Effect of follow-up counselling after HIV diagnosis through homebased HIV counselling and testing on linkage to HIV care in southwestern Uganda

Background: Home-based HIV counselling and testing (HBHCT) is highly acceptable and may be an effective strategy for HIV prevention and population-based test-and-treat programmes in sub-Saharan Africa (SSA). However, few data are available on linkage to care or on the effectiveness of strategies to increase linkage to care among HIVpositive persons identified through HBHCT in SSA. The aims of this PhD were to (i) systematically review the literature on linkage to care among HIV-positive adults diagnosed through HBHCT in SSA; and (ii) to conduct a cluster-randomised controlled trial to measure the effectiveness of a counselling intervention after HIV diagnosis through HBHCT in increasing linkage to care in rural Masaka district, Uganda. Methods: (i) Five databases (Medline, Embase, Global Health, Web of Science, and Africa-Wide information) were systematically searched for studies published between 1st January 2000 and 19th August 2016. Authors of studies for which some required information was missing were requested to provide additional data. (ii) For the trial, 28 rural communities were randomly allocated (1:1) to the intervention (HBHCT, referral, and brief home-based counselling sessions one and two months after HBHCT) or control group (HBHCT and referral only). HIV-positive adults (≥18 years) not yet in care were enrolled. Primary outcomes were linkage (registration with an HIV clinic) at 6 months after HBHCT, and time to linkage. Analyses were by intention-to-treat using random effects logistic regression and Cox regression with shared frailty. Results: (i) 19 eligible studies were identified; one had all the required data. Additional data were obtained for 13 studies; thus, 14 studies were included in the review. Linkage to care was generally lower (<33%) if HBHCT was followed by referral only, and higher (>80%) if some strategy was used to facilitate uptake of referral. Only one study was a randomised trial and most were susceptible to outcome ascertainment bias. (ii) In the trial, 551 individuals tested HIV-positive; 205 (37.2%) were already in care and thus ineligible. 302 (87.3% of those eligible) were enrolled (intervention, n=149). Retention was similar across trial arms (92% overall). Overall linkage to care was 42.1%. Counselling was associated with a 2.18-fold [95% confidence interval (CI)=1.26-3.78] increase in the odds of linkage. There was no evidence of a difference between arms in the rate of linkage in the first two months, but subsequently the rate of linkage was higher in the intervention arm (hazard ratio=4.87, 95% CI=1.79-13.27). Conclusion: Counselling substantially increases linkage to care among HIV-positive adults identified through HBHCT and can increase antiretroviral therapy coverage in SSA