Linkage to care following home-based HIV counseling and testing: a mixed methods study in rural South Africa
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Background: The mandate for scale up of home-based HIV counseling and testing (HBHCT) is strong. To maximize the benefits of testing, prompt linkage to care and treatment for HIV-positive clients is essential. Timely linkage can lead to decreased morbidity and mortality, as well as increased quality of life and life expectancy. Early treatment initiation can also reduce HIV transmission to uninfected partners. While data exists on the transition to care from mobile and facility-based HIV testing, less is known about the transition from HBHCT. Methods: A mixed methods study was conducted among a sample of 492 HIV-positive HBHCT clients in rural South Africa to: 1) determine the rate of linkage from HBHCT to facility-based services; and 2) identify factors that influence linkage. Clients were followed up to assess linkage to care, defined as providing a blood sample for a facility-based CD4 count. Using data from a cross-sectional survey conducted among a subsample of 196 clients 6-153 days after testing, Cox regression was performed to determine factors associated with linkage. To further explore potential barriers and facilitating factors, in-depth interviews were conducted with 30 clients who were purposively selected based on timely versus delayed care seeking. Results: Among 359 HIV-positive HBHCT clients, 62.1% (95% CI: 55.7% - 68.5%) linked to care within 3 months. For those who did not link promptly, barriers occurred at all levels: individual, relationships, community, and health systems. Delayed care seeking was influenced by poor psychological responses to the diagnosis; challenges surrounding disclosure and limited social support; lack of time, opportunity, and financial resources; and internalized negative experiences with the healthcare system. Often, barriers interacted and were subtly reinforced by stigma. Women and youth may be particularly vulnerable to these barriers. Conclusion: The findings highlight important gaps in our understanding, and provide the basis for policy and programmatic recommendations. Key recommendations include: 1) including HBHCT and monitoring of linkage to care in the role of community health workers; 2) offering tailored counseling and motivational interviewing; 3) conducting short-term intensive community-based support groups; 4) offering mobile point-of-care CD4 counts; and 5) piloting and evaluating community based nurse-initiated treatment.
Thesis (D.P.H.)--Boston University