If you don't remember your password, you can reset it by entering your email address and clicking the Reset Password button. You will then receive an email that contains a secure link for resetting your password
If the address matches a valid account an email will be sent to __email__ with instructions for resetting your password
Risk factors for late linkage to care and delayed antiretroviral therapy initiation among adults with HIV in sub-Saharan Africa: a systematic review and meta-analyses
Variation in HIV care linkage/treatment initiation across nations/settings in sub-Saharan Africa.
•
Low HIV care linkage and treatment initiation rates in most settings in sub-Saharan Africa.
•
Health care delivery factors affected care linkage/treatment initiation in adults.
•
Psychosocial/perceptual/sociodemographic factors associated with late care linkage.
Abstract
Objectives
Late treatment initiation threatens the clinical and public health benefits of antiretroviral therapy (ART). Quantitative synthesizes of the existing evidence related to this are lacking in sub-Saharan Africa (SSA), which would help ascertain the best evidence-based interventions. This review aimed to systematically synthesize the available literature on factors affecting linkage to care and ART initiation among adults with HIV in SSA.
Methods
Systematic searches were undertaken on four databases to identify observational studies investigating factors affecting both HIV care outcomes among adults (age ≥19 years) in SSA and were published between January 1, 2015 and June 1, 2021. RevMan-5 software was used to conduct meta-analyses and Mantel-Haenszel statistics to pool outcomes with a 95% confidence interval and <0.05 level of significance.
Results
A total of 46 studies were included in the systematic review, of which 18 fulfilled requirements for the meta-analysis. In both narrative review and meta-analyses, factors related to health care delivery, individual perception, and sociodemographic circumstances were associated with late linkage to care and delays in ART initiation.
Conclusion
This review identified a range of risk factors for late linkage to care and delayed ART initiation among adults with HIV in SSA. We recommend implementation of patient-centered intervention approaches to alleviate these barriers.
Antiretroviral therapy (ART) has transformed HIV infection from a fatal to a potentially manageable chronic disease and has significantly elongated the life expectancy of people living with HIV (PLWH) (
), PLWH in sub-Saharan African (SSA) countries often commence ART at advanced stages of infection (at CD4 count <200 cells/mm3 and/or World Health Organization (WHO) clinical stage III/IV) (
Individual studies reported various structural, psychosocial, perceptual, and sociodemographic circumstances as risk factors for late linkage to HIV care and ART initiation among PLWH in SSA. Among structural factors, barriers to health care delivery, such as distance to a health care facility, have been commonly reported (
). Psychosocial circumstances, including low social support and inability to disclose HIV status for fear of stigma, have been found to affect linkage to care and ART initiation (
Exploratory Analysis of Time from HIV Diagnosis to ART Start, Factors and effect on survival: A longitudinal follow up study at seven teaching hospitals in Ethiopia.
Test site predicts HIV care linkage and antiretroviral therapy initiation: a prospective 3.5 year cohort study of HIV-positive testers in northern Tanzania.
) have been strongly linked to the level of the patients’ engagement in care and ART initiation. Sociodemographic characteristics, such as younger age, male sex, lacking a partner, having a low wealth index and being employed have also been frequently reported to be associated with late linkage to care and delays in ART initiation (
Exploratory Analysis of Time from HIV Diagnosis to ART Start, Factors and effect on survival: A longitudinal follow up study at seven teaching hospitals in Ethiopia.
Previous reviews in the region also emphasized the influence of these factors on linkage to care and ART initiation. The reviews showed that transport costs associated with distant health care facilities, staff shortage, and poor-quality health services, mainly constituted supply-side challenges (
). At an individual level, low CD4 count and associated feelings of being healthy at earlier stages of the disease, low knowledge of treatment benefits, male sex, younger age, and being employed were associated with late linkage to care and ART initiation (
Across published studies, there are variations in definitions of HIV care-related health outcomes as well as contextual differences associated with the risk factors for late linkage to care and delayed ART initiation. The resulting lack of unequivocal evidence has substantially impeded successful implementation of available interventions as well as the development of novel strategies for improving care linkage and ART initiation (
Interventions to improve or facilitate linkage to or retention in pre-ART (HIV) care and initiation of ART in low- and middle-income settings - a systematic review.
), a few have quantitatively focused on factors of various levels relating to late linkage to care or delays in ART initiation. Further, most were conducted before endorsing the “Test and Treat” strategy (
), underscoring the need for more inclusive and up-to-date information. Our review aimed to systematically synthesize the available evidence on barriers to care linkage and ART initiation among adult PLWH in SSA to suggest contextually tailored intervention strategies.
Methods
This review was reported based on the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines (
) (see Supplementary file 1). The review protocol has been published in the International Prospective Register of Systematic Reviews (PROSPERO Number: CRD42021264398) (
A systematic review and meta-analyses on risk factors for late linkage to care and delayed antiretroviral therapy initiation among HIV infected adults in sub-Saharan Africa: a review protocol.
Studies: We reviewed observational studies analyzing factors affecting linkage to HIV care and/or ART initiation in the target population. Qualitative and intervention-based studies were not considered because the review aimed to quantify risk factors in a natural setting.
Participants: The review included adults diagnosed with HIV (as WHO defines: ≥19 years of age [
]) in SSA. Studies conducted on specialized population groups that may have a particular risk for the health outcomes under investigation include: individuals younger than 19 years of age, sex workers, men having sex with men, pregnant women, patients with tuberculosis (TB), and serodiscordant couples were excluded.
Exposures: Structural factors pertaining to health care access and other health care delivery barriers (e.g., distance to a health care facility) and psychosocial and personal determinants of late presentation for HIV care and ART initiation (such as the influence of social support, status disclosure and perceptions of early treatment initiation) were exposures of interest in the review. We also assessed the influence of sociodemographic factors, such as age, sex, marital status, and other characteristics.
Comparators: Although no restriction was made based on whether a study used comparators, individuals without an exposure of interest were considered the control group when comparisons were made.
Outcome measures: Rates of linkage to HIV care and ART initiation over a certain period of time (as defined by individual studies) were considered the main outcomes of the review. No restriction was made on the inclusion of studies based on the definition of the outcomes.
