Linkage to care
The study sample to assess linkage to care initially included 1945 patients. 2 patients were excluded from the sample because they died over follow-up and 43 were excluded because they were reported as transferring to another facility over follow-up and this information could not be corroborated (these patients were included in the dataset in sensitivity analyses to ensure that findings were consistent). The final sample included 1900 patients newly diagnosed with HIV (928 pre-intervention, 972 post-intervention).
There were not substantial differences in demographic characteristics of patients in the pre-intervention sample versus post-intervention sample, although data on certain patient characteristics were collected post-intervention only (Table
1). Overall, 60.2% of patients were female. 7.2% of patients were age < 10 years and 8.6% were 10–18 years. Among patients 10–18 years, sex demographics were more skewed: only 20.9% of those patients were male. While most patients (59.0%) were missing information on clinical stage at diagnosis, few patients with known stage were stage III-IV (6.0%). Among post-intervention patients, most (80.5%) were identified through facility-based non-prevention of mother-to-child transmission (PMTCT) testing; 7.1% came from PMTCT entry points and 10.1% came through patient outreach testing. 38.3% of patients were receiving their first HIV test, while 43.0% of patients were receiving their third HIV test or greater in the last year. 60.0% of the children < 10 years and 55.4% of adolescents 10–18 years were being tested for the first time. 3.4% of patients were known tuberculosis (TB) positive. There was a relatively high proportion of missing data on several demographic factors due to this information not being routinely documented at some facilities.
Table 1
Characteristics of 1900 patients testing HIV-positive pre- versus post-intervention at 20 facilities in Ugandaa
Total | 928 | | 972 | |
Sex |
Female | 558 | 60.1% | 586 | 60.3% |
Male | 370 | 39.9% | 386 | 39.7% |
Age group |
< 10 years | 72 | 7.8% | 65 | 6.7% |
10–18 years | 80 | 8.6% | 83 | 8.5% |
19–48 years | 683 | 73.6% | 729 | 75.0% |
49+ years | 71 | 7.7% | 59 | 6.1% |
Missing | 22 | 2.4% | 36 | 3.7% |
Clinical stage at diagnosis |
I | 290 | 31.3% | 296 | 30.5% |
II | 90 | 9.7% | 56 | 5.8% |
III | 19 | 2.1% | 17 | 1.8% |
IV | 6 | 0.7% | 5 | 0.5% |
Missing | 523 | 56.4% | 598 | 61.5% |
Entry point |
PMTCT | – | – | 69 | 7.1% |
Facility-based non-PMTCT | – | – | 782 | 80.5% |
Outreach | – | – | 98 | 10.1% |
Missing | – | – | 23 | 2.4% |
First HIV test |
Yes | – | – | 372 | 38.3% |
No | – | – | 567 | 58.3% |
Missing | – | – | 33 | 3.4% |
Third HIV test or greater in last year |
Yes | – | – | 418 | 43.0% |
No | – | – | 514 | 52.9% |
Missing | – | – | 40 | 4.1% |
TB status |
Positive | | | 33 | 3.4% |
Negative or unknown | | | 939 | 96.6% |
Marital status |
Married | – | – | 428 | 44.0% |
Never married | – | – | 269 | 27.7% |
Separated, divorced, or widowed | – | – | 104 | 10.7% |
Cohabitating | – | – | 32 | 3.3% |
Missing | – | – | 139 | 14.3% |
There were small increases in linkage to care after implementation of the intervention (Table
2; e.g. linkage to care within 1 month: 52.9% pre-intervention versus 54.9% post-intervention), but increases were not statistically significant regardless of the timeframe assessed (e.g. adjusted odds ratio, aOR for linkage within 1 month: 1.09, 95% confidence interval, CI: 0.78–1.53;
p = 0.63). Linkage to care did not change substantially over the intervention timeframe and there were not statistically significant increases in linkage in analyses stratified by sex or age group.
Table 2
Linkage to care among 1900 patients testing HIV-positive pre- versus post-interventiona
Total | 928 | | 972 | | | | | |
Same day linkage to care | 271 | 29.2% | 303 | 31.2% | 1.10 (0.81–1.50) | 0.59 | 1.09 (0.80–1.49) | 0.57 |
Linkage to care within one week | 432 | 46.6% | 472 | 48.6% | 1.08 (0.78–1.50) | 0.63 | 1.08 (0.79–1.49) | 0.62 |
Linkage to care within 1 month | 491 | 52.9% | 534 | 54.9% | 1.09 (0.77–1.54) | 0.65 | 1.09 (0.78–1.53) | 0.63 |
Linkage to care within 3 months | 516 | 55.6% | 562 | 57.8% | 1.09 (0.76–1.57) | 0.63 | 1.10 (0.77–1.57) | 0.60 |
However, change in linkage to care after implementation of the intervention varied greatly by facility and several facility-level characteristics predicted greater increases in linkage to care. Overall, there was a greater increase in linkage among smaller facilities/programs: level III facilities (13.4%) compared to level IV facilities (− 1.6%; effect estimate: 14.2, 95% CI: 0.5–27.9%; p = 0.04); facilities with fewer expert clients (< 5: 11.5%; 5+: − 4.4%; effect estimate: 14.3, 95% CI: 3.3–28.3%; p = 0.045); and facilities with fewer adult ART days per week (1 day: 16.7%; 2+ days: − 4.3%; effect estimate: 17.4, 95% CI: 3.9–30.9%; p = 0.01). There was also a greater increase in linkage among facilities reporting issues with phone funding at baseline (16.0%) compared to those who did not report this as an issue (− 0.1%; effect estimate: 15.8, 95% CI: 1.8–29.8%; p = 0.03).
