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Bruce Larson2, Kate Bistline1, Buyiswa Ndibong1, Thembi Xulu³, Alana Brennan¹², Lawrence Long¹,

Matt Fox², Sydney Rosen2

1Health Economics and Epidemiology Research Office, Johannesburg, South Africa2Boston University Center for International Health and Development , Boston, USA

3Right to Care, Johannesburg, South Africa

Rapid point-of-care CD4 testing at mobile HIV testing sites to increase linkage to care:

An evaluation of a pilot program in South Africa

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Introduction• Early identification of HIV-infected

individuals and improved linkage to care is a prerequisite for South Africa to achieve its goals for care and treatment.

• While mobile HIV counseling and testing (HCT) is well suited for early identification, little information exists on post-HCT linkage to care.

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The Pilot Intervention • A mobile HCT program around

Johannesburg (ACCESS VCT) piloted integration of point-of-care (POC) CD4 testing into routine practice to improve linkage to HIV care and treatment.

• The POC CD4 technology was the Pima™ Analyzer, provided to the site by Alere through a collaboration with USAID and the PEPFAR Program.

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Study Objective

• Primary objective:– Does integration of POC CD4 testing into

routine HCT services in a mobile program improve linkage to HIV care?

• Primary outcome: – The proportion of patients testing HIV

positive in the mobile HCT program who complete the first visit to their referral site within 8 weeks of testing positive.

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Methods• Access VCT provides HCT in mobile settings around Johannesburg

(nurses provide HCT services).

• During May – October 2010, multiple nurses offered HCT services at each mobile site (a day of operation across multiple locations).

• Each day, a subset of nurses also offered the POC CD4 test to positive patients.

• For each patient offered the POC CD4 test, the same nurse provided HIV testing and CD4 testing.

• Using patient-provided phone numbers, the HCT program made three efforts to reach all positive patients after 8 weeks to ask if they completed their referral visit to an HIV clinic, the first step in the initiation of HIV care.

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Results

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Cohort Characteristics  Standard HCT

plus POC CD4Standard HCT (No POC CD4)

p-value

Number 311 197  

Female (N and %)

194 (62.4%) 109 (55.3%) 0.11

Mean Age(STD)

34.0 (10.7) 34.3 (11.8) 0.77

Previous HIV testing

(N and %)

197 (59.4%) 112 (46.7%) 0.20

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Next Figure:

patients reached by phone

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Mobile HCT Patients tested HIV positive

(n = 508) 59.6% female

Standard Practice:HCT + referral for CD4

(n = 197)

Pilot Practice:HCT + Rapid CD4 + referral

(n = 311)

Not Called(n = 1)

Answered phone call(n = 122)

Not reached by phone(n = 74)

Received PIMA CD4 count(n = 263)

median [IQR] = 414[251-586]n=45 with CD4 < 200

Declined PIMA (n = 32)

Pima Technical Failure(n = 16)

Answered phone call (n = 167)

Not reached by phone(n = 96)

Risk difference “answered phone call” RD = 1.6% (95% CI: -10.5% - 7.4%)

Conclusion: For both groups, about 63% reached by phone after 8 weeks

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Next Figure:

completed referral visit

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Standard practice andanswered phone call

(n = 122)

Received PIMA CD4 count and answered phone call

(n = 167)

Risk difference “Completed referral visit within 8 weeks” RD = 26.14% (95% CI: 14.8% - 37.4%)

Conclusion: Substantially greater % of patients completed 1st referral visit among group receiving rapid CD4 at HCT

Note: Outcomes for 16 patients with technical failures similar to those not offered POC CD4 (11 of 16 contacted, 4 of 11 completed referral visit)

Completed 1st referral visit ≤8

weeks(n = 47, 38.5%)

Completed1st referral visit

≤8 weeks(n = 108, 64.7%)

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Conclusions

• POC CD4 testing can be integrated into routine HCT mobile program.

• About 90% of patients offered the POC test accepted the opportunity.

• No significant difference in patient characteristics between those offered the POC CD4 test and those not offered.

• mobile HCT program is successful in early identification of patients (i.e., median POC CD4 = 414).

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Conclusions

• For both study groups, about 63% were reached by phone after 8 weeks.

• A substantially larger percentage of patients receiving the POC CD4 test at HCT completed their first referral visit within 8 weeks of testing.

– Increase in referral completion from 38.5% to 64.7% (a 68% improvement)

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Next Steps

• Record systems need to track patients from mobile HCT to care and treatment sites if:

– linkage to care to be evaluated further; and – interventions to be developed and evaluated.

• Evaluate costs per test and cost-effectiveness.

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Thanks

• Patients• Access VCT• Right to Care (Busi Makhanya)• Alere (Glynis Davis)• National and Provincial Departments of

Health• USAID/South Africa (Melinda Wilson, Clint

Cavanaugh) • PEPFAR