Information sources and search strategy
We conducted systematic searches in databases including MEDLINE, PubMed, Web of Science, and Emcare. The search strategy was designed using the concepts ‘HIV/AIDS’, ‘ART’ and ‘Linkage to HIV Care or Initiation of ART’, and names of countries in SSA. Terms related to the concepts were used and combined with the MEDLINE filter. The search strategy for MEDLINE was: HIV or Human Immunodeficiency virus or AIDS or Acquired Immunodeficiency Syndrome or (HIV or AIDS or HIV-AIDS or Acquired Immunodeficiency Syndrome or Human immunodeficiency virus).tw,kf. and ART or Antiretroviral Therapy or Highly Active antiretroviral therapy and "linkage to care" or "presentation to care" or start* or initiate* or (antiretroviral* or anti-retroviral* or HAART or ART or anti-hiv).tw,kf. and (Angola or Benin or Botswana or Burkina Faso or Burundi or Cape Verde or Cameroon or Central African Republic or Chad or Comoros or Democratic Republic of the Congo or Congo or Cote D'ivoire or Equatorial Guinea or Eritrea or Eswatini or Ethiopia or Gabon or Gambia or Ghana or Guinea or Guinea-Bissau or Kenya or Lesotho or Liberia or Madagascar or Malawi or Mali or Mauritania or Mauritius or Mozambique or Namibia or Niger or Nigeria or Rwanda or “Sao Tome and Principe” or Senegal or Seychelles or Sierra Leone or Somalia or South Africa or South Sudan or Sudan or Tanzania or Togo or Uganda or Zambia or Zimbabwe). We adapted the search terms to use with other bibliographic databases along with database-specific filters. Studies involving adults (≥19 years), published in English language since 2015 and indexed up to June 1, 2021 were retrieved. We selected a period from 2015 for the review because this was the time when WHO announced the new “Test and Treat” strategy (
One review author (TGF) performed a screening of articles for their relevance to the review question with titles and abstracts. After removal of duplicate and irrelevant articles, the same author performed a full-text review on the retrieved articles on the basis of a protocol published in advance (
A systematic review and meta-analyses on risk factors for late linkage to care and delayed antiretroviral therapy initiation among HIV infected adults in sub-Saharan Africa: a review protocol.
). Three independent assessors (including the first author of the review: TGF) conducted a quality assessment (risk of bias) of the retrieved articles using the Effective Public Health Practice Project Quality Assessment Tool for Quantitative Studies (see Supplementary file 3). The quality assessment process considered the following characteristics: representativeness of participants (selection bias), appropriateness of the study design to answer study objectives, control of potential confounders, validity and reliability of data collection methods, and completeness of outcome data (withdrawals and dropouts). Disagreements between the assessors were resolved by discussion and decided by a final independent assessment where required.
Data abstraction
We used a format adapted from the Cochrane Systematic Review Checklist for Data Collection to extract data (see Supplementary file 4). Separate data extraction formats were used for linkage to care and ART initiation. The data extraction form included information regarding author, year, country, population, method, measurements, exposures, results, and conclusions. We contacted corresponding authors of seven primary studies for additional data regarding an exposure of interest versus the outcomes
Data synthesis
We provided a narrative review of the results across studies regarding exposures and outcomes. We conducted a meta-analysis when at least two studies measured the same exposure and outcome, using comparable definitions. A fixed-effect model was used when the number of studies was small (n <5) and when a substantial difference was observed between sample sizes, which could limit the generalizability of the findings beyond the included studies (
); otherwise, a random-effects model was applied to pool the outcomes with odds ratios (ORs) and to calculate 95% confidence intervals (CIs). Heterogeneity between studies in effect measures was determined using chi-square test and I2 statistic, and an I2 value of 75% was considered a high heterogeneity (
The Nordic Cochrane Centre, The Cochrane Collaboration,
Copenhagen2014
) to calculate pooled ORs by applying Mantel-Haenszel statistics for each outcome and a forest plot to present the results.
Results
The electronic literature search identified 2597 articles, of which 451 were duplicates and 2064 were irrelevant to the review question (based on the title and abstract appraisal). An additional 36 articles were removed after the full-text review that was based on the eligibility criteria (i.e., studies conducted on ineligible populations, qualitative studies, intervention studies, review articles, or articles lacking the desired outcomes: not reporting on linkage to care or ART initiation). Among the remaining 46 studies that were included in the review, 18 met the criteria for meta-analysis. Figure 1 depicts the selection process and number of articles excluded and retrieved at each stage.
Figure 1Study flow diagram. Study selection process and reasons for exclusion.
The characteristics of the 46 included studies are presented in Tables 1 and 2. Almost half (46%) of the studies were from eastern Africa: nine from Ethiopia, five from Kenya, three from Tanzania, and two each from Uganda and Rwanda. Those from southern Africa (South Africa, Malawi, Mozambique, and Zimbabwe) accounted for 39% of the review articles. Six studies were from western and central Africa: two from Cameroon, and one each from Guinea-Bissau, Nigeria, Senegal, and Cape Verde. One study used a clinic-based cohort across four countries (Uganda, Kenya, Tanzania, and Nigeria). More than half (52%) of the studies used a (mostly retrospective) cohort design (
High prevalence and excess mortality of late presenters among HIV-1, HIV-2 and HIV-1/2 dually infected patients in Guinea-Bissau - a cohort study from West Africa.
Test site predicts HIV care linkage and antiretroviral therapy initiation: a prospective 3.5 year cohort study of HIV-positive testers in northern Tanzania.
Linkage into care among newly diagnosed HIV-positive individuals tested through outreach and facility-based HIV testing models in Mbeya, Tanzania: a prospective mixed-method cohort study.
Exploratory Analysis of Time from HIV Diagnosis to ART Start, Factors and effect on survival: A longitudinal follow up study at seven teaching hospitals in Ethiopia.
Assessing linkage to and retention in care among HIV patients in Uganda and identifying opportunities for health systems strengthening: a descriptive study.
Perceived behavioural predictors of late initiation to HIV/AIDS care in Gurage zone public health facilities: a cohort study using health belief model.
Understanding the role of resilience resources, antiretroviral therapy initiation, and HIV-1 RNA suppression among people living with HIV in South Africa: a prospective cohort study.
Impact of the test and treat policy on delays in antiretroviral therapy initiation among adult HIV positive patients from six clinics in Johannesburg, South Africa: results from a prospective cohort study.
Factors associated with antiretroviral treatment initiation amongst HIV-positive individuals linked to care within a universal test and treat programme: early findings of the ANRS 12249 TasP trial in rural South Africa.
Factors affecting linkage to HIV care and ART initiation following referral for ART by a mobile health clinic in South Africa: evidence from a multimethod study.
Poor rates of linkage to HIV care and uptake of treatment after home-based HIV testing among newly diagnosed 15-to-49 year-old men and women in a high HIV prevalence setting in South Africa.
High prevalence and excess mortality of late presenters among HIV-1, HIV-2 and HIV-1/2 dually infected patients in Guinea-Bissau - a cohort study from West Africa.
