AIDS and Behavior

https://doi.org/10.1007/s10461-022-03844-w

ORIGINAL PAPER

Linkage to HIV Care and Early Retention in Care Rates in the Universal
Test-and-Treat Era: A Population-based Prospective Study in KwaZulu-
Natal, South Africa
Edward Nicol1,2  · Wisdom Basera1,3 · Ferdinand C Mukumbang1,4 · Mireille Cheyip5 · Simangele Mthethwa5 ·
Carl Lombard6 · Ngcwalisa Jama1,4 · Desiree Pass1 · Ria Laubscher6 · Debbie Bradshaw1,3

Accepted: 27 August 2022

© The Author(s) 2022

Abstract
HIV linkage, and retention are key weaknesses in South Africa’s national antiretroviral therapy (ART) program, with the
greatest loss of patients in the HIV treatment pathway occurring before ART initiation. This study investigated linkage-to
and early-retention-in-care (LTRIC) rates among adults newly diagnosed with HIV in a high-HIV prevalent rural district.
We conducted an observational prospective cohort study to investigate LTRIC rates for adults with a new HIV diagnosis
in South Africa. Patient-level survey and clinical data were collected using a one-stage-cluster design from 18 healthcare
facilities and triangulated between HIV and laboratory databases and registered deaths from Department of Home Affairs.
We used Chi-square tests to assess associations between categorical variables, and results were stratified by HIV status,
sex, and age. Of the 5,637 participants recruited, 21.2% had confirmed HIV, of which 70.9% were women, and 46.5%
were aged 25–34 years. Although 82.7% of participants were linked-to-care within 3 months, only 46.1% remained-in-care
12 months after initiating ART and 5.2% were deceased. While a significantly higher proportion of men were linked-to-
care at 3 months compared to women, a significant proportion of women (49.5%) remained-in-care at 12 months than
men (38.0%). Post-secondary education and child support grants were significantly associated with retention. We found
high linkage-to-care rates, but less than 50% of participants remained-in-care at 12 months. Significant effort is required
to retain people living with HIV in care, especially during the first year after ART initiation. Our findings suggest that
interventions could target men to encourage HIV testing.

Keywords  HIV care continuum · Linkage to care · HIV prevention · Retention · HIV epidemiology · Universal Test
and Treat · South Africa

Introduction
Edward Nicol
[email protected]
In 2014, The Joint United Nations Program on HIV/AIDS
1
Burden of Disease Research Unit, South African Medical (UNAIDS) launched the ’90-90-90’ goal ensuring that by
Research Council, Tygerberg, 7505, Cape TownP.O. Box 2020, 90% of people living with HIV (PLHIV) are diag-
19070, South Africa nosed, 90% of those diagnosed are initiated on antiretro-
2
Division of Health Systems and Public Health, Stellenbosch viral therapy (ART), and 90% of those on ART are virally
University, Cape Town, South Africa suppressed [1]. The World Health Organization (WHO) rec-
3
School of Public Health and Family Medicine, University of ommended the ‘Universal Test-and-Treat’ (UTT) strategy
Cape Town, Cape Town, South Africa – initiating all individuals testing positive on ART irrespec-
4
School of Public Health, University of the Western Cape, tive of their CD4 count and clinical staging [2] – as a fast-
Bellville, South Africa track strategy to achieve this goal. UTT is defined as starting
5
Centers for Disease Control and Prevention, Pretoria, South ART within 14 days of an initial HIV-positive diagnosis. In
Africa May 2016, following the recommendations by WHO, the
6
Biostatistics, South African Medical Research Council, Cape
Town, South Africa

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 AIDS and Behavior

Figure 1  A new 4-stage HIV Care Cascade and parallel loss-to-care.

