A major challenge to the scale up of provider
A major challenge to the scale-up of provider-initiated HIV testing and counselling is the time needed to provide detailed counselling when faced with inadequate staffing and other competing health-care priorities. Therefore, the Ugandan Ministry of Health developed a brief HIV counselling protocol in 2006, almost entirely removing individualised risk assessment and pre-test counselling, while retaining general prevention messages such as risk reduction options, HIV serostatus disclosure, and partner testing. Abbreviated counselling might reduce the time burden on providers and increase the numbers of patients tested for HIV; however, whether it compromises the efficacy of sexual risk reduction afforded by traditional, individualised counselling is still unclear.
After HIV diagnosis, rapid entry into care and initiation of antiretroviral therapy is needed to prevent secondary transmission and improve clinical outcomes; however, significant delays have been reported in prospective studies. Interventions to eliminate lags in entry into care could have an important effect on reducing secondary HIV transmission. The enhanced linkage to care intervention was an gamma secretase inhibitors of the case-management linkage model, which resulted in a significantly higher rate of successful linkage to HIV care compared with passive referral.
Results From May, 2008, to June, 2011, we screened 5214 people. 1327 were ineligible and 472 declined to participate (figure 1); 3415 were enrolled. After assignment to a counselling strategy, 26 people were excluded from the study. Of the remaining 3389 participants, 1003 (30%) were HIV-positive and 2386 (70%) were HIV-negative. Of the HIV-negative participants, 1323 were randomly assigned to be excluded from follow-up, leaving 2066 HIV-negative and HIV-positive participants in follow-up. Of the 2066 people in follow-up, 178 (9%) died, 166 (8%) moved or were lost to follow-up, and 1722 (83%) were still in follow-up at 1 year. Of the 2066 participants included in this analysis, 880 (43%) were men, and median age was 30 years (IQR 25–38). Table 1 shows baseline characteristics. Abbreviated HIV counselling and testing procedures took a median of 16 min (IQR 14–20), while the traditional sessions took a median of 47 min (IQR 45–50; p<0·0001). Similar proportions of patients in the abbreviated versus traditional group (232/832 [27·9%] vs 251/890 [28·2%]), reported risky sexual behaviour at any follow-up interview; the upper bound of the one-sided 95% CI for the difference was 3·2%. Therefore, because the difference was less than 6·5%, we rejected the null hypothesis of inferiority of abbreviated HIV counselling and testing overall, as well as by month of follow-up and HIV status (table 2). These results did not differ qualitatively when we used multiple imputation to account for missed visits and loss to follow-up (other than death), when adjusted for household wealth, and when we did a per-protocol analysis (data not shown). We did post-hoc analyses of loss to follow-up by counselling strategy overall and stratified by HIV status. Loss to follow-up was significantly lower in the traditional group than in the abbreviated group overall (adjusted hazard ratio [HR] 0·61, 95% CI 0·44–0·83), as well as in patients with HIV (0·58, 0·38–0·90), while the groups did not differ significantly when considering only HIV-negative patients (0·66, 0·42–1·04). 1003 people were HIV-positive, of whom 378 (38%) were men, median age was 31 years (IQR 27–38), and median CD4 cell count was 283 cells per mL (IQR 130–463). Employment category and baseline CD4 cell count were significantly associated with linkage to care group in bivariate analysis; therefore, the HRs are adjusted for these variables, with CD4 cell count modelled as a continuous covariate (table 3). We recorded no difference between linkage groups for mortality, receipt of prophylaxis for opportunistic infection, or receipt of HIV care (table 3). However, we report significant interactions (p<0·10) for two variables: time to HIV care was significantly different in women only (adjusted HR 0·80, 95% CI 0·66–0·96) and the effect of linkage to care on time to start of antiretroviral treatment was significantly different in men only (0·60, 0·41–0·87). In men with CD4 cell count of 250 cells per μL or less, median time to start of antiretroviral treatment was 107 days versus 192 days for enhanced linkage versus standard linkage (figure 2). In a post-hoc analysis, we recorded no difference between abbreviated and traditional HIV counselling and testing in time to HIV care, controlling for linkage to care group (data not shown).