Test site predicts HIV care linkage and antiretroviral therapy initiation: a prospective 3.5 year cohort study of HIV-positive testers in northern Tanzania.
Linkage into care among newly diagnosed HIV-positive individuals tested through outreach and facility-based HIV testing models in Mbeya, Tanzania: a prospective mixed-method cohort study.
Assessing linkage to and retention in care among HIV patients in Uganda and identifying opportunities for health systems strengthening: a descriptive study.
Linkage to care following an HIV diagnosis in three public sector clinics in eThekwini (Durban), South Africa: findings from a prospective cohort study.
Poor rates of linkage to HIV care and uptake of treatment after home-based HIV testing among newly diagnosed 15-to-49 year-old men and women in a high HIV prevalence setting in South Africa.
Factors associated with antiretroviral treatment initiation amongst HIV-positive individuals linked to care within a universal test and treat programme: early findings of the ANRS 12249 TasP trial in rural South Africa.
Perceived behavioural predictors of late initiation to HIV/AIDS care in Gurage zone public health facilities: a cohort study using health belief model.
Understanding the role of resilience resources, antiretroviral therapy initiation, and HIV-1 RNA suppression among people living with HIV in South Africa: a prospective cohort study.
Impact of the test and treat policy on delays in antiretroviral therapy initiation among adult HIV positive patients from six clinics in Johannesburg, South Africa: results from a prospective cohort study.
Exploratory Analysis of Time from HIV Diagnosis to ART Start, Factors and effect on survival: A longitudinal follow up study at seven teaching hospitals in Ethiopia.
Factors affecting linkage to HIV care and ART initiation following referral for ART by a mobile health clinic in South Africa: evidence from a multimethod study.
Length of time from the date of testing to linkage to care.
Age, sex, type of testing district, employment, level of education, household income, distance to the referral clinic, CD4 count at linkage, relationship status, HIV status disclosure
46% of participants linked to care within 365 days of HIV testing; the median time to linkage is 30 days.
Younger age (≤30 years) (AHR 0.58; 95% CI 0.50 - 0.68), male sex (AHR 0.86; 95% CI 0.76-0.98), having diagnosis in the more urban district (AHR 0.82; 95% CI 0.73-0.93), being employed (AHR 0.81; 95% CI 0.72 - 0.92) were associated with decreased hazard of linkage to care; nondisclosure of HIV status had more impact on linkage to care in men (AHR 0.53; 95% CI 0.42-0.66) than women (AHR 0.70; 95% CI 0.60-0.82).
Cases: individuals with HIV with CD4 count <350 cell/mm3 or WHO stage III/IV at first clinical visit. Controls: individuals with HIV with CD4 count ≥350 cell/mm3 or WHO stage I/II.
Age, sex, marital status, education, occupation, residence, pregnancy, number of sexual partners, wealth index, HIV status disclosure to a partner, year of presentation, household social support, illness as a cause for presentation to care, stigma and fear of losing a job
_
Age between 25-29 years (AOR 3.0; 95% CI 1.15-8.12) and 30-34 years (AOR 4.1; 1.35-12.46), having multiple sexual partners (AOR 6.0; 95% CI 1.28-28.02), lower wealth index (AOR 3.3; 95% CI 1.31-8.46), nondisclosure of HIV status to a partner (AOR 2.0; 95% CI 1.05-4.14), low household social support (AOR 2.3; 95% CI 1.26-4.30), severity of illness as a cause for presentation for care (AOR 4.3; 95% CI 2.26-8.0), fear of stigma (AOR 4.4; 95% CI 2.2-8.3), and fear of losing a job (AOR 6.8; 95% CI 1.8-24.54) were independent risk factors for late presentation for HIV care.
Cases: individuals with HIV presenting for care with CD4 count <350 cells/mm3. Controls: individuals with HIV presenting for care with CD4 count ≥350 cells/mm3.
Age, sex, level of education, employment, marital status, reason for HIV testing, status disclosure and distance to a health facility
_
Older age (≥60 years) (AOR 3.19; 95% CI 1.16-8.78) and medical indication for HIV testing (AOR 4.84; 95% CI 2.99-7.84) were associated with late presentation for care.
Late presentation for care defined as presentation with CD4 count < 200 cells/mm3 if enrolled between 2003 and 2011 and < 350 cells/mm3 if enrolled between 2012 and 2015 or WHO clinical stage III/IV in both periods.
Age, sex, marital status, educational status, religion, TB/HIV coinfection, baseline functional status, and a history of HIV testing,
Late presentation for care in 66.7% overall.
Females (AOR 1.2; 95% CI 1.03-1.5), TB/HIV coinfected patients (AOR 1.6; 95% CI 1.09-2.1), and patients without a history of HIV testing (AOR 1.2; 95% CI 1.1-1.4) were more likely to be presented late for care whereas older patients (25-50 years and 50+ years) compared with younger patients (15-24 years) (AOR 0.4; 95% CI 0.3-0.6) (AOR 0.4; 95% CI 0.2-0.6) were less likely to be presented late for care.
Late presentation for HIV cares defined as presentation with a CD4 count of < 350 cells/mm3 or WHO stages III/IV.
Age, sex, occupation, employment, religion, marital status, residence, and circumstance of diagnosis
Late presentation for care in 89.7% overall.
Students compared with employed individuals (AOR 0.50; 95% CI 0.26-0.98) and those who were diagnosed through routine screening compared with clinical suspicion (AOR 0.13; 95% CI 0.10-0.19) were less likely to be late presenters for care.
Time between initial HIV-positive diagnosis and enrollment in care.
Repeated HIV testing
Median time to be linked to care: 12.3 months in repeat testers; 1 month in single testers.
Repeated HIV testing was associated with delay in linkage to care; >1 year delay time in 15% of single testers, whereas in 51% of repeat testers, (P <0.001).
Factors affecting linkage to HIV care and ART initiation following referral for ART by a mobile health clinic in South Africa: evidence from a multimethod study.
Linkage to care defined as a visit to a health facility within 3 months of diagnosis.
Readiness for treatment, alcohol use, perceived stigma, belief about ARV side effects, denial of being HIV-positive, and HIV status disclosure
67% of participants linked to care within 3 months.
Disclosing HIV status to someone other than a sexual partner (AOR 2.99; 95% CI 1.13-7.91) and treatment readiness (AOR 2.97; 95% CI 1.05-8.34) were associated with more likelihood of linkage to care; individuals who reported good health (AOR 0.35; 95% CI 0.13-0.99), those who drank alcohol at least once weekly (AOR 0.35; 95% CI 0.12-0.98), and those who reported experiencing internalized stigma (AOR 0.32; 95% CI 0.11-0.91) were less likely to be linked to care.
