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Title: Improving linkage into HIV care among adults in Blantyre, Malawi
Author: MacPherson, Peter
Awarding Body: University of Liverpool
Current Institution: University of Liverpool
Date of Award: 2013
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This thesis is concerned with understanding the patient flow from diagnosis of HIV infection to initiation of antiretroviral therapy (ART). Untreated HIV-infected individuals have a high risk of progression to AIDS and death, and of transmitting infection to others. Interventions to ensure prompt linkage into HIV care and ART could have substantial individual and public health benefits. At the turn of the millennium, very few HIV-infected individuals in sub-Saharan Africa had access to lifesaving ART. Since then, national HIV care programmes, supported by international funding, have driven impressive achievements in scaling up ART delivery, with over 9 million people having initiated ART by the end of 2012. Despite these achievements, the majority of HIV infected adults in sub-Saharan Africa remain unaware of their HIV status, meaning that they do not have the opportunity to access ART. Additionally, concerning reports have arisen from a number of HIV care programmes about high rates of patient drop-out and death between diagnosis of HIV and ART initiation. Together, these factors could significantly hinder efforts to achieve universal knowledge of HIV status and coverage of ART. The uptake of HIV testing, and magnitude of and reasons for drop-out of care between HIV diagnosis and initiation of ART were investigated in a prospective cohort study and linked qualitative study at primary care level in Blantyre, Malawi. The main findings were of extremely low uptake of provider-initiated HIV testing and counselling (completed on only 13% of adult facility attendances) and high rates of patient loss to care before ART initiation. Difficulties in completing ART eligibility assessments (WHO clinical staging assessments and measurement of CD4 count) were the major barrier to successful initiation of ART, with over-busy clinics, rushed providers, as well as high patient care- seeking expenses being significant contributory factors. Other sub-Saharan African countries that have implemented the public health approaches to HIV care delivery are likely to face similar problems. To attempt to improve uptake of HTC and linkage into ART care, two novel interventions were investigated. A community-based cluster-randomised trial compared two approaches to improve linkage into HIV care: facility-based initiation of HIV care following home HIV self-testing (HIVST), or optional home initiation of HIV care following HIVST. Uptake of ART, completion of HIVST, reporting of positive HIVST results and retention on and adherence to ART were the outcomes of interest. Over 6-months of HIVST availability, there was a highly significant 3-fold increase in the proportion of the adult population initiating ART, and a doubling of the proportion of adults reporting positive HIVST results to community counsellors where home initiation of HIV care was available, indicating increased willingness to access home-based HIV care. Having identified substantial problems with the use of the WHO clinical staging system for identifying ART eligibility, the accuracy of a brief novel community health worker (CHW) ART eligibility assessment tool was compared against a gold standard of CD4 count. The CWH tool significantly outperformed the WHO clinical staging system in identifying CD4 count of <350 cells/mm3 in terms of sensitivity, positive predictive value, negative predictive value and area under the receiver operator characteristic curve. Nevertheless, overall performance of the CHW tool was still suboptimal with nearly half of ART eligible participants missed, and was worse when compared against the new WHO-recommended ART eligibility threshold of CD4<500 cell/mm3. In conclusion, suboptimal rates of facility-based HTC and subsequent linkage into care are potential major stumbling blocks in efforts to achieve universal access to ART. Current ART eligibility tools are either not widely available (CD4 count measurement), or are insensitive, overly-complex and time-consuming (WHO clinical staging system). Home initiation of HIV care following community-based HIVST overcomes these barriers, with high uptake of HIVST achieved over short time-frame and substantial and significantly increased population-level rates of ART initiation. In an era where “test-and- treat” is increasingly being seen as a strategy to impact upon the HIV epidemic, interventions that improve uptake of testing and linkage into care, such as home HIVST and initiation of HIV care, will be required.
Supervisor: Lalloo, D. G.; Squire, S. B.; Corbett, E. L. Sponsor: Not available
Qualification Name: Thesis (Ph.D.) Qualification Level: Doctoral
EThOS ID:  DOI: Not available
Keywords: R Medicine (General)