title: Interventions to improve or facilitate linkage to or retention in pre-ART (HIV) care and initiation of ART in low- and middle-income settings--a systematic review.
abstract: BACKGROUND
  Several approaches have been taken to reduce pre-antiretroviral therapy (ART) losses between HIV testing and ART initiation in low- and middle-income countries, but a systematic assessment of the evidence has not yet been undertaken. The aim of this systematic review is to assess the potential for interventions to improve or facilitate linkage to or retention in pre-ART care and initiation of ART in low- and middle-income settings.
  
  
  METHODS
  An electronic search was conducted on Medline, Embase, Global Health, Web of Science and conference databases to identify studies describing interventions aimed at improving linkage to or retention in pre-ART care or initiation of ART. Additional searches were conducted to identify on-going trials on this topic, and experts in the field were contacted. An assessment of the risk of bias was conducted. Interventions were categorized according to key domains in the existing literature.
  
  
  RESULTS
  A total of 11,129 potentially relevant citations were identified, of which 24 were eligible for inclusion, with the majority (n=21) from sub-Saharan Africa. In addition, 15 on-going trials were identified. The most common interventions described under key domains included: health system interventions (i.e. integration in the setting of antenatal care); patient convenience and accessibility (i.e. point-of-care CD4 count (POC) testing with immediate results, home-based ART initiation); behaviour interventions and peer support (i.e. improved communication, patient referral and education) and incentives (i.e. food support). Several interventions showed favourable outcomes: integration of care and peer supporters increased enrolment into HIV care, medical incentives increased pre-ART retention, POC CD4 testing and food incentives increased completion of ART eligibility screening and ART initiation. Most studies focused on the general adult patient population or pregnant women. The majority of published studies were observational cohort studies, subject to an unclear risk of bias.
  
  
  CONCLUSIONS
  Findings suggest that streamlining services to minimize patient visits, providing adequate medical and peer support, and providing incentives may decrease attrition, but the quality of the current evidence base is low. Few studies have investigated combined interventions, or assessed the impact of interventions across the HIV cascade. RESULTS from on-going trials investigating POC CD4 count testing, patient navigation, rapid ART initiation and mobile phone technology may fill the quality of evidence gap. Further high-quality studies on key population groups are required, with interventions informed by previously reported barriers to care.
authors.affiliation: Health Economics and Epidemiology Research Office (HE2RO), WITS Health Consortium, University of the Witwatersrand, Johannesburg, South Africa.
authors.forename: Darshini
authors.initials: D
authors.lastname: Govindasamy
authors.affiliation: Malawi Liverpool Wellcome Trust Clinical Research Programme, Blantyre, Malawi; gdarsh@gmail.com.
authors.forename: Jamilah
authors.initials: J
authors.lastname: Meghij
authors.affiliation: HIV/AIDS Department, World Health Organization, Geneva, Switzerland.
authors.forename: Eyerusalem
authors.initials: E
authors.lastname: Kebede Negussi
authors.affiliation: HIV/AIDS Department, World Health Organization, Geneva, Switzerland.
authors.forename: Rachel
authors.initials: R
authors.lastname: Clare Baggaley
authors.affiliation: HIV/AIDS Department, World Health Organization, Geneva, Switzerland.
authors.forename: Nathan
authors.initials: N
authors.lastname: Ford
authors.affiliation: Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, United Kingdom.
authors.forename: Katharina
authors.initials: K
authors.lastname: Kranzer
mesh_terms: D017954:Africa South of the Sahara; D044966:Anti-Retroviral Agents / Q000627:therapeutic use*; D023241:Antiretroviral Therapy, Highly Active / Q000379:methods*; D001521:Behavior Therapy / Q000379:methods*; D003906:Developing Countries; D015658:HIV Infections / Q000175:diagnosis* / Q000188:drug therapy*; D006801:Humans; D010349:Patient Compliance / Q000523:psychology* / Q000706:statistics & numerical data
chemical_list: D044966:Anti-Retroviral Agents
keywords: ART eligibility; ART initiation; HIV; antiretroviral therapy; attrition; linkage to care; low- and middle-income countries; pre-ART; retention in care
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