title: The Link4Health study to evaluate the effectiveness of a combination intervention strategy for linkage to and retention in HIV care in Swaziland: protocol for a cluster randomized trial.
abstract: BACKGROUND
  Gaps in the HIV care continuum contribute to suboptimal individual health outcomes and increased risk of HIV transmission at the population level. Implementation science studies are needed to evaluate clinic-based interventions aimed at improving retention of patients across the continuum.
  
  
  METHODS
  Link4Health uses an unblended cluster site-randomized design to evaluate the effectiveness of a combination intervention strategy (CIS) as compared to standard of care on linkage to and retention in care among HIV-diagnosed adults in Swaziland. The CIS intervention targets a multiplicity of structural, behavioral, and biomedical barriers through five interventions: (1) point-of-care CD4 testing at time of HIV testing, (2) accelerated antiretroviral therapy (ART) initiation for eligible patients, (3) mobile phone appointment reminders, (4) care and prevention packages, and (5) non-cash financial incentives for linkage and retention. The unit of randomization is a network of HIV clinics inclusive of a secondary facility coupled with an affiliated primary facility. Ten study units were randomized based on implementing partner, geographic location, and historic volume of HIV patients. Target enrollment was 2200 individuals, each to be followed for 12 months. Eligibility criteria includes HIV-positive test, age >18 years, willing to receive HIV care at a clinic in the study unit and consent to study procedures. Exclusion criteria included previous HIV care in the past 6 months, planning to leave the community, and current pregnancy. The primary study outcome is linkage within 1 month and retention at 12 months after testing HIV positive. Secondary outcomes include viral load suppression at 12 months, time to ART eligibility and initiation, participant acceptability, and cost-effectiveness. The trial status is that study enrollment is complete and follow-up procedures are ongoing.
  
  
  CONCLUSIONS
  Link4Health evaluates a novel and pragmatic combination intervention strategy to improve linkage to and retention in care among adults with HIV in Swaziland. If the strategy is found to be effective, this study has the potential to inform HIV service delivery in resource-limited settings.
  
  
  BACKGROUND
  Clinicaltrials.gov NCT01904994.
authors.affiliation: ICAP, Mailman School of Public Health, Columbia University, 722 West 168th Street, New York, NY, 10032, USA. mollymcnairy@gmail.com.|Weill Cornell Medical College, New York, NY, USA. mollymcnairy@gmail.com.
authors.forename: Margaret L
authors.initials: ML
authors.lastname: McNairy
authors.affiliation: ICAP, Mailman School of Public Health, Columbia University, 722 West 168th Street, New York, NY, 10032, USA. ab3857@columbia.edu.
authors.forename: Averie B
authors.initials: AB
authors.lastname: Gachuhi
authors.affiliation: ICAP, Mailman School of Public Health, Columbia University, 722 West 168th Street, New York, NY, 10032, USA. mrl2013@columbia.edu.
authors.forename: Matthew R
authors.initials: MR
authors.lastname: Lamb
authors.affiliation: ICAP, Mailman School of Public Health, Columbia University, 722 West 168th Street, New York, NY, 10032, USA. hn2158@columbia.edu.|Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, NY, USA. hn2158@columbia.edu.
authors.forename: Harriet
authors.initials: H
authors.lastname: Nuwagaba-Biribonwoha
authors.affiliation: ICAP, Mailman School of Public Health, Columbia University, 722 West 168th Street, New York, NY, 10032, USA. sb3391@columbia.edu.
authors.forename: Sean
authors.initials: S
authors.lastname: Burke
authors.affiliation: Centers for Disease Control, Mbanane, Swaziland. Peter.Ehrenkranz@gatesfoundation.org.
authors.forename: Peter
authors.initials: P
authors.lastname: Ehrenkranz
authors.affiliation: Ministry of Health, Kingdom of Swaziland, Mbabane, Swaziland. smazibuko11@gmail.com.
authors.forename: Sikhathele
authors.initials: S
authors.lastname: Mazibuko
authors.affiliation: ICAP, Mailman School of Public Health, Columbia University, 722 West 168th Street, New York, NY, 10032, USA. rs2462@columbia.edu.
authors.forename: Ruben
authors.initials: R
authors.lastname: Sahabo
authors.affiliation: ICAP, Mailman School of Public Health, Columbia University, 722 West 168th Street, New York, NY, 10032, USA. nmp6@columbia.edu.
authors.forename: Neena M
authors.initials: NM
authors.lastname: Philip
authors.affiliation: Ministry of Health, Kingdom of Swaziland, Mbabane, Swaziland. vjokello@gmail.com.
authors.forename: Velephi
authors.initials: V
authors.lastname: Okello
authors.affiliation: ICAP, Mailman School of Public Health, Columbia University, 722 West 168th Street, New York, NY, 10032, USA. wme1@columbia.edu.|Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, NY, USA. wme1@columbia.edu.
authors.forename: Wafaa M
authors.initials: WM
authors.lastname: El-Sadr
mesh_terms: D000328:Adult; D019380:Anti-HIV Agents / Q000627:therapeutic use; D002985:Clinical Protocols; D013541:Eswatini; D015658:HIV Infections / Q000175:diagnosis / Q000188:drug therapy / Q000628:therapy*; D006801:Humans; D055118:Medication Adherence / Q000523:psychology; D010349:Patient Compliance / Q000523:psychology; D015397:Program Evaluation
chemical_list: D019380:Anti-HIV Agents