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Linkage to HIV Care and Antiretroviral Therapy by HIV Testing Service Type in Central Mozambique: A Retrospective Cohort Study

Gerdts, Sarah E. MPH*; Wagenaar, Bradley H. MPH*,†; Micek, Mark A. MD, MPH†,‡; Farquhar, Carey MD, MPH*,‡; Kariaganis, Marina MD§; Amos, Juvenal MD, MPH§; Gimbel, Sarah RN, PhD, MPH‡,‖; Pfeiffer, James PhD, MPH†,‡; Gloyd, Stephen MD, MPH†,‡; Sherr, Kenneth PhD, MPH†,‡

JAIDS Journal of Acquired Immune Deficiency Syndromes: June 1st, 2014 - Volume 66 - Issue 2 - p e37–e44
doi: 10.1097/QAI.0000000000000081
Implementation and Operational Research: Epidemiology and Prevention
IOR articles

Background: Access to antiretroviral therapy (ART) has increased dramatically in resource-limited settings since its introduction a decade ago. However, ART coverage remains low in countries with the highest disease burden, which may be partially explained by poor testing to care linkages. HIV testing service may impact early attrition in the HIV treatment cascade.

Methods: A retrospective cohort study was conducted in 18 clinics in central Mozambique using routine patient data and monthly reports. Patients referred from voluntary counseling and testing (VCT) were compared with those referred from prevention of mother-to-child transmission (PMTCT) for 3 outcomes: (1) enrollment at an HIV clinic ≤30 days after testing HIV positive, (2) CD4 test ≤30 days after enrollment, and (3) ART initiation ≤90 days after first CD4 test.

Results: Patient retention in the HIV care system dropped at each step from HIV testing to ART initiation. Enrollment in HIV care was not significantly different between PMTCT and VCT [risk ratio (RR) = 0.84, 0.72 < RR < 1.02]. Women tested in PMTCT were less likely to have a CD4 test ≤30 days after enrollment when adjusting for age, education level, and marital status (adjusted RR = 0.84, 0.70 < RR < 1.00), and were less likely to initiate ART ≤90 days after their first CD4 test when adjusting for age, education, and marital status (adjusted RR = 0.56, 0.44 < RR < 0.71).

Conclusions: Poor linkages between HIV testing and care hamper efforts to improve coverage for HIV care and treatment services. Increased loss to follow-up among women diagnosed in PMTCT relative to VCT is worrisome and merits further qualitative research and programmatic attention.

*Department of Epidemiology, University of Washington, Seattle, WA;

Health Alliance International, Seattle, WA;

Department of Global Health, University of Washington, Seattle, WA;

§Ministry of Health, Mozambique; and

Department of Family Child Nursing, University of Washington, Seattle, WA (Micek is now with the Department of Medicine, University of Wisconsin–Madison, Madison, WI, USA).

Correspondence to: Kenneth Sherr, PhD, MPH, University of Washington, 107 45th Avenue NE, Seattle, WA 98105 (e-mail:

The authors have no funding or conflicts of interest to disclose.

Supported by the President's Emergency Plan for AIDS Relief, the African Health Initiative of the Doris Duke Charitable Foundation, and NIAID, NCI, NIMH, NIDA, NICHD, NHLBI, NIA, NIGMS, NIDDK of the National Institutes of Health under award number P30AI027757. K. S. was supported by Grant Number K02TW009207 from the Fogarty International Center. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.

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Received November 22, 2013

Accepted November 22, 2013

© 2014 by Lippincott Williams & Wilkins