To achieve UNAIDS 90 90 90 targets, the 90% of PLHIV who know their status must link to care and initiate treatment. We report linkage to care rates, time to link, and follow up provided to HIV-positive persons not on ART identified through the Botswana Combination Prevention Project (BCPP).
BCPP is a randomized controlled trial designed to evaluate the impact of a combination prevention (CP) package on HIV incidence in 30 communities in Botswana. HIV testing was conducted in the 15 CP communities and included home-based and mobile testing. Newly identified and known HIV-positive persons not on ART were given point of care CD4 tests, referrals to local HIV clinics, SMS appointment reminders, incentives for keeping appointments (US $2 airtime cards) and home and/or phone counselor visits for up to 90 days if not registered at the HIV clinic.
Overall, 40,628 persons were assessed for HIV status (tested or showed documentation of HIV status); 24% (9,586/40,628) were HIV-positive. Among all HIV-positive persons identified, 2,593 not on ART were referred to the local HIV clinic. Of those referred, 77% (1,997/2,593) linked to care within 30 days, 82% (2,126/2,593) within 90 days, and 84% (2,182/2,593) within 1 year. For women age 16-24, linkage to care rates were 83%, but lower for same-age men (72%). Of persons over 24 years of age, linkage to care rates were similar for women (85%) and men (84%). Of those who linked, 68% (1,492/2,182) registered with only an SMS reminder, and 58% (858/1,492) of these received an incentive upon registering. Of the 32% (690/2,182) who did not keep initial appointments, counselors provided an average of 2.2 counseling visits and re-appointments before they linked to the clinic. Of HIV-positive persons who never linked (16%, 411/2,593), 70% were employed compared to 40% of those who did link. Persons who never linked reported being too busy, unable to miss school/work, or not ready to accept HIV status as reasons for not keeping appointments.
Most HIV-positive persons referred to the clinic linked within the first 30 days, and linked with minimal follow up needed. Both women and men linked to care at high rates; however, men age 16-24 and employed persons may need additional tracking and expanded availability of clinical care to ensure they initiate treatment. Tracking referrals is a critical intervention to ensure resources are spent on those who do not link and need additional intervention to access care and treatment.