South African government announced the phased rollout of count had dropped to ≤ 500 cells/µL and/or who had clinical
the UTT strategy from September 2016 [3]. manifestations of AIDS at the time of diagnosis) for HIV
An estimated 7.9million South Africans were living with care [9]. It was also estimated that the retention in care rates
HIV in 2017 [4], with an incidence of 276,000 in the same of PLHIV in low- and middle-income countries before UTT
year [5]. It is also estimated that by 2017, 84.9% of South at 12 months was 78% [10]. While the linkage to and reten-
Africans knew their HIV status. Of these, 70% were on ART tion in care rates of PLHIV before the UTT era was well-
and of those on ART, 87.3% had achieved viral suppression documented, little is known on these rates in the era of UTT.
(latest viral load < 400 copies/cm3) [4]. It is predicted that This study aimed to investigate the linkage to and retention
through the UTT program, South Africa could end HIV as a in care proportions of an HIV-positive cohort in a high HIV
public health concern by 2030. Nevertheless, the evidence prevalent rural district in South Africa.
on the impact of UTT and how UTT has improved the effi-
ciency and quality of HIV care at the population-level is still
scarce [6]. Despite the drop in HIV incidence (–5.7%) and Methods
HIV-related deaths (–10.5%) from 2007 to 2017, there is a
dearth of evidence to inform the impact of UTT toward the Study Framework
90-90-90 goal by 2020 [5]. However, the general impres-
sion was that South Africa is making progress in the fight This study was guided by the new cascade of HIV care
against the HIV epidemic. in the UTT era (Fig.1) [11]. We found this cascade useful
The literature suggests that ending AIDS by 2030 because it provides both breadth (ranging from first to final
depends on how successful health systems are in linking event) and depth (number of cascade stages that was anal-
PLHIV testing HIV-positive into care, completion of a ysed) [12], which aligned with our study objectives.
first medical clinic visit after HIV diagnosis, and achiev- Even though this new cascade of UTT is depicted to be
ing early and lifelong retention in care [7]. Before the UTT linear in nature, in reality, patients cycle in and out of care,
era, only 45% of newly diagnosed HIV-positive individuals leaving at one stage and re-entering at another in what has
were linked to care in the KwaZulu-Natal Province of South been described as the “side door” in the cascade [11]. Our
Africa [8], with an estimated 79% considered late presen- study focused on the first three stages of the new HIV treat-
tation (i.e., HIV diagnosis was done when the CD4 + cell ment cascade.

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AIDS and Behavior

Figure 2  Map of the uThukela rural district for the Linkage to Care study in uThukela district between December 2017 – August 2019.

Study Design population (19%) with the largest number of service deliv-
ery challenges, primarily due to remote mountainous areas,
An observational cohort design was undertaken in a single poor road infrastructure, and the lowest ratio of fixed clinics.
high-prevalence rural district over 21 months from Decem-
ber 2017 to August 2019, in 18 primary health care facili- Sampling approach
ties in the uThukela district. Adults older than 18 years
of age seeking testing for HIV in different facilities were We undertook a sample size calculation based on the pri-
approached to enroll and requested to complete a self- mary outcome; the proportion linked to HIV care. Link-
administered questionnaire. age to care for enrolled HIV-positive adult participants
was defined as the completion of a first medical clinic visit
Setting within 3 months of HIV-positive diagnosis as evidenced by
a record in Tier.Net. Data on linkage to HIV care rates and
The district is comprised of three newly formed local the uptake of UTT in uThukela district was unknown at the
municipalities (LMs) – Fig.2. The Alfred Duma LM is the time of designing the study. However, findings of previous
most populated (51%) with the largest town (Ladysmith), surveillance data from KwaZulu-Natal in South Africa dem-
which is also the seat of power for both the Alfred Duma onstrate an average linkage to care of 62% post-HIV testing
local municipality (LM) and the uThukela district munic- in the first year [8].
ipality (DM). The Inkosi Langalibalele LM is the second We, therefore, proposed a linkage to care rate of 10%
most populated (30%), with a sparsely rural and densely higher than 62% based on the possible impact of UTT on
urban population. The Okhahlamba LM has the smallest HIV care uptake rates. Assuming a null proportion of 62%

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 AIDS and Behavior

Table 1  Power and sample size calculations using the coefficient of variation between clusters in the Linkage to Care study in uThukela district
between December 2017 – August 2019
Matched pairs
p1 p2 delta alpha Beta k1 k2 m1 m2 rho N
0.62 0.72 0.10 0.05 0.80 9 9 50 50 0.02 900
Where p - linkage to care proportions; delta – difference between proportions; alpha - z values used for calculating type 1 error; beta - z value
used for calculating power; rho – inter-cluster correlation; m – average cluster size and k - number of clusters. N - sample size for study period
allowing for cluster randomization

