title: Linkage into care among newly diagnosed HIV-positive individuals tested through outreach and facility-based HIV testing models in Mbeya, Tanzania: a prospective mixed-method cohort study.
abstract: Linkage to care is the bridge between HIV testing and HIV treatment, care and support. In Tanzania, mobile testing aims to address historically low testing rates. Linkage to care was reported at 14% in 2009 and 28% in 2014. The study compares linkage to care of HIV-positive individuals tested at mobile/outreach versus public health facility-based services within the first 6 months of HIV diagnosis.
  
  
  
  Rural communities in four districts of Mbeya Region, Tanzania.
  
  
  
  A total of 1012 newly diagnosed HIV-positive adults from 16 testing facilities were enrolled into a two-armed cohort and followed for 6 months between August 2014 and July 2015. 840 (83%) participants completed the study.
  
  
  
  We compared the ratios and time variance in linkage to care using the Kaplan-Meier estimator and Log rank tests. Cox proportional hazards regression models to evaluate factors associated with time variance in linkage.
  
  
  
  At the end of 6 months, 78% of all respondents had linked into care, with differences across testing models. 84% (CI 81% to 87%, n=512) of individuals tested at facility-based site were linked to care compared to 69% (CI 65% to 74%, n=281) of individuals tested at mobile/outreach. The median time to linkage was 1 day (IQR: 1-7.5) for facility-based site and 6 days (IQR: 3-11) for mobile/outreach sites. Participants tested at facility-based site were 78% more likely to link than those tested at mobile/outreach when other variables were controlled (AHR=1.78; 95% CI 1.52 to 2.07). HIV status disclosure to family/relatives was significantly associated with linkage to care (AHR=2.64; 95% CI 2.05 to 3.39).
  
  
  
  Linkage to care after testing HIV positive in rural Tanzania has increased markedly since 2014, across testing models. Individuals tested at facility-based sites linked in significantly higher proportion and modestly sooner than mobile/outreach tested individuals. Mobile/outreach testing models bring HIV testing services closer to people. Strategies to improve linkage from mobile/outreach models are needed.
authors.affiliation: NIMR-Mbeya Medical Research Centre (MMRC), Mbeya, Tanzania.|School of Public Health, University of Western Cape, Cape Town, South Africa.
authors.forename: Erica Samson
authors.initials: ES
authors.lastname: Sanga
authors.affiliation: School of Public Health, University of Western Cape, Cape Town, South Africa.|School of Public Health, Mekelle University, Mekelle, Ethiopia.
authors.forename: Wondwossen
authors.initials: W
authors.lastname: Lerebo
authors.affiliation: National Institute for Medical Research (NIMR), Dar es Salaam, Tanzania.
authors.forename: Adiel K
authors.initials: AK
authors.lastname: Mushi
authors.affiliation: NIMR-Mbeya Medical Research Centre (MMRC), Mbeya, Tanzania.|Division of Infectious Diseases and Tropical Medicine, Medical Centre of the University of Munich (LMU), Munich, Germany.
authors.forename: Petra
authors.initials: P
authors.lastname: Clowes
authors.affiliation: NIMR-Mbeya Medical Research Centre (MMRC), Mbeya, Tanzania.
authors.forename: Willyhelmina
authors.initials: W
authors.lastname: Olomi
authors.affiliation: NIMR-Mbeya Medical Research Centre (MMRC), Mbeya, Tanzania.
authors.forename: Leonard
authors.initials: L
authors.lastname: Maboko
authors.affiliation: School of Public Health, University of Western Cape, Cape Town, South Africa.|University of Montreal Hospital Research Centre and School of Public Health, Université de Montréal, Montreal, Quebec, Canada.
authors.forename: Christina
authors.initials: C
authors.lastname: Zarowsky
mesh_terms: D000328:Adult; D018791:CD4 Lymphocyte Count; D003153:Community Health Services; D005260:Female; D015658:HIV Infections / Q000175:diagnosis* / Q000188:drug therapy; D006297:Health Services Accessibility / Q000706:statistics & numerical data*; D006801:Humans; D053208:Kaplan-Meier Estimate; D008297:Male; D008403:Mass Screening; D008875:Middle Aged; D008952:Mobile Health Units / Q000706:statistics & numerical data*; D015999:Multivariate Analysis; D016016:Proportional Hazards Models; D011446:Prospective Studies; D012424:Rural Population; D012698:Serologic Tests; D011795:Surveys and Questionnaires; D013636:Tanzania; D061665:Time-to-Treatment / Q000706:statistics & numerical data*
keywords: Facility-based HIV testing; HIV; Linkage to care; Mbeya-Tanzania; Mobile and outreach HIV testing