Improvements in testing services are needed if the global target of 90-90-90 is to be achieved. Client or provider -initiated and home-based HIV counseling and testing (VCT, PICT and HBT, respectively) are all complementary testing modalities to be considered when selecting local appropriate interventions. Linkage to HIV care throughout the cascade is a crucial indicator and yet there is little data on linkage across testing modalities. We aimed to compare the linkage rates between VCT, PICT and HBT in Southern Mozambique.
Between 2014 and 2015, we prospectively enrolled 341, 432 and 396 new adult HIV diagnoses through VCT, PICT and HBT respectively in a semi-rural area served by the Manhiça District Hospital (MDH). Passive follow-up information was obtained through the MDH electronic HIV patient tracking and demographic surveillance system. Loss to Follow up (LTF) at each step of the care cascade was defined within 3 months of testing. Logistic regression was used to estimate the impact of testing modality on LTF at each step of the cascade.
Among the 1169 enrolled patients, 56% were female with a median age of 34, 35 and 38.4 years in VCT, PICT and HBT respectively (p<0.0001). Linkage differed according to testing modality and cascade step. Of those tested at VCT, PICT and HBT, 99% (n=336), 92% (n=397) and 29% (n=113) respectively enrolled in care (p=0, 0001) while 51%, 42% and 53% of those enrolled attended the 1st clinic visit. PICT was significantly associated with a higher risk of LTF both at enrollment and 1st clinical visit (p=0.0001 and 0.0215 respectively). Women, older participants and those reporting work absenteeism were less likely to be LTF for the 1st visit. Significant predictors of LTF at the staging step included being male (p=0.04) and having individual testing (p=0.05). Among those individuals eligible for ART, there was no significant difference in ART initiation between HIV testing cohorts (67, 63 and 68% for VCT, PICT and HBT respectively).
HBT participants were more likely not to enroll in care as compared to VCT and PICT, but there was no difference in LTF for initiating ART among those eligible. Areas relying on HBT should implement additional measures to ensure linkage to care after testing. Regardless of testing modality, there is a considerable block in the cascade of care before the 1st clinic visit leading to very low rates of ART initiation.