Exploratory Analysis of Time from HIV Diagnosis to ART Start, Factors and effect on survival: A longitudinal follow up study at seven teaching hospitals in Ethiopia.
Time from HIV infection (estimated as time between previous negative test and first positive test) to linkage to care.
Age, sex, education, food security, socioeconomic status, residence, distance to a clinic, knowledge of HIV status, and presence of a household member on ART
4.9 years for 50% of HIV seroconverters.
Individuals of age 40-49 years (AOR 1.54; 95% CI 1.14-2.08) and those who were aware of their HIV status from previous testing (AOR 1.35; 95% CI 1.09-1.68) were more likely to be linked to care, whereas males were less likely to be linked to care compared with women (AHR 0.49; 95% CI 0.37-0.64).
Linkage into care among newly diagnosed HIV-positive individuals tested through outreach and facility-based HIV testing models in Mbeya, Tanzania: a prospective mixed-method cohort study.
Age, sex, marital status, time required to reach a clinic, testing site, presence of family member taking ARVs, reason for diagnosis and status disclosure
78% of participants linked to care within 6 months; 84% for those tested at health facilities; 69% for those tested at mobile sites.
Having HIV diagnosis at a health facility (AHR 1.78; 95% CI 1.52-2.07), disclosure of HIV status (AOR 2.64; 95% CI 2.05-3.39) and intention to get treatment as a reason for diagnosis (AOR 1.25; 95% CI 1.06-1.45) were associated with more likelihood of linkage to care.
Test site predicts HIV care linkage and antiretroviral therapy initiation: a prospective 3.5 year cohort study of HIV-positive testers in northern Tanzania.
Age, sex, education, marital status, testing site, depression, stigma, social support, residence, occupation, wealth index and reason for testing
70.4% of participants linked to care within 6 months; 17.1% delayed more than 6 months.
Having HIV diagnosis at community sites (AOR 2.89; 95% CI 1.79-4.66) was associated with delayed or no linkage to care, but testing due to illness had a protective effect (AOR 0.58; 95% CI 0.34-0.96).
Delayed linkage to care defined as not having a CD4 count measurement within 3 months of HIV diagnosis.
Age, sex, religion, marital status, educational level, status disclosure, residence, time taken to reach ART site, alcohol use and presence of chronic diseases
Delays in linkage to care in 22.4% overall.
Higher CD4 count (>500 cells/mm3) (AOR 3.60; 95% CI 0.60-10.40) and lower WHO stages (I/II) (AOR 5.40; 95% CI 1.90-15.20) were associated with delayed linage to care.
Late engagement in care defined as having a baseline CD4 count ≤100 cells/mm3.
Age, sex, baseline CD4 count, travel time to clinic, education, disclosure status, economic status, social support, alcohol use, psychiatric illness, TB infection and point of entry into care
Late engagement in care in 23% overall.
Male sex (AOR 1.54; 95% CI 1.35-1.75), age >24 years (AOR 1.62; 95% CI 1.02-2.56), more than 1-hour travel time to a clinic (AOR 1.18; 95% CI 1.04-1.34), having TB infection (AOR 2.77; 95% CI 2.40-3.19) and accessing care through home-based counseling and testing services (AOR 2.98; 95% CI 2.15-4.13) were associated with late engagement in care.
Cases: individuals with HIV with a baseline CD4 of <200/mm3 or WHO clinical stage III/IV. Controls: individuals with HIV with a baseline CD4 of ≥200/mm3 or WHO clinical stage I/II.
Age, sex, marital status, residence, monthly income, education, religion, reason for HIV testing, stigma and receipt of HIV information
_
Male sex (AOR 7.68; 95% CI 4.08-14.75), having HIV diagnosis due to illness (AOR 2.99; 95% CI 1.54-5.79) and stigma (AOR 2.99:95 %CI:1.54-5.79) were associated with late presentation for care; receiving information on HIV (AOR 0.37; 95% CI 0.18-0.78) and earning a monthly income of >USD250 (AOR 0.32; 95% CI 0.76-0.67) had a protective effect.
Linkage to care defined as completing at least one clinic visit and/or self-reported use of Cotrimoxazole/ART.
Age, sex, education, marital status, religion, occupation, income and community type
Linkage to care in 74% overall.
Males (APRR: 0.84; 95% CI 0.77-0.91), individuals of younger age (15-24 years) (APRR: 0.72; 95% CI 0.63-0.82) and those who have never married (APRR: 0.84; 95% CI 0.71-0.99) were less likely to be enrolled in care.
Assessing linkage to and retention in care among HIV patients in Uganda and identifying opportunities for health systems strengthening: a descriptive study.
Linkage to care defined as registering for pre-ART or ART care within 1 month of HIV diagnosis.
Age, sex, facility and location
Linkage to care in 53% overall.
Linkage to care was lower in rural health facilities compared with urban health facilities (AOR 0.64; 95% CI 0.43-0.95) and in adolescents (age 10-18 years) compared with adults (age 19-48 years) (AOR 0.58; 95% CI 0.35-0.96).
Late presentation for HIV care refers to diagnosis at CD4 count ≤500 cells/mm3 and/or at any of the WHO stages.
Age, sex and facility location
Late presentation for care in 78% overall.
Higher likelihood of late presentation for care in males (AOR 2.73; 95% CI 1.50 - 4.94), individuals of older age (>40 years) (AOR 2.72; 95% CI 2.02 - 3.66) and in those accessing care from urban health facilities (AOR 1.59; 95% CI 1.34-1.90).
High prevalence and excess mortality of late presenters among HIV-1, HIV-2 and HIV-1/2 dually infected patients in Guinea-Bissau - a cohort study from West Africa.
Late presentation for care defined as presentation with a CD4 count below 200 cells/mm3.
Age, sex, marital status and education
Late presentation for care in 49% overall.
Male sex (AOR 1.49; 95% CI 1.24-1.80), having no partner (AOR 1.30; 95% CI 1.05-1.61) and age >30 years (AOR 1.66; 95% CI 1.36-2.02) were risk factors for late presentation for care.
Linkage to care defined as having a first CD4 count available within 3 months of diagnosis.
Age, sex, clinical stage and testing modality
Linkage to care in 74% overall.
Older age (>35 years) (ASHR: 2.17; 95% CI 1.56-3.01), having a previous negative HIV test (ASHR: 1.43; 95% CI 1.16-1.76) and advanced WHO stage (stage III/IV) (ASHR:1.46; 95% CI 1.14- 1.87) were positively associated with linkage to care whereas HBT (ASHR: 0.62; 95% CI 0.47-0.83) and PICT (ASHR: 0.76; 95% CI 0.61-0.94) were negatively associated with linkage to care compared with VCT.
