Enhanced Linkage to HIV Care Following Home-Based HIV Testing in Rural Uganda

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 DESCRIPTION (provided by applicant): Throughout sub-Saharan Africa there is a pressing need to facilitate early and easier entry into HIV care and treatment; up to two-thirds of patients are lost to follow up between testing HIV positive and initiation of antiretroviral (ARV) treatment Timely linkage to care reduces mortality rates, improves treatment outcomes, and through its effect on viral load, decreases the likelihood of transmitting HIV to others. Home-based HIV testing and counseling (HBHCT), which identifies those who are HIV positive at earlier disease stages than other HIV testing approaches, is becoming a large component of many sub-Saharan African countries' HIV prevention programs, including Uganda's. HBHCT in the Ugandan setting may also be the most cost-effective HIV testing approach per person tested, per person testing for the first time, and per new HIV infection identified. The importance of HBHCT is particularly critical as access to HIV treatment increases and as "treatment as prevention" and "test and treat" approaches expand. Paper-based referral to care, sometimes adding follow-up home visits, is the most common linkage-to-care approach with HBHCT. Linkage to care may be especially challenging with HBHCT since the testing occurs in the home at a distance from a health facility, which may decrease the likelihood that individuals seek care. Our proposed intervention will provide the first evidence from a randomized trial testing a linkage intervention in the context of HBHCT in sub-Saharan Africa. We propose to test an intervention which enhances a linkage to care intervention tested in an urban Ugandan provider-initiated HIV testing setting and found to reduce time to HIV care among women and ARV initiation among men. The intervention facilitated linkage by: providing orientation to the HIV care system, counseling to help clients identify and reduce barriers to engagement in care, and assistance disclosing and identifying a treatment supporter. We will enhance the original intervention in order to increase its impact on multiple outcomes--beyond those studied the previous trial. Specifically, we propose to add an additional counseling session and increase the emphasis on seeking social support to overcome HIV-related stigma. We will compare our enhanced intervention to the standard-of-care for linkage and extend the findings of the previous intervention trial in a different public health-relevant HIV testing setting and context-HBHCT. More importantly, we will examine the impact of the intervention on HIV viral suppression as well as intermediate outcomes across the HIV care continuum. The aims of our project are: (1) In a cluster randomized trial compare the effectiveness of the enhanced linkage to care intervention vs. standard-of-care (paper based referrals) at achieving HIV viral suppression and intermediate outcomes of linkage to care, receipt of opportunistic infection prophylaxis, and ART initiation among those eligible for antiretroviral therapy (ART). (2) Using the standard-of-care group as a natural history control, collect longitudinal data on barriers to and facilitators of linkage to and retention in care and treatment and HIV viral suppression. (3) Estimate the cost and cost-effectiveness of the intervention, as compared to standard-of-care, in terms of major study outcomes.