Retention in care
Initially, 1442 patients who initiated on ART within the specified time frame were included in the study sample. However, 28 patients were excluded from the sample because they died over the 6 months of study follow-up and 58 were excluded because they were reported as transferring to another facility over follow-up and this information could not be corroborated (although these patients were included in the dataset in sensitivity analyses to ensure that findings were consistent). The final sample included 1356 patients newly initiated on ART (678 pre-intervention, 678 post-intervention).
Overall, 63.0% of patients newly initiated on ART were female; 4.2% were age less than 10 years and 4.1% were age 10–18 years (Table
3). Again, among patients 10–18 years, sex demographics were skewed: only 18.2% of those patients were male. Among patients from the post-intervention period, 39.4% initiated ART within 1 month of diagnosis and 6.3% initiated at least 1 year after diagnosis (note that Test and Treat policies were not implemented universally until 2017 in Uganda, when all patients became eligible for ART initiation regardless of CD4 T-cell count; however, some facilities with high-risk patients started Test and Treat prior to 2017). 5.1% of patients were stage III or IV at initiation and 6.3% of patients were missing clinical stage at initiation, while 15.6% of patients had a CD4 count < 350 cells/mcL at initiation and 66.4% had missing CD4 information. Finally, 19.0% of patients were pregnant at initiation. There was a relatively high proportion of missing data on several demographic factors due to this information not being routinely documented at some facilities.
Table 3
Characteristics of 1356 patients initiating antiretroviral therapy pre- versus post-interventiona
Total | 678 | | 678 | |
Sex |
Female | 408 | 60.2% | 446 | 65.8% |
Male | 270 | 39.8% | 232 | 34.2% |
Age group |
< 10 years | 30 | 4.4% | 27 | 4.0% |
10–18 years | 20 | 3.0% | 35 | 5.2% |
19–48 years | 542 | 79.9% | 558 | 82.3% |
49+ years | 64 | 9.4% | 54 | 8.0% |
Missing | 22 | 3.2% | 4 | 0.6% |
Time from diagnosis to ART initiation |
< 1 month | – | – | 267 | 39.4% |
1- < 3 months | – | – | 49 | 7.2% |
3- < 6 months | – | – | 28 | 4.1% |
6- < 12 months | – | – | 26 | 3.8% |
12+ months | – | – | 43 | 6.3% |
Missing | – | – | 265 | 39.1% |
Clinical stage at initiation |
I | – | – | 432 | 63.7% |
II | – | – | 168 | 24.8% |
III | – | – | 30 | 4.4% |
IV | – | – | 5 | 0.7% |
Missing | – | – | 43 | 6.3% |
CD4 count at initiation |
< 200 cells/mcL | – | – | 36 | 5.3% |
200- < 350 cells/mcL | – | – | 70 | 10.3% |
350- < 500 cells/mcL | – | – | 73 | 10.8% |
500+ cells/mcL | – | – | 49 | 7.2% |
Missing | – | – | 450 | 66.4% |
Pregnancy/lactation status at initiation |
Pregnant | – | – | 129 | 19.0% |
Lactating | – | – | 15 | 2.2% |
None | – | – | 534 | 78.8% |
Patient appointment attendance appeared to increase after implementation of the intervention in univariable models as well as models adjusted for patient age and sex (Table
4). The percentage of patients coming to their first appointment increased from 85.3 to 90.3% (aOR: 1.61, 95% CI: 1.05–2.47,
p = 0.03) and the percentage of patients coming to at least 4 appointments over 6 months of follow-up increased from 58.0 to 67.1% (aOR: 1.50, 95% CI: 1.11–2.04,
p = 0.01). Overall, the mean number of patient appointments increased after the intervention from 3.7 to 4.3 (effect estimate: 0.67, 95% CI: 0.29–1.04,
p = 0.002) and more patients (44.5% pre-intervention versus 55.2% post-intervention) adhered to their appointment schedule (aOR: 1.58, 1.13–2.22,
p = 0.01). In models using the full data set, the increase in MOH-defined retention (coming to at least one appointment 3–6 months after ART initiation) was not statistically significant (71.7% versus 75.7%, aOR: 1.25, 95% CI: 1.25, 95% CI: 0.94–1.67,
p = 0.12). However, in sensitivity analyses, we noted that patient retention increased each month over the 3-month study enrollment period after the intervention was implemented. If the first month of intervention implementation was considered a “ramp-up” period and those data were excluded, the increase in retention before versus after the intervention became statistically significant (71.7% versus 77.6%, aOR: 1.41, 95% CI: 1.08–1.84,
p = 0.01).