the reactive participants was then reviewed using data from

the NHLS database and the rapid mortality survey (RMS),
which uses the participants’ national identification number
and contains information on the deaths registered by the
South African Department of Home Affairs (Fig.3).
On the day of enrolment, trained fieldworkers had a wait-
ing room talk which informed people attending the clinic
about the research and invited them to volunteer to partici-
Figure 3 Schematic overview of the data collection process for the pate. Individuals who were willing to volunteer were given
Linkage to Care study in uThukela district (2017–2019). the study information and screened for enrollment in a pri-
vate room. Eligible participants were given full study infor-
(i.e., the reported linkage to care proportion from previ- mation, completed the informed consent process, and were
ous systematic reviews) and a proposed proportion of 72% then enrolled in the study. Participants consented to having
(based on the potential UTT influence), a minimum sample research staff obtain their HIV test outcomes from the clinic
size of 18 clusters with a cluster size of 50 participants was records, access records in health care databases, and track
required to test the difference between the linkage to care outcomes including vital status.
proportions with 80% power (Table1). We assumed cluster To be eligible for enrolment in the study, participants
randomization with an interclass correlation (ICC) (of the must have been aged 18 years and older, intended to take
clusters in consideration) of 0.02 and significance level of an HIV test in one of the participating primary care facili-
0.05 [13]. The sample and power calculations were done ties from December 2017 to June 2018 and have had access
using Stata 16.0 [14]. to a cell phone and willingness to provide contact details.
We selected 18 facilities from the district based on the Participants who were under age 18 years at the time of
HIV testing uptake rates; these were facilities likely to yield enrolment, without access to a cell phone or unwilling to
the required minimum number of tests to increase the prob- provide contact details, and those testing at non-medical
ability of enrolling 10 people per day. We assumed a conser- sites – prison health facilities or through antenatal care,
vative number of 10 people to be enrolled from the targeted were excluded from the study.
18 facilities per month equaling to 60 participants over the
six-month data collection period yielding a possible 1,080 Data collection tool and process
participants, which would cover the required sample size
of 900 participants (Table1). The study adopted a conve- Data were collected using isiZulu and English REDCap-
nience sampling of reactive participants until this target was based questionnaires, and medical record reviews. While
reached from the participating facilities (Fig.3). There was prospective participants were waiting in the HIV testing
a pilot study conducted in November 2017 over two weeks queue, fieldworkers invited them to enroll in the study.
to test the data collection instruments and review the study Each questionnaire took between 45 and 60min to com-
processes. Over the next few months (December 2017 to plete, depending on whether it was self-administered or
June 2018) the baseline cohort of HIV reactive participants completed with assistance. Demographic data and potential
was enrolled using the study inclusion criteria. barriers and enablers of linkage to care information were
Participants with a positive result for antibodies against collected at recruitment and during the 4-month follow-up
HIV were regarded as reactive participants. The linking of visit. The data collected using the questionnaire included
the enrolled participants was assessed four months after the demographic information, socio-economic characteristics,
date of enrolment via a follow-up interview. Beyond the reasons for testing, and intimate partner violence. At the
four-month mark until 12 months, the linkage outcomes end of the day, each participant’s HIV results were retrieved
i.e., continued visitation by the reactive participants to the from clinic records in order to categorize them for the study.
health care system was assessed. At 12 months, retention of