Linkage to care defined as first visit to the treatment center within 90 days of diagnosis.
Age, sex and distance to a health facility
Linkage to care in 23.8% overall; 52.7% in those who were diagnosed using VCT; 17.7% in PICT cases; 10.2% in CBSS cases.
Higher hazards of linkage to care were observed in facility-based VCT compared with community-based serosurvey (AHR 6.95; 95% CI 4.39-11.00) and in individuals whose house is <1km away from the treatment center compared with that ≥5km (AHR 4.67; 95% CI 1.16-18.76).
Advanced HIV disease (defined as CD4 count <200 cells/mm3 or WHO stage III/IV) at enrollment to care.
Age, sex, marital status and occupation
Advanced HIV disease in 60% overall; 66% in males and 56% in females.
Male sex (P <0.001) and unemployment (P <0.001) were significantly associated with an advanced HIV disease; individuals of age ≤25 years were less likely to have an advanced HIV disease (P =0.002).
Linkage to care following an HIV diagnosis in three public sector clinics in eThekwini (Durban), South Africa: findings from a prospective cohort study.
Linkage to care defined as return to a clinic for CD4 count results within 3 months of diagnosis.
Age, sex, marital status, education, employment, stigma, disclosure, depression, coping strategy, travel time to a clinic, baseline WHO stage and belief in ART safety and efficacy
Linkage to care in 54.1% overall.
Age < 30 years (AOR 0.52; 95% CI 0.33-0.82), holding positive-outcome belief in care (AOR 0.50; 95% CI 0.33-0.75), belief in ART efficacy (AOR 0.29; 95% CI 0.14-0.61), positive reframing as a coping strategy (AOR 0.74; 95% CI 0.55-0.99) and disclosure of HIV status (AOR 0.40; 95% CI 0.21-0.75) were associated with lower odds of nonlinkage to care.
Poor rates of linkage to HIV care and uptake of treatment after home-based HIV testing among newly diagnosed 15-to-49 year-old men and women in a high HIV prevalence setting in South Africa.
Linkage to care defined as first visit to an HIV clinic within 12 weeks of HIV testing.
Age, sex, education, monthly income, marital status, previous HIV diagnosis, baseline CD4 count, stigma, HIV status disclosure, depression and emotional support
Linkage to care in 55% overall.
Thinking that test results were wrong was associated with lower odds of linkage to care (AOR 0.46; 95% CI 0.23-0.93) whereas disclosure of HIV status to someone increased the likelihood of care linkage (AOR 2.31: 95% CI 1.07-4.97).
Late linkage to care defined as having WHO stage III/IV or CD4 count ≤350 cells/mm3 at first clinic visit.
Age, sex, marital status, and HIV testing source
Late linkage to care in 27.3% overall based on WHO stage and 65.5% based on CD4 count.
Having HIV test via VCT compared with community-based testing (AOR 2.39; 95% CI 1.24-4.60), being male (AOR 1.38; 1.04-1.83), being divorced/widowed (AOR 1.55; 95% CI 1.15-2.08) and being in the age group of <50 years (AOR 1.72; 95% CI 1.09-2.74) were significantly associated with late linkage to care.
AHR: Adjusted hazards ratio; AOR: Adjusted odds ratio; APRR: Adjusted prevalence risk ratio; ART: Antiretroviral therapy; ARV: Antiretroviral; ASHR: Adjusted subhazard ratio; CBSS: Community-based serosurvey; HBT: Home-based testing; OR: Odds ratio; PICT: Provider-initiated counseling and testing; RR: Relative risk; USD: United States dollars; VCT: Voluntary counseling and testing; WHO: World Health Organization
Time from the date of first record of CD4 count to date of ART initiation.
Age, sex, distance to a clinic, residence, presence of previously HIV care-linked household member, employment status, wealth index and CD4 count
ART initiation in 57% overall within 6 months; 67% in patients with CD4 ≤50 cells/mm3; 48% in patients with CD4 count 301-350 cells/mm3.
The hazards of ART initiation fell by 17% for every 100-cell increase in baseline CD4 count; higher rate of ART initiation among older patients (age >55 years) compared with younger patients (age 18-24 years) (HR: 1.65; 95% CI 1.27-2.15).
Factors associated with antiretroviral treatment initiation amongst HIV-positive individuals linked to care within a universal test and treat programme: early findings of the ANRS 12249 TasP trial in rural South Africa.
ART initiation defined as the first-time antiretroviral therapy dispensed since baseline clinic visit (either offered immediate ART or at CD4 count ≤350 cells/mm3).
Age, sex, education, household wealth, perception of stigma, distance between homesteads and clinic, having a regular partner, HIV status disclosure, social support, psychological distress, time between referral and baseline clinic visit and baseline CD4 count
Median duration for ART initiation: 1.08 (range: 0.69-2.09) months; overall rate of ART initiation: 49.5% at first month; 82.2% at third month; and 88.7% at sixth month.
Patients with CD4 count of >350 cells/mm3 compared with those with CD4 count of ≤100 cells/mm3 (HR: 0.3; 95% CI 0.2-0.4) and those without a regular partner (HR: 0.5; 95% CI 0.4-0.8) were less likely to initiate ART whereas patients of ≥50 years of age initiate ART more compared with those aged 16-29 years (HR: 1.5; 95% CI 1.0-2.3).
Age, sex, CD4 count at enrollment, and route of HIV testing
ART initiation in 84% overall; 65.7% within 3 months; median time of ART initiation from HIV testing: 59 days; 189 days in those tested through HIV serosurvey; 16 days in those tested at ART clinic.
Lower ART initiation rate was observed in those who had a CD4 count of >500 cells/mm3 compared with those who had ≤350 cells/mm3 (HR: 0.12; 95% CI 0.09-0.17) and in those who tested through HIV serosurvey compared with those who were tested at ART clinic (HR: 0.75; 95% CI 0.62-0.91).
Perceived behavioural predictors of late initiation to HIV/AIDS care in Gurage zone public health facilities: a cohort study using health belief model.
Cases: 160 delayed ART initiators (CD4 count <350 cells/mm3 or WHO clinical stage III/IV). Controls: 160 early ART initiators (CD4 count ≥350 cells/mm3 or WHO clinical stage I/II).
sex, marital status, education, occupation, wealth index, length of time lived with HIV, knowledge and perception of the importance of ART and self-efficacy
Person time incidence density of ART initiation: 4.46 per 100 person-months of observation; incidence density of delay in ART initiation: 2.21 per 100 person-months.