Table 4
Retention in care and adherence to appointment schedule among 1356 patients initiating antiretroviral therapy pre- versus post-interventiona
Total | 678 | | 678 | | | | | |
Came to first appointment | 578 | 85.3% | 612 | 90.3% | 1.60 (1.04–2.47) | 0.03 | 1.61 (1.05–2.47) | 0.03 |
Came to at least 4 appointments | 393 | 58.0% | 455 | 67.1% | 1.48 (1.10–1.99) | 0.01 | 1.50 (1.11–2.04) | 0.01 |
Mean number of appointments | 678 | 3.7 (2.2) | 678 | 4.3 (2.4) | 0.65 (0.28–1.02) | 0.002 | 0.67 (0.29–1.04) | 0.002 |
Adhered to appointment schedule (within 1 week)a | 236 | 44.5% | 295 | 55.2% | 1.54 (1.10–2.15) | 0.01 | 1.58 (1.13–2.22) | 0.01 |
Came to an appointment 3–6 months after initiation (MOH-defined retention) | 486 | 71.7% | 513 | 75.7% | 1.23 (0.92–1.64) | 0.17 | 1.25 (0.94–1.67) | 0.12 |
Came to an appointment 3–6 months after initiation (MOH-defined retention), excluding first month of post-intervention enrollments | 486 | 71.7% | 347 | 77.6% | 1.37 (1.06–1.78) | 0.02 | 1.41 (1.08–1.84) | 0.01 |
The increases in patient adherence to appointment schedule and retention in care were more pronounced in pediatric and adolescent patients ages less than 19 years (Table
5). For example, adherence to appointment schedule increased from 33.3 to 60.9% in patients under 19 years (aOR: 3.31, 95% CI: 1.41–7.79, p = 0.01) and retention increased from 64.0 to 83.9% (aOR: 2.92, 95% CI: 1.31–6.51, p = 0.01).
Table 5
Retention in care and adherence to appointment schedule pre- versus post-intervention stratified by age groupa
< 10 years | 30 | | 27 | | | |
Came to at least 4 appointments | 17 | 56.7% | 21 | 77.8% | 2.65 (0.74–9.53) | 0.14 |
Adhered to appointment schedule | 9 | 36.0% | 17 | 85.0% | 12.39 (3.64–42.19) | < 0.001 |
MOH-defined retention | 22 | 73.3% | 25 | 92.6% | 4.36 (0.94–20.20) | 0.06 |
10–18 years | 20 | | 35 | | | |
Came to at least 4 appointments | 11 | 55.0% | 23 | 65.7% | 1.41 (0.49–4.04) | 0.52 |
Adhered to appointment schedule | 4 | 28.6% | 11 | 42.3% | 2.01 (0.52–7.71) | 0.31 |
MOH-defined retention | 10 | 50.0% | 27 | 77.1% | 3.43 (1.19–9.83) | 0.02 |
19+ years | 606 | | 612 | | | |
Came to at least 4 appointments | 353 | 58.3% | 408 | 66.7% | 1.44 (1.05–1.97) | 0.02 |
Adhered to appointment schedule | 218 | 45.7% | 265 | 54.8% | 1.46 (1.03–2.06) | 0.03 |
MOH-defined retention | 440 | 72.6% | 458 | 74.8% | 1.14 (0.84–1.56) | 0.40 |
< 19 years | 50 | | 62 | | | |
Came to at least 4 appointments | 28 | 56.0% | 44 | 71.0% | 1.95 (0.83–4.59) | 0.13 |
Adhered to appointment schedule | 13 | 33.3% | 28 | 60.9% | 3.31 (1.41–7.79) | 0.01 |
MOH-defined retention | 32 | 64.0% | 52 | 83.9% | 2.92 (1.31–6.51) | 0.01 |
Greater increases in retention were observed in facilities that demonstrated a stronger leadership and participation score (mean increase of 9.3% in facilities scoring 4–8 versus mean decrease of 5.5% at facilities with a score of < 4; effect estimate: 16.1, 95% CI: 5.5–26.7%; p = 0.01).
The annual cost per additional patient retained in care was estimated to be $47, dropping to $32 if data from the one-month intervention ramp-up period were excluded.