title: Immediate Blood Draw for CD4+ Cell Count Is Associated with Linkage to Care in Durban, South Africa: Findings from Pathways to Engagement in HIV Care.
abstract: BACKGROUND
  Timely linkage to care by newly-diagnosed HIV+ individuals remains a significant challenge to achieving UNAIDS 90-90-90 goals. Current World Health Organization (WHO) guidelines recommend initiating anti-retroviral treatment (ART) regardless of CD4+ count, with priority given to those with CD4+ <350 cells/μl. We evaluated the impact of not having a day-of-diagnosis CD4+ count blood draw, as recommended by South African guidelines, on time to linkage, using data from a prospective cohort study.
  
  
  METHODS
  Individuals (N = 2773) were interviewed prior to HIV counseling and testing at three public sector primary care clinics in the greater Durban area; 785 were newly-diagnosed and eligible for the cohort study; 459 (58.5%) joined and were followed for eight months with three structured assessments. Linkage to care, defined as returning to clinic for CD4+ count results, and day-of-diagnosis blood draw were self-reported.
  
  
  RESULTS
  Overall, 72.5% did not have a day-of-diagnosis CD4+ count blood draw, and 19.2% of these never returned. Compared with a day-of-diagnosis blood draw, the adjusted hazard ratio of linkage (AHRlinkage) associated with not having day-of-diagnosis blood draw was 0.66 (95%CI: 0.51, 0.85). By 4 months, 54.8% of those without day-of-diagnosis blood draw vs. 75.2% with one were linked to care (chi-squared p = 0.004). Of those who deferred blood draw, 48.3% cited clinic-related and 51.7% cited personal reasons. AHRlinkage was 0.60 (95%CI: 0.44, 0.82) for clinic-related and 0.53 (95%CI: 0.38, 0.75) for personal reasons relative to having day-of-diagnosis blood draw.
  
  
  CONCLUSIONS
  Newly-diagnosed HIV+ individuals who did not undergo CD4+ count blood draw on the day they were diagnosed-regardless of the reason for deferring-had delayed linkage to care relative to those with same-day blood draw. To enhance prompt linkage to care even when test and treat protocols are implemented, all diagnostic testing required before ART initiation should be performed on the same day as HIV testing/diagnosis. This may require modifying clinic procedures to enable overnight blood storage if same-day draws cannot be performed, and providing additional counseling to encourage newly-diagnosed individuals to complete day-of-diagnosis testing. Tracking HIV+ individuals via clinic registries should commence immediately from diagnosis to reduce these early losses to care.
authors.affiliation: HIV Center for Clinical and Behavioral Studies, New York State Psychiatric Institute, Columbia University, New York, New York, United States of America.|Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, New York, United States of America.
authors.forename: Susie
authors.initials: S
authors.lastname: Hoffman
authors.affiliation: HIV Center for Clinical and Behavioral Studies, New York State Psychiatric Institute, Columbia University, New York, New York, United States of America.
authors.forename: Theresa M
authors.initials: TM
authors.lastname: Exner
authors.affiliation: Ibis Reproductive Health, Johannesburg, South Africa.
authors.forename: Naomi
authors.initials: N
authors.lastname: Lince-Deroche
authors.affiliation: HIV Center for Clinical and Behavioral Studies, New York State Psychiatric Institute, Columbia University, New York, New York, United States of America.|Department of Biostatistics, Mailman School of Public Health, Columbia University, New York, New York, United States of America.
authors.forename: Cheng-Shiun
authors.initials: CS
authors.lastname: Leu
authors.affiliation: South African Medical Research Council, HIV Prevention Research Unit, Durban, South Africa.
authors.forename: Jessica L
authors.initials: JL
authors.lastname: Phillip
authors.affiliation: Epidemiology & Biostatistics Program, CUNY Graduate School of Public Health and Health Policy, City University of New York, New York, New York, United States of America.
authors.forename: Elizabeth A
authors.initials: EA
authors.lastname: Kelvin
authors.affiliation: HIV Center for Clinical and Behavioral Studies, New York State Psychiatric Institute, Columbia University, New York, New York, United States of America.
authors.forename: Anisha D
authors.initials: AD
authors.lastname: Gandhi
authors.affiliation: HIV Center for Clinical and Behavioral Studies, New York State Psychiatric Institute, Columbia University, New York, New York, United States of America.|Department of Biostatistics, Mailman School of Public Health, Columbia University, New York, New York, United States of America.
authors.forename: Bruce
authors.initials: B
authors.lastname: Levin
authors.affiliation: South African Medical Research Council, HIV Prevention Research Unit, Durban, South Africa.
authors.forename: Dinesh
authors.initials: D
authors.lastname: Singh
authors.affiliation: HIV Center for Clinical and Behavioral Studies, New York State Psychiatric Institute, Columbia University, New York, New York, United States of America.
authors.forename: Joanne E
authors.initials: JE
authors.lastname: Mantell
authors.affiliation: Ibis Reproductive Health, Cambridge, Massachusetts, United States of America.
authors.forename: Kelly
authors.initials: K
authors.lastname: Blanchard
authors.affiliation: South African Medical Research Council, HIV Prevention Research Unit, Durban, South Africa.
authors.forename: Gita
authors.initials: G
authors.lastname: Ramjee
mesh_terms: D000293:Adolescent; D000328:Adult; D000554:Ambulatory Care Facilities; D044966:Anti-Retroviral Agents / Q000627:therapeutic use; D018791:CD4 Lymphocyte Count; D015496:CD4-Positive T-Lymphocytes / Q000166:cytology*; D015331:Cohort Studies; D005260:Female; D015658:HIV Infections / Q000175:diagnosis* / Q000188:drug therapy / Q000401:mortality; D006801:Humans; D007407:Interviews as Topic; D008297:Male; D016017:Odds Ratio; D015397:Program Evaluation; D016016:Proportional Hazards Models; D057566:Self Report; D015996:Survival Rate; D013997:Time Factors; D014944:World Health Organization; D055815:Young Adult
chemical_list: D044966:Anti-Retroviral Agents