HIV care uninformed individuals (OR:1.94; 95% CI 1.06-3.56), those who did not perceive susceptibility to (OR: 8.46; 95% CI 3.92-18.26) and severity of the consequences of late ART initiation (OR:6.13; 95% CI 2.95-12.73), those who did not believe in the health benefits of ART (OR: 3.12; 95% CI 1.53-6.33) and lack self-efficacy (OR:2.35; 95% CI 1.09-5.05) had more likelihood of delayed ART initiation.
Time between enrollment in care and ART initiation
Repeated HIV-positive testing
Rate of ART initiation: 56.6% within <30 days in single HIV-positive testers; 46.4% in repeat HIV-positive testers.
The median time of ART initiation was significantly longer in repeat HIV-positive testers than single testers (1.2 months; IQR: 0.5-9.1 months vs. 0.7 months; IQR: 0.5-9.2 months; P < 0.034).
Rate of ART initiation within 14 and 60 days of treatment eligibility
Age, sex, residence, location of health facility, baseline CD4 count, WHO stage, pregnancy, and TB coinfection
Rate of ART initiation: 53.6% within 14 days and 75.5% within 60 days; median time of ART initiation 12 days.
Pregnancy (HR: 3.1; 95% CI 2.9-3.4), WHO stage II illness compared with stage I (HR: 1.17; 95% CI 1.05-1.30) and extremely low CD4 count (< 50 cells/mm3) (HR: 1.22: 95% CI 1.04-1.43) were associated with higher likelihood of ART initiation; age >45 years compared with age 15-24 years (HR: 0.67; 95% CI 0.58-0.77), TB coinfection (OR: 0.37; 95% CI 0.28-0.50), having diagnosis at a rural health facility (HR: 0.76; 95% CI 0.69-0.84), and WHO stage IV illness (OR: 0.57; 95 % CI: 0.39-0.82) were associated with lower likelihood of ART initiation.
Factors affecting linkage to HIV care and ART initiation following referral for ART by a mobile health clinic in South Africa: evidence from a multimethod study.
Readiness for treatment, alcohol use, perceived stigma, belief about ARV side effects, denial of being HIV-positive and HIV status disclosure
Rate of ART initiation in 62% overall.
Readiness for treatment was positively associated with ART initiation (AOR 3.20; 95% CI 1.09-9.39) whereas alcohol use (AOR 0.24; 95% CI 0.08-0.73) and perceived stigma (AOR 0.20; 95% CI 0.05-0.89) were negatively associated with ART initiation.
Late ART initiation defined as starting treatment at a CD4 count of <150 cells/mm3 or WHO Stage IV
Age, sex, education, relationship status, alcohol use, psychological distress, stigma, history of holy water use for HIV, residence, knowing someone on ART, HIV status disclosure, social support and reason for HIV diagnosis
Median time between enrollment in care and ART initiation 2.9 months overall; 1.1 months in women and 5.3 months in men.
Being male (AOR 2.02; 95% CI 1.50 - 2.73), having a high psychological distress (AOR 1.96; 95% CI 1.34-2.87), perceived communication barriers with health care providers (AOR 2.42; 95% CI 1.24 to 4.75), referral from PICT service compared with VCT (AOR 1.47; 95% CI 1.07-2.04), having a history of TB treatment (AOR 2.16; 95% CI 1.43 - 3.25) and not having had a clinic visit for at least 6 months before ART initiation (AOR 2.02; 95% CI 1.10-3.72) were associated with higher odds of late ART initiation; testing for HIV because of partner's death or illness associated with lower odds of late ART initiation (AOR 0.64; 95% CI 0.42-0.95).
Exploratory Analysis of Time from HIV Diagnosis to ART Start, Factors and effect on survival: A longitudinal follow up study at seven teaching hospitals in Ethiopia.
Time from eligibility for ART (CD4 count ≤500 cells/mm3 or WHO stage III) to treatment initiation
Age, sex, baseline WHO stage and CD4 count and disclosure status
Rate of ART initiation in 48% overall within 1 month of eligibility.
Lower risk of delayed ART initiation was observed in older adults (>24 years) compared with their younger counterparts (15-24 years) (OR: 0.77; 95% CI 0.63-0.95), in those who enrolled within 1-week of HIV diagnosis compared with those enrolled within >1 months (OR: 0.79: 95% CI 0.65-0.97), but a higher risk in those who had a higher baseline CD4 count (≥100 cells/mm3) compared with <100 cells/mm3 (OR: 1.15; 95% CI 1.02-1.31).
Time from eligibility for ART (≤350 cells/mm3 or WHO stage IV) to treatment initiation
Age, sex, point of entry into care, CD4 count and WHO stage at eligibility and facility type and type of setting
Rate of ART initiation in 80% overall within 12 months of eligibility.
Women (ASHR: 0.8; 95% CI 0.8- 0.9), younger patients (15-20 years of age) (ASHR: 0.8; 95% CI 0.8-0.9) and those who enrolled in care through inpatient wards compared with VCT (ASHR: 0.8; 95% CI 0.7-0.9) were less likely to start ART; patients with a CD4 count of <200 cells/mm3 were more likely to start ART compared with CD4 count >350 cells/mm3 (ASHR: 2.8; 95% CI 1.7-4.5).
Age, sex, education, occupation, pregnancy, residence, economic status, household wealth index, distance to the closest clinic, presence of a household member on ART and CD4 count
Rate of ART initiation in 67% overall; 68.2% in men and 60.2% in women.
A higher rate of ART initiation was seen in men with a residence distance of <2km from the nearest clinic (AOR 1.62; 95% CI 1.14-2.28) and in those who lived in a household where at least one person was on ART (AOR 1.54; 95% CI 1.07-2.21); a higher rate of ART initiation in women of age ≥ 45 years (AOR 1.94; 95% CI 1.24-3.05), in those without pregnancy (AOR 1.72; 95% CI 1.28-2.31), had higher wealth index (AOR 1.38; 95% CI 1.04-1.86) and had ART history in the household (AOR 1.41; 95% CI 1.05-1.89); a lower rate of ART initiation in men (AOR 0.29; 95% CI 0.09-0.90) and women (AOR 0.46; 95% CI 0.28-0.75) with a CD4 count of 201-350 cells/mm3 compared with ≤100 cells/mm3.
186 ART ineligible individuals at enrollment in care (CD4 count >350 cells/mm3 and WHO HIV stage I/II)
Cohort (2008-2012)
Rate of ART initiation within 48 months of follow-up
Age, sex, baseline WHO stage and CD4 count
Rate of ART initiation in 48.4% overall; median time of ART initiation: 18 months.