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AIDS and Behavior

Tier.Net, an electronic database for Infectious Disease categorical variables was corrected using the second order
Epidemiology and Research [15] and the National Health correction of Rao and Scott and converted into an F statistic
Laboratory System’s (NHLS) TrakCare database, also [21]. Confidence intervals and p-values of less than or equal
referred to as the NHLS’ central data warehouse (CDW) to 0.05 were reported to consider statistical significance for
were used to track participants who tested positive as they the various characteristics of the sample.
interacted with the health care system for CD4, viral load
measurements, and ART use. The NHLS’ central data ware-
house (CDW) probabilistic linkage algorithm was used to Results
link the results for individuals using names, dates of birth,
sex, initial laboratory identification, testing facility name A total of 5,637 participants were recruited from Decem-
etc. ber 2017 to June 2018 after screening 6,126 participants at
The vital status of participants was checked at the end enrolment for inclusion eligibility. A small proportion of
of the 12 months follow-up to explain their possible non- participants were excluded from the study sample because
participation – linkage to care and retention in care. This of failed eligibility checks (0.9% – 53/6,126) and data qual-
was done using the RMS. As for retention in care, the pres- ity issues (7.1% – 436/6,126) (Fig.4). Participants were
ence and timing of the most recent viral load measurements grouped into two cohorts for analysis: newly diagnosed
for each patient obtained from TIER.Net/NHLS was con- HIV-positive and those who tested negative (Fig.5).
sidered [16].
Once extracted from the NHLS’ CDW, TIER.Net and the HIV testing and status awareness
RMS, the records were de-identified and merged with the
REDCap-based participant questionnaires using the unique Those who underwent HIV testing as a proportion of the
enrolment ID number in Stata 16.0 [14] for analysis. Link- screened study sample was 95.3% (5,372/5,637). A small
age to HIV care was defined as successful completion of a proportion, 0.6% (31/5,372) of those who tested on the day
first medical clinic visit within 3 months of HIV-positive of recruitment had their records misplaced or lost at the
diagnosis as evidenced by a record in Tier.Net [17, 18]. facility and 4.7% (265/5,637) of the participants included
Retention in care was defined as remaining in contact with those who intended to test but did not test on the day of
HIV care services once linked to the services viz. ART ini- recruitment. Overall, the proportion of those who did not
tiation and the frequency of clinic visits or recorded CD4 receive their results was 5.3% (296/5,637) inclusive of
count and viral load tests conducted within one year and those who did not test and those who had their results lost.
captured in Tier.Net and the NHLS database [19]. Of the proportion that knew their status, 94.7%
(5,341/5,637) had the following outcomes for their HIV sta-
Data analysis tus; 73.6% (4,147/5,637) tested HIV negative while 21.2%
(1,194/5,637) tested HIV-positive (Fig.5).
Questionnaire data were collected electronically via RED- The majority of participants who tested were women –
Cap [20], while mortality data and patient blood test results 69.6% (3,921/5,637) and had either a high school or a ter-
were extracted from the RMS and NHLS CDW respectively tiary education 92.0% [(2,866 + 2,257)/5,566]. Overall, the
using Microsoft Excel. Statistical analyses were completed association between socio-demographic characteristics and
using the svyset command in STATA 16.0 (14) to incorpo- knowledge of HIV status after recruitment into the study
rate the one stage cluster study design of the sample. The was not statistically significant for most variables (Table2).
primary sampling unit was the name of the facility which A higher proportion of males knew their HIV status
represented the cluster were the survey participants came compared to females (96.0%: 1,648/1,716 vs. 94.2%:
from stratified by the facility type. There was no finite popu- 3,693/3,921, respectively) which was statistically signifi-
lation correction since the number of possible participants cant (F = 4.8 and p = 0.05). Those who learned of their status
was not known beforehand. Once set, proportions were during their visit to the facility were significantly older than
reported with their respective 95% confidence intervals those who did not get to know their status (28 years; IQR:
(CIs) since most of the variables were categorical. Continu- 23–35 vs. 26 years; IQR: 22–33 respectively – z=-2.6 and
ous data were reported as medians, interquartile range (IQR) p = 0.01).
since the data was skewed. Linkage to and retention in care
were expressed as proportions of the HIV-positive cohort. Linked to care
The Mann-Whitney test was used to investigate differences
between numerical variables, while the Pearson’s chi- Of the 1,194 participants diagnosed HIV-positive at base-
squared test which was used to assess associations between line, 728 (61.0%) and 987 (82.7%) were linked to care

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 AIDS and Behavior

Figure 4  Consort diagram detail-

ing the recruitment of the study
participants into the Linkage to
Care study in uThukela district
between December 2017 – June
2018.

level of education recorded, 665 (56.5%) had high school

education while 434 (36.9%) had a tertiary education. Over-
all, almost all the socio-demographic characteristics were
similar with respect to whether participants were linked to
care or not, excluding sex (Table3). A higher proportion of
males were linked to care at 3 months post HIV-positive
diagnosis when compared to females (85.1%: 292/343 vs.
81.7%: 695/851; F = 5.9 and p = 0.03).

Figure 5  Distribution of HIV testing outcomes and awareness in the Retention in careOf the 1,194 individuals who tested
Linkage to Care study cohort in uThukela district between December HIV-positive, 551 (46.1%) were still accessing care in
2017 - August 2019.
a health care facility at 12 months. There were some
observed differences in the baseline socio-demographic
within 14 days and 3 months respectively, while 207 characteristics between participants who remained in
(17.3%) were identified as not linked to care at the time. Of care at 12 months and those who dropped out of care
those that were linked to care within 3 months after know- (Table4). The proportion of females that remained in
ing their HIV status and initiating ART, 64.1% (633/987) care at 12 months was significantly higher than males
returned to the facility at the time they were told to do so [49.5%, 419/847 vs. 38.0%, 132/347; p = 0.01). The
by the counselor. Reasons given for delaying the return tertiary education group had the highest proportion of
or not returning to the clinic for HIV care during the four- those retained in care at 12 months (51.3%, 215/419)
month follow-up period included a lack of money for trans- and the least proportion was recorded in the no educa-
portation (26.5%, 236/889), not being able to take time off tion group (23.8%, 5/21). Those seeking care in urban
work (28.9%, 254/879), or inconvenient appointment date areas were more likely to remain in care than those
(19.6%, 174/888). Also reported were issues with accessing in the rural areas, however, place of residence was
the facilities as they were too far (29.1%, 259/889). not a determining factor for retention in care (F = 2.0
Of the 1,194 HIV-positive participants, 851 (71.3%) were and p = 0.18). In addition, participants who use public
females, 793 (66.4%) came from clinics and 105 (8.8%) transport to access health facilities were more likely
were from hospitals. Of the 1,177 participants with their to be in care than those who access health facilities by

