Close to 60% of adults benefiting from point-of-care
CD4 cell count testing at HIV testing sites, accelerated antiretroviral therapy (ART)
initiation and SMS appointment reminders were retained in care after one year, compared
to just 44% of those receiving the standard of care in Mozambique,
according to findings from the Engage4Health study presented last week at the
Conference on Retroviruses and Opportunistic Infections (CROI 2017) in Seattle.
The study also found that people who received the
enhanced intervention were much more likely to be linked to care within one
month of diagnosis. Over 90% of those who received the enhanced intervention
were linked to care within one month, compared to 63% of those who received the
standard of care. People who received the enhanced intervention were five times
more likely to link to care on the day of diagnosis (RR: 5.7 [95% CI: 4.8-6.7])
and twice as likely to have linked to care within one week, when compared to
the standard of care group (RR: 2.0 [95% CI: 1.9-2.2]).
Despite the considerable success of HIV programmatic
scale-up in sub-Saharan Africa, timely linkage to care after HIV diagnosis and
sustained retention in care have been identified as major weaknesses across the
continuum of care. Barriers at each step of the continuum persist. Identification
of scalable interventions to strengthen linkage to and retention in HIV care is
critical for individual and population benefits of ART.
Findings show that less than half of people with HIV in
Mozambique enrol in care within a month of their diagnosis. Among those who do
enrol in care, less than half are still in care 12 months later. Such low rates
of linkage to and retention in care highlight the challenge of ensuring
effective, long-term HIV treatment.
Led by ICAP, in partnership with the Center for
Collaboration in Health and Mozambique’s Ministry of Health and funded by USAID,
the Engage4Health study evaluated the effectiveness of a combination intervention
strategy (CIS) compared to the standard of care (SOC) on the combined outcome of linkage to
care within one month and retention in care at 12 months following HIV
diagnosis. A subset of CIS participants received, in addition, non-cash
financial incentives (CIS+FI).
The Engage4Health study was a cluster-randomised
controlled trial conducted at ten health facilities from 2013 to 2016.
From April 2013 to June 2015 adults over 18 years of
age who were newly diagnosed with HIV, not currently pregnant, or enrolled in HIV care
or receiving ART in the prior six months and willing to get
HIV care at the diagnosing health facility, were enrolled from clinics in
Maputo and the more rural area of Inhambane Province. Participants were followed
for 12 months.
Of the 2004 (744, 493 and 767 in the CIS, CIS+FI and
SOC arms, respectively), two-thirds of participants were female with a mean age
of 34 years, half were married and approximately one quarter were unemployed.
Participants were referred mainly from voluntary testing and counselling sites.
The standard of care at the time comprised laboratory
referral for CD4 testing, returning for results in two to four weeks, and ART
counselling at a separate clinic visit.
The CIS-FI cohort received up to three pre-paid cell
phone cards equivalent to US$5 in value, one for linkage within one
month, the second for retention at six months and the third at 12 months.
Approximately 90% of participants were interviewed at
one month and approximately 80% at 12 months.
The primary outcome, linkage to care within month and
retention at 12 months, was 35%, 57% and 55% for the SOC, CIS and CIS-FI
This breaks down to rates for those linked to care
within one month as follows: 63%, 94% and 95% for the SOC, CIS and CIS-FI
CIS and CIS-FI cohorts had similar very high linkage
While the retention rates at 12 months remained
similar for the CIS and CIS-FI cohorts there was, nonetheless, a considerable
loss to follow-up across all groups: 56%,
42% and 45% were lost to follow-up, respectively.
The unadjusted relative risk for the primary outcome
compared to the SOC arm was RR: 1.6 (95% CI: 1.5-1.8) and 1.6 (95% CI: 1.4-1.8)
for the CIS and CIS-FI cohorts, respectively.
For the CIS cohort there was a 20% improvement in
retention at six months and 30% at 12 months compared to the SOC group.
In a sensitivity analysis with the primary outcome expanded
from clinic of diagnosis to include any clinic the primary outcome rate was
46%, 70% and 68% for the SOC, CIS and CIS-FI cohorts, respectively. Increases were
in the same proportion for all three groups. The unadjusted relative risk was
similar for both cohorts and was unchanged.
Presenting findings from the study, Dr Matthew Lamb concluded that combination strategies
improved linkage within one month plus retention at 12 months following HIV
diagnosis by 50 to 60%.
However, this improvement was due primarily to the
significantly enhanced linkage to care rather than changes in retention.
Financial incentives provided no additional benefit.