Early ART initiation was associated with stage II illness (HR: 2.30; 95% CI 1.26-4.21) and a lower CD4 count (351-500 cells/mm3) (HR: 1.70; 95% CI 1.01-2.98).
Initiating ART within 2 months of eligibility for ART
Age, sex, CD4 count and WHO clinical stage at the time of eligibility, type of health facility, volume of patients served in a facility, facility location, and facility ownership
Rate of ART initiation in 75% overall; median time of ART initiation: 1 month.
A higher rate of ART initiation was seen in patients with CD4 count of <200 cells/mm3 (HR 1.38; 95% CI 1.23-1.55) but lower in those who were served in a health facility with above median patient volume (OR 0.57; 95% CI 0.45-0.72).
Age, sex, marital status, occupation, residence, CD4 count, WHO stage, and presence of TB coinfection
Rate of ART initiation in 78% overall within 3 months of eligibility; median time to initiate ART 2 months.
Lower enrollment CD4 count (<200 cells/mm3) and higher WHO stage (III/IV) were associated with more likelihood of ART initiation (HR 3.5; 95% CI 2.3-5.3); patients with CD4 count of <200 cells/mm3 at eligibility-initiated ART with less delay (HR: 0.3; 95% CI 0.2-0.6).
ART initiation defined as having a clinically confirmed ART initiation date and/or self-reported use of ART
Age, sex, education, marital status, religion, occupation, income, and community type
ART initiation in 63% overall.
Males (APRR 0.75; 95% CI 0.69-0.82), individuals of younger age groups (age 15-24 years) (APRR 0.69; 95% CI 0.60-0.80) and those who had never married (APRR 0.80; 95% CI 0.66-0.95) were less likely to use ART.
ART initiation within 3, 6 and 12 months of linkage to care
Age, sex and residence
ART initiation 80.9%, 86.8% and 94.1% within 3, 6 and 12 months of linkage to care respectively in individuals diagnosed using facility-based approaches; 63%, 77.8% and 85.2% within 3, 6 and 12 months respectively in individuals diagnosed using community-based serosurvey.
There was no statistically significant association between testing modality and ART initiation.
Late ART initiation defined as having a CD4 count ≤200 cells/mm3 and/or AIDS-defining illness
Age, sex, education, marital status, religion, occupation, residence, HIV status disclosure, functional status, baseline CD4 count and WHO stage, length of time between HIV testing and enrollment in care, substance use, and medication before ART
Late ART initiation in 67.3% overall.
Individuals in the age group of 35 to 44 years (AOR 3.85; 95% CI 1.68-8.82), those who were unmarried (AOR 1.88; 95% CI 1.13-3.03), and those who were bedridden (AOR 4.68; 95% CI 1.49-14.68) were more likely to initiate ART late.
The hazards of initiating ART were lower in individuals with a higher CD4 count (≥500 cells/mm3) (AHR 0.32; 95% CI 0.28 to 0.37) and those in the age group of 18 to 29 years.
Understanding the role of resilience resources, antiretroviral therapy initiation, and HIV-1 RNA suppression among people living with HIV in South Africa: a prospective cohort study.
ART initiation in 40.4% overall; 30% in males and 45.7% in females.
ART initiators were younger (median age = 31.9 years), females and individuals with less advanced HIV infection (CD4 >100 cells/mm3 and/or WHO stage I/II).
Impact of the test and treat policy on delays in antiretroviral therapy initiation among adult HIV positive patients from six clinics in Johannesburg, South Africa: results from a prospective cohort study.
ART initiation on the date of diagnosis and within 30 days
Age, sex, education, marital status, employment, baseline CD4 count, number of adults in a household, and a travel time to a clinic
ART initiation on the date of diagnosis in 20.2% overall; 71.9% within 30 days.
Women were more likely to take up ART on the diagnosis date (ARR 1.3; 95% CI 1.0-1.9) and had a higher rate of 30-day ART initiation (AHR 1.2; 95% CI 1.0-1.4) compared with males; living in a two-adult home increased the rate of 30-day ART initiation compared with living alone (AHR 1.2; 95% CI 1.0-1.5); older participants (age ≥40 years) were less likely to take up ART on the diagnosis date (ARR 0.6; 95% CI 0.4-0.9) compared with patients in the 18-24 age group.
Almost three-quarters (72%) of the studies were assessed as ‘moderate’ or ‘strong’ quality regarding the representativeness of participants, and 61% of them were scored as ‘moderate’ regarding the appropriateness of the study design. Most studies (70%) were assessed as having a strong performance in controlling confounders (i.e., controlled at least 80% of relevant confounders). Only 10 (22%) studies described the validity and/or reliability of the data collection tools, of which three studies were assessed as ‘strong’ in this regard. Similarly, nine (20%) studies considered the risk of dropout and withdrawal, and three of them reported a follow-up rate of more than 80% (a strong performance). This criterion was inapplicable in most (67%) of the studies. Overall, one study was assessed as ‘strong’ and 24 other studies (52%) were assessed as having a moderately strong methodologic quality on the Effective Public Health Practice Project tool (see Supplementary file 5).
Measurements
In most studies, the rate of linkage to care was determined based on the time since diagnosis (
Test site predicts HIV care linkage and antiretroviral therapy initiation: a prospective 3.5 year cohort study of HIV-positive testers in northern Tanzania.
Linkage into care among newly diagnosed HIV-positive individuals tested through outreach and facility-based HIV testing models in Mbeya, Tanzania: a prospective mixed-method cohort study.
Exploratory Analysis of Time from HIV Diagnosis to ART Start, Factors and effect on survival: A longitudinal follow up study at seven teaching hospitals in Ethiopia.
Assessing linkage to and retention in care among HIV patients in Uganda and identifying opportunities for health systems strengthening: a descriptive study.
Factors affecting linkage to HIV care and ART initiation following referral for ART by a mobile health clinic in South Africa: evidence from a multimethod study.
Linkage to care following an HIV diagnosis in three public sector clinics in eThekwini (Durban), South Africa: findings from a prospective cohort study.
Poor rates of linkage to HIV care and uptake of treatment after home-based HIV testing among newly diagnosed 15-to-49 year-old men and women in a high HIV prevalence setting in South Africa.
High prevalence and excess mortality of late presenters among HIV-1, HIV-2 and HIV-1/2 dually infected patients in Guinea-Bissau - a cohort study from West Africa.
Factors associated with antiretroviral treatment initiation amongst HIV-positive individuals linked to care within a universal test and treat programme: early findings of the ANRS 12249 TasP trial in rural South Africa.
