested with a positive result, 38.9% were found to be non-disclosures. Similar prevalence of non-disclosures was found in clinical-testing modalities, 29.4% (95% CI 26.7 to 32.3) for PICT strategy and 13.0% (95% CI 10.9 to 15.3) for VCT. Prior history of missed visits (adjusted prevalence ratio (APR) 4.2, 95% CI 2.6 to 6.8), younger age (APR 2.5, 95% CI 1.4 to 4.4) and no prior history of treatment ((APR) 1.4, 95% CI 1.0 to 2.1) were significantly associated with non-disclosure as compared to patients who self-reported. When considering non-disclosures as people living with HIV (PLWHIV) aware of their HIV-status, the proportion of PLWHIV aware increased from 78.3% (95% CI 74.2 to 81.6) to 86.8% (95% CI 83.4 to 89.6). CONCLUSION: More than one-third of individuals testing HIV-positive did not disclose their previous positive HIV-diagnosis to counsellors. This proportion varied according to testing modality and age. In the absence of an efficient and non-anonymous tracking system for HIV-testers, repeat testing of non-disclosures leads to wasted resources and may distort programmatic indicators. Developing interventions that ensure appropriate psychosocial support are needed to encourage this population to disclose their status and optimize scarce resources