title: Linkage to HIV care and antiretroviral therapy by HIV testing service type in Central Mozambique: a retrospective cohort study.
abstract: BACKGROUND
  Access to antiretroviral therapy (ART) has increased dramatically in resource-limited settings since its introduction a decade ago. However, ART coverage remains low in countries with the highest disease burden, which may be partially explained by poor testing to care linkages. HIV testing service may impact early attrition in the HIV treatment cascade.
  
  
  METHODS
  A retrospective cohort study was conducted in 18 clinics in central Mozambique using routine patient data and monthly reports. Patients referred from voluntary counseling and testing (VCT) were compared with those referred from prevention of mother-to-child transmission (PMTCT) for 3 outcomes: (1) enrollment at an HIV clinic ≤30 days after testing HIV positive, (2) CD4 test ≤30 days after enrollment, and (3) ART initiation ≤90 days after first CD4 test.
  
  
  RESULTS
  Patient retention in the HIV care system dropped at each step from HIV testing to ART initiation. Enrollment in HIV care was not significantly different between PMTCT and VCT [risk ratio (RR) = 0.84, 0.72 < RR < 1.02]. Women tested in PMTCT were less likely to have a CD4 test ≤30 days after enrollment when adjusting for age, education level, and marital status (adjusted RR = 0.84, 0.70 < RR < 1.00), and were less likely to initiate ART ≤90 days after their first CD4 test when adjusting for age, education, and marital status (adjusted RR = 0.56, 0.44 < RR < 0.71).
  
  
  CONCLUSIONS
  Poor linkages between HIV testing and care hamper efforts to improve coverage for HIV care and treatment services. Increased loss to follow-up among women diagnosed in PMTCT relative to VCT is worrisome and merits further qualitative research and programmatic attention.
authors: *Department of Epidemiology, University of Washington, Seattle, WA; †Health Alliance International, Seattle, WA; ‡Department of Global Health, University of Washington, Seattle, WA; §Ministry of Health, Mozambique; and ‖Department of Family Child Nursing, University of Washington, Seattle, WA (Micek is now with the Department of Medicine, University of Wisconsin-Madison, Madison, WI, USA).
authors: Sarah E
authors: SE
authors: Gerdts
authors: Bradley H
authors: BH
authors: Wagenaar
authors: Mark A
authors: MA
authors: Micek
authors: Carey
authors: C
authors: Farquhar
authors: Marina
authors: M
authors: Kariaganis
authors: Juvenal
authors: J
authors: Amos
authors: Sarah
authors: S
authors: Gimbel
authors: James
authors: J
authors: Pfeiffer
authors: Stephen
authors: S
authors: Gloyd
authors: Kenneth
authors: K
authors: Sherr
mesh_terms: D000293:Adolescent; D000328:Adult; D019380:Anti-HIV Agents / Q000627:therapeutic use*; D018791:CD4 Lymphocyte Count; D003695:Delivery of Health Care / Q000379:methods*; D005260:Female; D005500:Follow-Up Studies; D015658:HIV Infections / Q000175:diagnosis* / Q000188:drug therapy* / Q000517:prevention & control; D006801:Humans; D018445:Infectious Disease Transmission, Vertical / Q000517:prevention & control; D059012:Lost to Follow-Up; D008297:Male; D008403:Mass Screening; D009073:Mozambique; D016017:Odds Ratio; D012017:Referral and Consultation; D012189:Retrospective Studies; D012959:Socioeconomic Factors; D055815:Young Adult
chemical_list: D019380:Anti-HIV Agents