title: Does provider-initiated counselling and testing (PITC) strengthen early diagnosis and treatment initiation? Results from an analysis of an urban cohort of HIV-positive patients in Lusaka, Zambia.
abstract: BACKGROUND
  Building on earlier works demonstrating the effectiveness and acceptability of provider-initiated counselling and testing (PITC) services in integrated outpatient departments of urban primary healthcare clinics (PHCs), this study seeks to understand the relative utility of PITC services for identifying clients with early-stage HIV-related disease compared to traditional voluntary testing and counselling (VCT) services. We additionally seek to determine whether there are any significant differences in the clinical and demographic profile of PITC and VCT clients.
  
  
  METHODS
  Routinely collected, de-identified data were collated from two cohorts of HIV-positive patients referred for HIV treatment, either from PITC or VCT in seven urban-integrated PHCs. Univariate and multivariate analyses were conducted to compare the two cohorts across demographic and clinical characteristics at enrolment.
  
  
  RESULTS
  Forty-five per cent of clients diagnosed via PITC had CD4 < 200, and more than 70% (i.e. two thirds) had CD4 < 350 at enrollment, with significantly lower CD4 counts than that of VCT clients (p < 0.001). PITC clients were more likely to be male (p = 0.0005) and less likely to have secondary or tertiary education (p < 0.0001). Among those who were initiated on antiretroviral therapy (ART), PITC clients had lower odds of initiating treatment within four weeks of enrollment into HIV care (adjusted odds ratio, or AOR: 0.86; 95% confidence interval, or CI: 0.75-0.99; p = 0.035) and significantly lower odds of retention in care at six months (AOR: 0.84; CI: 0.77-0.99; p = 0.004).
  
  
  CONCLUSIONS
  In Lusaka, Zambia, large numbers of individuals with late-stage HIV are being incidentally diagnosed in outpatient settings. Our findings suggest that PITC in this setting does not facilitate more timely diagnosis and referral to care but rather act as a "safety net" for individuals who are unwilling or unable to seek testing independently. Further work is needed to document the way provision of clinic-based services can be strengthened and linked to community-based interventions and to address socio-cultural norms and socio-economic status that underpin healthcare-seeking behaviour.
authors.affiliation: Centre for Infectious Disease Research in Zambia, Lusaka, Zambia. globalstopp@gmail.com
authors.forename: Stephanie M
authors.initials: SM
authors.lastname: Topp
authors.forename: Michelle S
authors.initials: MS
authors.lastname: Li
authors.forename: Julien M
authors.initials: JM
authors.lastname: Chipukuma
authors.forename: Matimba M
authors.initials: MM
authors.lastname: Chiko
authors.forename: Evelyn
authors.initials: E
authors.lastname: Matongo
authors.forename: Carolyn
authors.initials: C
authors.lastname: Bolton-Moore
authors.forename: Stewart E
authors.initials: SE
authors.lastname: Reid
mesh_terms: D000293:Adolescent; D000328:Adult; D000554:Ambulatory Care Facilities / Q000458:organization & administration; D015331:Cohort Studies; D003376:Counseling / Q000379:methods* / Q000458:organization & administration*; D042241:Early Diagnosis; D005260:Female; D015658:HIV Infections / Q000175:diagnosis* / Q000188:drug therapy*; D006302:Health Services Research; D006801:Humans; D008297:Male; D008875:Middle Aged; D010342:Patient Acceptance of Health Care / Q000523:psychology / Q000706:statistics & numerical data; D014505:Urban Population; D055815:Young Adult; D015024:Zambia