Access to HIV care in the context of universal test and treat: challenges within the ANRS 12249 TasP cluster-randomized trial in rural South Africa.
We aimed to quantify and identify associated factors of linkage to HIV care following home-based HIV counselling and testing (HBHCT) in the ongoing ANRS 12249 treatment-as-prevention (TasP) cluster-randomized trial in rural KwaZulu-Natal, South Africa.



Individuals ≥16 years were offered HBHCT; those who were identified HIV positive were referred to cluster-based TasP clinics and offered antiretroviral treatment (ART) immediately (five clusters) or according to national guidelines (five clusters). HIV care was also available in the local Department of Health (DoH) clinics. Linkage to HIV care was defined as TasP or DoH clinic attendance within three months of referral among adults not in HIV care at referral. Associated factors were identified using multivariable logistic regression adjusted for trial arm.



Overall, 1323 HIV-positive adults (72.9% women) not in HIV care at referral were included, of whom 36.9% (n=488) linked to care <3 months of referral (similar by sex). In adjusted analyses (n=1222), individuals who had never been in HIV care before referral were significantly less likely to link to care than those who had previously been in care (<33% vs. >42%, p<0.001). Linkage to care was lower in students (adjusted odds-ratio [aOR]=0.47; 95% confidence interval [CI] 0.24-0.92) than in employed adults, in adults who completed secondary school (aOR=0.68; CI 0.49-0.96) or at least some secondary school (aOR=0.59; CI 0.41-0.84) versus ≤ primary school, in those who lived at 1 to 2 km (aOR=0.58; CI 0.44-0.78) or 2-5 km from the nearest TasP clinic (aOR=0.57; CI 0.41-0.77) versus <1 km, and in those who were referred to clinic after ≥2 contacts (aOR=0.75; CI 0.58-0.97) versus those referred at the first contact. Linkage to care was higher in adults who reported knowing an HIV-positive family member (aOR=1.45; CI 1.12-1.86) versus not, and in those who said that they would take ART as soon as possible if they were diagnosed HIV positive (aOR=2.16; CI 1.13-4.10) versus not.



Fewer than 40% of HIV-positive adults not in care at referral were linked to HIV care within three months of HBHCT in the TasP trial. Achieving universal test and treat coverage will require innovative interventions to support linkage to HIV care.
INSERM U1219 - Centre Inserm Bordeaux Population Health, Université de Bordeaux, Bordeaux, France.|Centre INSERM U1219 - Bordeaux Population Health, ISPED, Université de Bordeaux, Bordeaux, France.|INSERM, UMR_S 1136, Pierre Louis Institute of Epidemiology and Public Health, Team of research in Social Epidemiology, F-75013, Paris, France.|Sorbonne Universités, UPMC Univ Paris 06, UMR_S 1136, Pierre Louis Institute of Epidemiology and Public Health, Team of research in Social Epidemiology, F-75013, Paris, France; melanie.plazy@isped.u-bordeaux2.fr.
Mélanie
M
Plazy
INSERM, UMR_S 1136, Pierre Louis Institute of Epidemiology and Public Health, Team of research in Social Epidemiology, F-75013, Paris, France.|Sorbonne Universités, UPMC Univ Paris 06, UMR_S 1136, Pierre Louis Institute of Epidemiology and Public Health, Team of research in Social Epidemiology, F-75013, Paris, France.
Kamal El
KE
Farouki
Africa Centre for Population Health, University of KwaZulu-Natal, Mtubatuba, South Africa.|Research Department of Infection and Population Health, UCL, London, UK.
Collins
C
Iwuji
Africa Centre for Population Health, University of KwaZulu-Natal, Mtubatuba, South Africa.
Nonhlanhla
N
Okesola
INSERM U1219 - Centre Inserm Bordeaux Population Health, Université de Bordeaux, Bordeaux, France.|Centre INSERM U1219 - Bordeaux Population Health, ISPED, Université de Bordeaux, Bordeaux, France.
Joanna
J
Orne-Gliemann
Africa Centre for Population Health, University of KwaZulu-Natal, Mtubatuba, South Africa.|Centre Population et Développement, Ceped UMR 196 Paris Descartes IRD, IRD, Paris, France.
Joseph
J
Larmarange
INSERM, U1018, Centre for Research in Epidemiology and Population Health, CESP, Epidemiology of Occupational and Social Determinants of Health, Villejuif, France.
France
F
Lert
Human Health and Development, Faculty of Medicine, University of Southampton, Southampton, UK.|Global Health Research Institute, University of Southampton, Southampton, UK.
Marie-Louise
ML
Newell
INSERM U1219 - Centre Inserm Bordeaux Population Health, Université de Bordeaux, Bordeaux, France.|Centre INSERM U1219 - Bordeaux Population Health, ISPED, Université de Bordeaux, Bordeaux, France.
François
F
Dabis
INSERM, UMR_S 1136, Pierre Louis Institute of Epidemiology and Public Health, Team of research in Social Epidemiology, F-75013, Paris, France.|Sorbonne Universités, UPMC Univ Paris 06, UMR_S 1136, Pierre Louis Institute of Epidemiology and Public Health, Team of research in Social Epidemiology, F-75013, Paris, France.
Rosemary
R
Dray-Spira
D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D015331:Cohort Studies; D003376:Counseling; D005260:Female; D015658:HIV Infections / Q000517:prevention & control / Q000628:therapy*; D006297:Health Services Accessibility; D006801:Humans; D016015:Logistic Models; D008297:Male; D008875:Middle Aged; D012017:Referral and Consultation; D012424:Rural Population; D013019:South Africa; D055815:Young Adult
HIV/AIDS; South Africa; home-based HIV counselling and testing; linkage to care; universal test and treat