title: Assessment of linkages from HIV testing to enrolment and retention in HIV care in Central Mozambique.
abstract: Effectiveness of the rapid expansion of antiretroviral therapy (ART) throughout sub-Saharan Africa is highly dependent on adequate enrolment and retention in HIV care. However, the measurement of both has been challenging in these settings. This study aimed to assess enrolment and retention in HIV care (pre-ART and ART) among HIV-positive adults in Central Mozambique, including identification of barriers and facilitators.
  
  
  
  We assessed linkages to and retention in HIV care using a mixed quantitative and qualitative approach in six districts of Manica and Sofala provinces. We analyzed routine district and health facility monthly reports and HIV care registries from April 2012 to March 2013 and used single imputation and trimmed means to adjust for missing values. In eight health facilities in the same districts and period, we assessed retention in HIV care among 795 randomly selected adult patient charts (15 years and older). We also conducted 25 focus group discussions and 53 in-depth interviews with HIV-positive adults, healthcare providers and community members to identify facilitators and barriers to enrolment and retention in HIV care.
  
  
  
  Overall, 46% of the monthly HIV testing reports expected at the district level were missing, compared to 6.4% of the pre-ART registry reports. After adjustment for missing values, we estimated that the aggregate numbers of adults registered in pre-ART was 75% of the number of persons tested HIV-positive in the six districts. In the eight health facilities, 40% of the patient charts for adults enrolled in pre-ART and 44% in ART were missing. Of those on ART for whom charts were found, retention in treatment within 90 and 60 days prior to the study team visit was 34 and 25%, respectively. Combining these multiple data sources, the overall estimated retention was 18% in our sample. Individual-level factors were perceived to be key influences to enrolment in HIV care, while health facility and structural-level factors were perceived to be key influences of retention.
  
  
  
  Efforts to increase linkages to and retention in HIV care should address individual, health facility, and structural-level factors in Central Mozambique. However, their outcomes cannot be reliably assessed without improving the quality of routine health information systems.
authors.affiliation: Department of Anthropology, University of Washington, Seattle, WA, USA.|Health Alliance International, Seattle, WA, USA; celsoi@uw.edu.
authors.forename: Celso Azarias
authors.initials: CA
authors.lastname: Inguane
authors.affiliation: Health Alliance International, Seattle, WA, USA.|Department of Global Health, University of Washington, Seattle, WA, USA.
authors.forename: Stephen
authors.initials: S
authors.lastname: Gloyd
authors.affiliation: Centro de Investigação Operacional de Beira (CIOB), Ministry of Health, Beira, Mozambique.
authors.forename: João Luis
authors.initials: JL
authors.lastname: Manuel
authors.affiliation: Office of HIV/AIDS, USA, Agency for International Development, Washington, DC, USA.
authors.forename: Charlene
authors.initials: C
authors.lastname: Brown
authors.affiliation: Office of HIV/AIDS, USA, Agency for International Development, Washington, DC, USA.
authors.forename: Vincent
authors.initials: V
authors.lastname: Wong
authors.affiliation: Health Alliance International, Seattle, WA, USA.|Department of Global Health, University of Washington, Seattle, WA, USA.|Faculdade de Medicina, Universidade Eduardo Mondlane, Maputo, Mozambique.|Manhiça Research Center (CISM), Manhiça, Mozambique.
authors.forename: Orvalho
authors.initials: O
authors.lastname: Augusto
authors.affiliation: Health Alliance International, Seattle, WA, USA.|Department of Global Health, University of Washington, Seattle, WA, USA.
authors.forename: Wisal Mustafa
authors.initials: WM
authors.lastname: Hassan
authors.affiliation: Centro de Investigação Operacional de Beira (CIOB), Ministry of Health, Beira, Mozambique.
authors.forename: Lúcia
authors.initials: L
authors.lastname: Vieira
authors.affiliation: Health Alliance International, Seattle, WA, USA.
authors.forename: Pires
authors.initials: P
authors.lastname: Afonso
authors.affiliation: Centro de Investigação Operacional de Beira (CIOB), Ministry of Health, Beira, Mozambique.
authors.forename: Mehol
authors.initials: M
authors.lastname: Jamnadás
authors.affiliation: Health Alliance International, Seattle, WA, USA.
authors.forename: Jama Joy
authors.initials: JJ
authors.lastname: Bernard
authors.affiliation: Health Alliance International, Seattle, WA, USA.
authors.forename: James
authors.initials: J
authors.lastname: Cowan
authors.affiliation: HIVCore/Population Council, Washington, DC, USA.
authors.forename: Samuel
authors.initials: S
authors.lastname: Kalibala
authors.affiliation: Health Alliance International, Seattle, WA, USA.|Department of Global Health, University of Washington, Seattle, WA, USA.
authors.forename: James
authors.initials: J
authors.lastname: Pfeiffer
mesh_terms: D000293:Adolescent; D000328:Adult; D003695:Delivery of Health Care; D005260:Female; D017144:Focus Groups; D015658:HIV Infections / Q000175:diagnosis* / Q000628:therapy*; D006268:Health Facilities; D006801:Humans; D008297:Male; D008403:Mass Screening; D009073:Mozambique; D010342:Patient Acceptance of Health Care; D012111:Residence Characteristics; D055815:Young Adult
keywords: HIV care; Mozambique; linkages; retention; treatment