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AIDS and Behavior

Table 2  Demographic characteristics of participants disaggregated by knowledge of HIV status on the day of recruitment into the Linkage to Care
study in uThukela district between December 2017 - June 2018
Variable Total (N = 5,637) Knows HIV status Doesn’t know HIV
(KHS) (N = 5,341) status (DKHS)
(N = 296)
n % 95% CI n % 95% CI n % 95% CI F p-value
value
Nationality 5,572 98.8 97.8–99.4 5,279 98.8 97.8–99.4 293 99.0 97.2– 0.3 0.78
South African citizen 51 0.9 0.4–2.2 49 0.9 0.4–2.2 2 0.7 99.6
Other SADC 8 0.1 0.07–0.3 7 0.1 0.1–0.3 1 0.3 0.1–3.7
Other African 4 0.1 0.02–0.2 4 0.1 0.02–0.23 0 0 0.1–1.5
Other outside Africa 2 0 0.01–0.1 2 0 0.01–0.15 0 0 -
None -
Facility type 3,772 66.9 58.1–74.7 3,558 66.6 57.8–74.4 214 72.3 38.6– 1.9 0.17
Clinics 870 15.4 9.4–24.4 860 16.1 9.9–25.2 10 3.4 91.6
Gateway 300 5.3 2.6–10.6 296 5.5 2.6–11.3 4 1.4 0.6–16.7
Hospital 695 12.3 9.8–15.4 627 11.7 9.6–14.3 68 23.0 0.1–11.9
Mobile clinic 6.1–57.6
Sex 1,716 30.4 27.4–33.7 1,648 30.9 27.9–33.9 68 23.0 16.4– 4.8 0.05
Male 3,921 69.6 66.3–72.6 3,693 69.1 66.1–72.1 228 77.0 31.3
Female 68.7–
83.7
Ethnicity 5,619 99.7 99.2–99.9 5,325 99.7 99.2–99.9 294 99.3 95.0-99.9 0.9 0.44
Black African 12 0.2 0.07–0.6 10 0.2 0.1–0.6 2 0.7 0.1–5.1
Colored/Mixed ancestry 1 0.02 0.002-0.2 1 0.02 0.002-0.2 0 0 -
White 5 0.1 0.04–0.2 5 0.1 0.04–0.2 0 0 -
Indian/Asian
Education level 107/5,566 1.9 1.4–2.7 102 1.9 1.4–2.7 5 1.7 0.6–5.1 0.2 0.84
No education 336/5,566 6.0 5.0-7.3 315 6.0 5.0-7.2 21 7.3 3.7–13.8
Primary education 2,866/5,566 51.5 47.8–55.2 2,717 51.5 47.6–55.3 149 51.7 44.6–
High school education 2,257/5,566 40.5 36.5–44.7 2,144 40.6 36.4–45.0 113 39.2 58.8
Tertiary education 31.5–
47.6
Age, median (IQR) 5,627 28 23–35 5,333 28 23–35 294 26 22–33 -2.6* 0.01
Age categories 1,943/5,627 34.5 29.8–39.6 1,824 34.2 29.4–39.4 119 40.5 33.2– 1.2 0.32
18–24 years 1,310/5,627 23.3 21.7–25.0 1,243 23.3 21.7–25.0 67 22.8 48.2
25–29 years 916/5,627 16.3 14.2–18.6 875 16.4 14.3–18.8 41 13.9 18.8–
30–34 years 1,029/5,627 18.3 15.7–21.2 984 18.5 15.9–21.3 45 15.3 27.4
35–49 years 429/5,627 7.6 6.0-9.6 407 7.6 6.0-9.7 22 7.5 9.9–19.4
50 + years 10.1–
22.6
4.5–12.1
Marital status 475/5,517 8.6 6.7–11.0 447 8.5 6.6–11.0 28 9.8 5.5–16.9 1.5 0.24
Married (living together) 178/5,517 3.2 2.2–4.7 161 3.1 2.1–4.5 17 6.0 3.8–9.3
Married (living separately) 724/5,517 13.1 9.8–17.3 690 13.2 9.8–17.6 34 11.9 8.9–15.8
Cohabiting 3,479/5,517 63.1 56.9–68.8 3,305 63.2 56.8–69.1 174 61.1 54.9–
Dating 661/5,517 12.0 8.7–16.2 629 12.0 8.7–16.4 32 11.2 66.9
Single 6.3–19.1
Access to US$14 in emergencies 3,412/5,525 61.8 53.2–67.8 3,238 61.8 55.2–67.9 174 61.3 52.8– 0.02 0.89
Very/somewhat difficult 2,113/5,525 38.2 32.2–44.7 2,003 38.2 32.1–44.8 110 38.7 69.1
Fairly/very easy 30.9–
47.2
Received child support grant 2,537/5,511 46.0 42.0-50.1 2,396 45.8 42.0-49.7 141 50.0 34.6–65.4 0.3 0.56
p-value of ≤ 0.05 was considered statistically significant
p-values derived using Mann Whitney U-test for continuous data
p-values derived using Pearson’s Chi-squared test considered the one stage cluster design
proportions (%) for the columns reported as n/N (except if data is missing - denominator added in the n column) and the associated 95% CI
IQR – Interquartile range; CI – Confidence Interval; US$ – United States of American Dollar; DKHS – Don’t know HIV status; KHS – Knows
HIV status
* z value reported

