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

Objective: 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. Setting: Rural communities in four districts of Mbeya Region, Tanzania. Participants: 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. Main outcome: measures 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. Results: 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). Conclusions: 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.

研究目的
护理衔接（Linkage to care）是HIV检测与HIV治疗、照护及支持之间的桥梁。在坦桑尼亚，移动检测旨在解决长期以来较低的检测率问题。2009年，该国的护理衔接率据报道为14%，2014年升至28%。本研究对比了HIV确诊后前6个月内，通过移动/外展检测服务与公立医疗机构检测服务的HIV阳性个体的护理衔接情况。

研究场景
坦桑尼亚姆贝亚地区四个区县的农村社区。

研究对象
2014年8月至2015年7月期间，从16家检测机构招募的1012名新确诊HIV阳性成年人，将其纳入双臂队列研究并开展6个月随访。其中840名（83%）参与者完成了全部研究流程。

主要结局指标
本研究采用Kaplan-Meier估计法与Log-rank检验对比护理衔接的比例与时间差异，并使用Cox比例风险回归模型评估与护理衔接时间差异相关的影响因素。

研究结果
随访满6个月时，所有受访者的护理衔接率为78%，不同检测模式间存在显著差异。医疗机构检测点的受检者护理衔接率为84%（95%置信区间81%~87%，n=512），而移动/外展检测点的受检者护理衔接率为69%（95%置信区间65%~74%，n=281）。医疗机构检测点的受检者护理衔接中位时间为1天（四分位距（Interquartile Range, IQR）：1~7.5），移动/外展检测点则为6天（四分位距（Interquartile Range, IQR）：3~11）。在控制其他变量的情况下，医疗机构检测点的受检者护理衔接概率较移动/外展检测点高78%（调整后风险比（Adjusted Hazard Ratio, AHR）=1.78；95%置信区间1.52~2.07）。向家属/亲属披露HIV感染状态与护理衔接显著相关（调整后风险比（Adjusted Hazard Ratio, AHR）=2.64；95%置信区间2.05~3.39）。

研究结论
自2014年以来，坦桑尼亚农村地区HIV阳性个体检测后的护理衔接率在各类检测模式下均已显著提升。医疗机构检测点的受检者护理衔接比例显著更高，且衔接时间较移动/外展检测点略有提前。移动/外展检测模式可将HIV检测服务更贴近目标人群。当前仍需制定针对性策略以提升移动/外展检测模式下的护理衔接率。