Mobile testing units show success in linking people to HIV care, treatment

Linkage to facility-based HIV care from a mobile testing unit is feasible, South African researchers report in the advance online edition of the Journal of Acquired Immune Deficiency Syndromes.

In a stratified random sample of 192 newly diagnosed individuals who had received CD4 test results, linkage to care was best among those who were ART eligible, Darshini Govindasamy and colleagues found.

The lower the CD4 cell count the greater the linkage to care: all of those with CD4 counts at or under 200 cells/mm³, two-thirds of those with CD4 counts of 201-350 cells/mm³ and a third of those with CD4 counts over 350 cells/mm³ linked to care.

An estimated two million people died as a result of HIV/AIDS in sub-Saharan Africa in 2008. South Africa now has the largest ART programme in the world, yet half of those in need of treatment do not get it. And a large number of those who do present for care, present late with low CD4 cell counts increasing their risk of early death.

In South Africa traditional HIV counselling and testing (HCT) sites at stationary facilities have increased and consequently so have the numbers tested. Yet this has not resulted in increased numbers on treatment and in care.

Transport costs, being male and having a low CD4 cell count have been well documented as the primary barriers of non-linkage to care.

Successful early diagnosis of HIV has to be accompanied by strategies that assure timely linkage to care and treatment so improving health outcomes.

Mobile testing units offer several advantages: people are often tested at an earlier stage of HIV; it is easier for hard-to-reach and high-risk populations to test; and they are cost-effective. However, maintaining on-going HIV care may prove difficult, requiring referral to stationery facilities.

The authors note no studies have looked at the performance of mobile testing units in linking people diagnosed with HIV to care at public health facilities.

The authors chose to look at whether disease progression as defined by CD4 cell count had an effect on access to care and the associated barriers in a nurse-run, counsellor-supported mobile testing unit.

From August 2008 until December 2009 those diagnosed for the first time with HIV were identified retrospectively from the mobile unit records. Those who got a CD4 cell count were prospectively followed from April to June 2010 to determine linkage to HIV care.

The unit, in the Cape Metropolitan region, Western Cape, South Africa, provides free HCT services to underserved communities.

Along with free client-initiated HCT free screening for other chronic conditions including high blood pressure, diabetes and obesity as well as TB is offered. The population is predominantly black Xhosa-speaking Africans.

Following rapid testing and a positive result and CD4 testing individuals are given detailed referral letters to help their access to care. Individuals are called when results of CD4 counts are available (within 72 hours). Those with no contact number are followed up by home visit or letter. Counselling is provided and patients are encouraged to go to clinics for either pre-ART care or to start ART as appropriate.

Of the 6738 records, overall prevalence of new diagnosis was 6.9% (463), of which 376 met the study’s inclusion criteria.

Because of a higher proportion of patients with CD4 counts at or above 350 cells/mm³ the authors took one-third of patients from this cohort (76), together with all 36 individuals with CD4 cell counts at or below 200 cells/mm³, and the 80 patients with CD4 counts between 201 and 350 cells/mm³.

Of the sample 27% (43) did not get their CD4 test result. Being female, having a CD4 cell count at or under 350 cells/mm³ and having a cellphone improved the likelihood of getting a CD4 count result. These results echo recent studies in South Africa showing a high loss to follow-up prior to receiving a CD4 test result; highlighting the critical need for point of care CD4 testing in both mobile and stationary facilities.

Of the 145 (73%) remaining individuals 10 refused to participate and 56 could not be traced in spite of previously having been contacted and receiving their CD4 counts.

52.5% (49) linked to care, including 100% of those ART-eligible. While the sample size is small, note the authors, the results are considerably higher than in studies of stationary facilities, where rates of post-diagnosis linkage to care varied from 30% to 80% among the ART-eligible.

Over 70% said that the mobile unit’s referral letter helped them access care at a public health facility.

Nonetheless over 30% of those eligible to start ART still had not started two months after their diagnosis but were still in the ART screening process. These results support other studies in sub-Saharan Africa also showing a delay in starting ART after diagnosis.

Having a higher CD4 count, no TB symptoms, not having disclosed and being employed increased the risks of not accessing care.

Not being able to access public health facilities was the most common barrier reported (41%) to linking to care. Other barriers included: 13% worried about ART toxicity and side effects and 9% fearing stigma and disclosure.

Extending hours and opening on the weekends at public facilities and setting up workplace programmes with mobile units could improve linkage to care for the employed, note the authors.

Limitations include the small sample size; the inability to track over 40% of eligible study participants in spite of persistent follow-up so potentially biasing the findings; and incorrect contact information. The study was undertaken 6-18 months after HIV diagnosis makingfollow-up especially challenging.

Strengths include validation of self-reported linkage to HIV care; trained bilingual counsellors assured minimal respondent bias; no incentives were given for participation.

The authors note HIV services at the mobile unit and public health facilities were free so their findings can be generalised to similar settings.

The authors conclude that while linkage to care was best among those ART-eligible, there is an urgent need to design interventions to improve linkage to care for the employed.

Govindasamy D et al. Linkage to HIV care from a mobile testing unit in South Africa by different CD4 count strata. Advance online edition JAIDS doi: 10.1097/QAI.0b013e31822e0c4c, 2011.