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 AIDS and Behavior

Table 3  Socio-Demographic characteristics of the HIV-positive participants at baseline and linkage in care at 3 months of follow-up in uThukela
district between December 2017 - August 2019 (N = 1,194)
Variable Total Linked in care (LiC) Not linked in care
(N = 1,194) (N = 987) (nLiC) N = 207)
n % 95% CI n % 95% CI n % 95% CI F-value p-value
Nationality 1,180 98.8 97.1– 976 98.9 97.3– 204 98.6 94.2–99.7 0.6 0.57
South African citizen 11 0.9 99.5 9 0.9 99.5 2 1.0 0.1–6.5
Other SADC 2 0.2 0.3–2.6 1 0.1 0.4–2.3 1 0.5 0.1-4.0
Other African 1 0.1 0.04–0.7 1 0.1 0.01–0.9 0 0 -
None 0.01–0.7 0.01–0.9
Facility type 793 66.4 54.3– 637 64.5 51.8– 156 75.4 59.5–86.5 3.1 0.07
Clinics 229 19.2 76.7 190 19.3 75.5 39 18.8 9.5–33.8
Gateway 105 8.8 13.4– 100 10.1 13.1– 5 2.4 0.3–18.0
Hospital 67 5.6 26.7 60 6.1 27.3 7 3.4 2.0-5.6
Mobile clinic 2.4–27.1 3.0-29.5
3.2–9.7 3.3–11.0
Sex 343 28.7 25.9– 292 29.6 26.9– 51 24.6 20.1–29.8 5.9 0.03
Male 851 71.3 31.7 695 70.4 32.4 156 75.4 70.2–79.9
Female 68.3– 67.6–
74.1 73.1
Ethnicity 1,191 99.7 99.2– 984 99.7 99.0-99.9 207 100 - 0.3 0.70
Black African 2 0.2 99.9 2 0.2 0.1–0.8 0 0 -
Colored/Mixed ancestry 1 0.1 0.04–0.7 1 0.1 0.01–0.9 0 0 -
Indian/Asian 0.01–0.7
Education level 21/1,177 1.8 1.0-3.3 18 1.8 1.1–3.2 3 1.5 0.3–7.4 0.6 0.59
No education 57/1,177 4.8 4.0-5.8 50 5.1 4.2–6.3 7 3.4 1.7–6.6
Primary education 665/1,177 56.5 50.1– 552 56.7 49.7– 113 55.4 49.1–61.6
High school education 434/1,177 36.9 62.7 353 36.3 63.5 81 39.7 32.0–48.0
Tertiary education 30.1– 29.2–
44.2 44.0
Age, median (IQR) 1,193 30 25–37 986 30 25.0– 207 31 25–38 0.3* 0.75
37.0
Age categories 269/1,193 22.5 19.3– 220 22.3 18.7– 49 23.7 19.6–28.3 0.4 0.76
18–24 years 293/1,193 24.6 26.2 243 24.6 26.4 50 24.2 19.1–30.1
25–29 years 251/1,193 21.0 21.7– 210 21.3 21.5– 41 19.8 17.0–23.0
30–34 years 317/1,193 26.6 27.7 259 26.3 28.1 58 28.0 21.2–36.0
35–49 years 63/1,193 5.3 18.7– 54 5.5 18.6– 9 4.3 2.4–7.6
50 + years 23.6 24.3
23.0-30.5 22.7–
4.2–6.7 30.2
4.2–7.1
Marital status 68/1,168 5.8 3.7–9.1 55 5.7 3.5-9.0 13 6.5 3.3–12.3 0.5 0.67
Married (living together) 29/1,168 2.5 1.4–4.3 25 2.6 1.6–4.2 4 2.0 0.5–7.7
Married (living separately) 178/1,168 15.2 11.1– 150 15.5 11.0-21.4 28 14.0 8.1–23.2
Cohabiting 725/1,168 62.1 20.6 593 61.3 55.7– 132 66.0 55.5–75.1
Dating 168/1,168 14.4 56.4– 145 15.0 66.5 23 11.5 5.1–24.0
Single 67.4 10.2–
9.4–21.4 21.6
Access to US$14 in emergencies 714/1,171 61.0 52.2– 595 61.2 51.9– 119 60.1 51.3–68.3 0.1 0.74
Very/somewhat difficult 457/1,171 39.0 69.1 378 38.8 69.7 79 39.9 31.7–48.7
Fairly/very easy 30.9– 30.3–
47.9 48.2
Received child support grant 527/1,169 45.1 42.1–48.1 438 45.2 41.6–48.9 89 44.5 36.0-53.3 0.02 0.89
p-value of ≤ 0.05 was considered statistically significant
p-values derived using Mann Whitney U-test for continuous data
p-values derived using Chi-squared test considered the one stage cluster design
proportions (%) for the columns reported as n/N (except if data is missing - denominator added in the n column) and the associated 95% CI
IQR – Interquartile range; CI – Confidence Interval; US$ – United States of American Dollar; LiC – Linked in Care; nLiC – Not linked in care
* z value reported

