Identifying scalable interventions to strengthen linkage to and retention in HIV care is essential to ensuring individual and population benefits of ART.
Engage4Health, a cluster-randomized controlled trial implemented at 10 health facilities in Mozambique, evaluated the effectiveness of a combination intervention strategy (CIS) vs the standard of care (SOC) on the combined outcome of linkage to care within 1 month and retention in care at 12 months following HIV diagnosis. CIS included: (1) point-of-care CD4+ count at HIV testing sites; (2) accelerated ART initiation for eligible patients; and (3) SMS appointment reminders. A subset of CIS participants additionally received non-cash financial incentives (CIS+FI). Adults >18 years newly diagnosed with HIV and willing to receive HIV care at the diagnosing health facility were enrolled from 4/13-6/15 and followed for 12 months. Main analyses assessed outcomes at the diagnosing facility using medical record abstraction, while sensitivity analyses examined outcomes at any health facility using self-reports collected during follow-up interviews. Log-Poisson models were used to estimate the relative risk (RR) of outcomes in intent-to-treat analyses, with additional models adjusting for clustering within sites and patient characteristics using propensity score matching.
Among 2004 participants (N=744 CIS, 493 CIS+FI, 767 SOC), 64% were women and the mean age was 34 years (standard deviation = 10). As shown in the table, 57% receiving CIS and 55% receiving CIS+FI achieved the primary outcome versus 35% receiving SOC (RR vs SOC: 1.63 [95%CI:1.45-1.83] for CIS; 1.56 [95%CI:1.37-1.76] for CIS+FI). Participants in the CIS (94%, RR vs SOC 1.50 [95%CI:1.42-1.49]) and CIS+FI (94%, RR 1.49 vs SOC [95%CI:1.41-1.58]) groups had higher linkage to care at 1 month versus those in the SOC (63%) group; and higher 12-month retention (CIS 59%, RR vs SOC 1.31 [95%CI:1.19-1.45], and CIS+FI 55%, RR vs SOC 1.24 [95%CI:1.11-1.38]) relative to those in SOC (45%). In sensitivity analyses considering self-reported linkage and retention at any health facility, 73% in CIS, 72% in CIS+FI, and 47% in SOC achieved the primary outcome (RR vs SOC: 1.55 [95%CI: 1.35-1.77] for CIS; 1.53 [95%CI: 1.32-1.77] for CIS+FI).
The CIS offers a feasible approach for enhancing outcomes across the HIV care continuum, particularly linkage to care following diagnosis. No additional benefit of non-cash financial incentives was observed.