Perceived behavioural predictors of late initiation to HIV/AIDS care in Gurage zone public health facilities: a cohort study using health belief model.
Factors affecting linkage to HIV care and ART initiation following referral for ART by a mobile health clinic in South Africa: evidence from a multimethod study.
). The remaining 12 studies measured the length of time between ART eligibility (based on guidelines available at a particular period of time) and ART initiation (
Exploratory Analysis of Time from HIV Diagnosis to ART Start, Factors and effect on survival: A longitudinal follow up study at seven teaching hospitals in Ethiopia.
Understanding the role of resilience resources, antiretroviral therapy initiation, and HIV-1 RNA suppression among people living with HIV in South Africa: a prospective cohort study.
Impact of the test and treat policy on delays in antiretroviral therapy initiation among adult HIV positive patients from six clinics in Johannesburg, South Africa: results from a prospective cohort study.
). In this review, we used more inclusive definitions for both outcomes. Accordingly, we defined late linkage to HIV care as engagement in care at CD4 count <350 cells/mm3 or at WHO clinical stage III/IV and delayed ART initiation as starting HIV medication at CD4 count <350 cells/mm3 or WHO clinical stage III/IV.
Linkage to HIV care
A summary of care linkage results is presented in Table 1.
identified a median time to care linkage after HIV infection as 4.9 years. Among studies that investigated the rate of linkage to care since diagnosis, the rate was within 3 months of diagnosis (
Factors affecting linkage to HIV care and ART initiation following referral for ART by a mobile health clinic in South Africa: evidence from a multimethod study.
Linkage to care following an HIV diagnosis in three public sector clinics in eThekwini (Durban), South Africa: findings from a prospective cohort study.
Test site predicts HIV care linkage and antiretroviral therapy initiation: a prospective 3.5 year cohort study of HIV-positive testers in northern Tanzania.
Linkage into care among newly diagnosed HIV-positive individuals tested through outreach and facility-based HIV testing models in Mbeya, Tanzania: a prospective mixed-method cohort study.
Exploratory Analysis of Time from HIV Diagnosis to ART Start, Factors and effect on survival: A longitudinal follow up study at seven teaching hospitals in Ethiopia.
), whereas the former study reported care engagement in 75% of PLWH within 1 week of diagnosis, only 46% were linked to care within 12 months in the latter. However, a more recent study in South Africa reported a rate of 55% within 12 weeks of diagnosis (
Poor rates of linkage to HIV care and uptake of treatment after home-based HIV testing among newly diagnosed 15-to-49 year-old men and women in a high HIV prevalence setting in South Africa.
) identified a prevalence of 23%, defining late presentation as engagement in care at CD4 count ≤100 cells/mm3.
Structural, psychosocial, perceptual, and sociodemographic factors were reported to be associated with late linkage to care. Eight studies identified health care delivery factors (
Test site predicts HIV care linkage and antiretroviral therapy initiation: a prospective 3.5 year cohort study of HIV-positive testers in northern Tanzania.
Linkage into care among newly diagnosed HIV-positive individuals tested through outreach and facility-based HIV testing models in Mbeya, Tanzania: a prospective mixed-method cohort study.
Assessing linkage to and retention in care among HIV patients in Uganda and identifying opportunities for health systems strengthening: a descriptive study.
), accessing care at a rural health care facility compared with an urban health facility, and having diagnosis through community-based approaches compared with health facility-based approaches were identified as risk factors for late linkage to care (
Test site predicts HIV care linkage and antiretroviral therapy initiation: a prospective 3.5 year cohort study of HIV-positive testers in northern Tanzania.
Linkage into care among newly diagnosed HIV-positive individuals tested through outreach and facility-based HIV testing models in Mbeya, Tanzania: a prospective mixed-method cohort study.
Assessing linkage to and retention in care among HIV patients in Uganda and identifying opportunities for health systems strengthening: a descriptive study.
Test site predicts HIV care linkage and antiretroviral therapy initiation: a prospective 3.5 year cohort study of HIV-positive testers in northern Tanzania.
Linkage into care among newly diagnosed HIV-positive individuals tested through outreach and facility-based HIV testing models in Mbeya, Tanzania: a prospective mixed-method cohort study.
Factors affecting linkage to HIV care and ART initiation following referral for ART by a mobile health clinic in South Africa: evidence from a multimethod study.
Linkage to care following an HIV diagnosis in three public sector clinics in eThekwini (Durban), South Africa: findings from a prospective cohort study.
Poor rates of linkage to HIV care and uptake of treatment after home-based HIV testing among newly diagnosed 15-to-49 year-old men and women in a high HIV prevalence setting in South Africa.
Test site predicts HIV care linkage and antiretroviral therapy initiation: a prospective 3.5 year cohort study of HIV-positive testers in northern Tanzania.
Linkage into care among newly diagnosed HIV-positive individuals tested through outreach and facility-based HIV testing models in Mbeya, Tanzania: a prospective mixed-method cohort study.
Factors affecting linkage to HIV care and ART initiation following referral for ART by a mobile health clinic in South Africa: evidence from a multimethod study.
Linkage to care following an HIV diagnosis in three public sector clinics in eThekwini (Durban), South Africa: findings from a prospective cohort study.
Linkage into care among newly diagnosed HIV-positive individuals tested through outreach and facility-based HIV testing models in Mbeya, Tanzania: a prospective mixed-method cohort study.
Factors affecting linkage to HIV care and ART initiation following referral for ART by a mobile health clinic in South Africa: evidence from a multimethod study.
Linkage to care following an HIV diagnosis in three public sector clinics in eThekwini (Durban), South Africa: findings from a prospective cohort study.
Poor rates of linkage to HIV care and uptake of treatment after home-based HIV testing among newly diagnosed 15-to-49 year-old men and women in a high HIV prevalence setting in South Africa.
Poor rates of linkage to HIV care and uptake of treatment after home-based HIV testing among newly diagnosed 15-to-49 year-old men and women in a high HIV prevalence setting in South Africa.
Factors affecting linkage to HIV care and ART initiation following referral for ART by a mobile health clinic in South Africa: evidence from a multimethod study.
Exploratory Analysis of Time from HIV Diagnosis to ART Start, Factors and effect on survival: A longitudinal follow up study at seven teaching hospitals in Ethiopia.
Exploratory Analysis of Time from HIV Diagnosis to ART Start, Factors and effect on survival: A longitudinal follow up study at seven teaching hospitals in Ethiopia.
Sociodemographic characteristics, such as age, sex, marital status, employment, and wealth index, influenced linkage to care. Younger age (below 30 years) (
00432-5&id=gr1.jpg){kind=link}
Studies included in other categories