foot (F = 1.0 and p = 0.38). Participants who had access to a child support grant (50.7%, 269/531) were more

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AIDS and Behavior

likely to be retained in care at 12 months post HIV setting meeting for HIV service delivery research and guid-
diagnosis (F = 5.8 and p = 0.03). Also, those who found ance consultation held at the end of 2018 organised by the
it very difficult to access R200 ($14) in emergency World Health Organization (WHO) suggested that rapid
cases 49.5% (348/703) were less likely to be retained ART initiation should consider ART initiation within 7 days
in care at 12 months post HIV diagnosis; however, the with the offer of same-day ART. It is argued that reductions
association was not statistically significant (F = 1.0 in the time frame for measuring linkage to care, to 7 days
and p = 0.34). and 28 days from date of diagnosis, would provide a better
reflection of the impact of UTT on the rate of ART uptake.
The high linkage to care rate (83%) observed in the study
Over a third (75.9% − 418/551) of those retained in care may have been related to the fact that we reported on link-
at 12 months were virally suppressed based on the records age to care at 3 months from date of diagnosis, as the UTT
from the NHLS database. The mortality in this HIV-pos- initiation protocols had not yet been fully adopted in all the
itive cohort at 12 months was 5.2% (62/1,194). A higher provinces and facilities in South Africa. However, our study
proportion of those who died were female (54.8%, 34/62); shows that 61% of the HIV-positive participants linked to
however, we could not ascertain the cause of death from the care within 14 days of being diagnosed HIV-positive. Even
RMS. when same day ART initiation is available for all people
who test positive for HIV, psychosocial and health systems
factors have contributed to delays for many patients in ini-
Discussion tiating ART [25, 26]. Without appropriate linkage to care
interventions, UTT is unlikely to be successful [27], espe-
In this study, we sought to investigate the proportion of cially because through UTT more people become eligible
PLHIV linked to care within 3 months after testing HIV- for ART [11].
positive and those retained in care 12 months after initiat- An eight-year longitudinal study conducted before the
ing ART in a rural district in KwaZulu-Natal (KZN), South UTT era in KZN, South Africa identified linkage to care
Africa. Our study recorded a linkage to care rate of 83% in (defined as “the proportion of patients who engage with for-
the first three months after testing HIV-positive, which is mal health-care sector for HIV-related health care”) as the
higher than findings from other studies. Johnson et al. [22] biggest weakness of treatment programs, with less than half
reported a national linkage rate of 57% and 62% for KZN. (45%) of the 82% PLHIV who knew their HIV status suc-
However, the Human Sciences Research Council (HSRC) cessfully linked to care [8]. Within the UTT era, our study
study reported a linkage rate of 76% for the uThukela DM indicated improved linkage to care rates (83%) with very
[4]. There is scarcity of reports on the progress made on both poor rates of overall early retention in care at 12 months.
linkages to care and ART initiation since the implementa- This finding implies that efforts towards improving reten-
tion of UTT and same-day initiation. Variations in the defi- tion and viral load suppression among PLHIV should be
nitions and time points for measurements from HIV-positive strengthened through the adoption of differentiated service
diagnosis to ART initiation also make it difficult to com- delivery models such as the Fast-Track Treatment Initiation
pare results obtained from different studies. A study con- Counselling [28]. Although our study did not indicate any
ducted in South Africa to assess the impact of a health app gains in early retention in care in the era of UTT, gains of
for Android smartphones providing HIV-related laboratory UTT on early linkage to care is confirmed in another study
results, information, support, and appointment reminders to conducted in Malawi [29]. Alhaj and colleagues [29] found
engage and link patients to care indicated that before the that PLHIV initiated under the UTT era showed increased
intervention, only 47% (162/345) of the study participants early retention in care behaviors compared to those initiated
were linked to care between two weeks and eight months before UTT (83.0% compared to 76.2%, respectively).
[23]. This was before UTT was adopted in South Africa in In our study, a higher proportion of men were linked
September of 2016, which could explain the lower linkage to care compared to women within three months. Another
to care rates compared to our study findings obtained from study conducted in the provinces of Gauteng and Limpopo
data collected between 2017 and 2019. of South Africa also showed comparative linkage to care
Although three months from date of diagnosis was the rates for men and women up to 90 days but became lower
time frame used to define linkage to care before UTT, Rosen, in men during the 90–365 days after testing [30]. While
and colleagues [24] argue that in the context of UTT where we found that a greater proportion of men were becoming
treatment uptake is meant to be accelerated, 28 days from aware of their HIV status and were linked to care compared
date of diagnosis has demonstrated to be a more appropri- to women, women demonstrated better treatment-seeking
ate time frame to measure linkage to care. A recent priority behaviors. Several studies across the sub-Saharan continent

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 AIDS and Behavior

Table 4  Socio-Demographic characteristics of HIV-positive participants at baseline and retention in care after 12 months of follow-up in uThukela
district between December 2017 - August 2019 (N = 1,194)
Variable Total Retained in care Not retained in care
(N = 1,194) (RiC) (nRiC)
(N = 551) (N = 643)
n % 95% CI n % 95% CI n % 95% CI F p-value
value
Nationality 1,181 98.9 97.8–99.5 550 99.8 98.5–100 631 98.1 96.1–99.1 1.9 0.16
South African citizen 9 0.8 0.3–1.8 0 0 - 9 1.4 0.5–3.8
Other SADC 2 0.2 0.04–0.7 0 0 - 2 0.3 0.1–1.3
Other African 2 0.2 0.04–0.7 1 0.2 0.02–1.5 1 0.2 0.02–1.3
None
Facility type 798 66.8 53.8–77.7 358 65.0 42.1–82.6 440 68.4 53.4–80.4 0.2 0.78
Clinic 220 18.4 12.0-27.3 101 18.3 6.4–42.4 119 18.5 10.3–31.0
Gateway 101 8.5 2.1–28.2 57 10.3 2.1–38.3 44 6.8 2.1–20.0
Hospital 75 6.3 3.1–12.4 35 6.4 2.6–14.6 40 6.2 3.1–12.0
Mobile clinic
Sex 847 70.9 67.7–74.0 419 76.0 71.0-80.4 428 66.6 62.5–70.4 8.5 0.01
Female 347 29.1 26.3–32.0 132 24.0 19.6–29.0 215 33.4 29.6–37.5
Male
Ethnicity 1,191 99.7 99.2–99.9 551 100 - 640 99.5 98.6–99.9 1.4 0.28
Black African 2 0.2 0.04–0.6 0 0 - 2 0.3 0.1–1.1
Colored/Mixed ancestry 1 0.1 0.01–0.7 0 0 - 1 0.2 0.02–1.5
Indian/Asian
Education level 21/1,178 1.8 0.8–3.9 5 0.9 0.4-2.0 16 2.5 1.1–5.9 2.9 0.05
No education 60/1,178 5.1 3.9–6.7 25 4.6 2.7–7.6 35 5.6 4.3–7.2
Primary education 678/1,178 57.6 52.1–62.8 303 55.3 48.0-62.4 375 59.5 54.5–64.4
High school education 419/1,178 35.6 29.3–42.4 215 39.2 30.9–48.2 204 32.4 27.3–37.9
Tertiary education
Age, median (IQR) 1,193 30 25–37 551 30 26–37 642 30 25.0–37.0 -1.5* 0.14
Age categories 258/1,193 21.6 18.4–25.3 112 20.3 15.3–26.6 146 22.7 20.1–25.6 0.7 0.56
18–24 years 305/1,193 25.6 22.3–29.1 136 24.7 21.0-28.8 169 26.3 21.4–31.9
25–29 years 250/1,193 21.0 18.4–23.8 121 22.0 17.9–26.7 129 20.1 17.1–23.5
30–34 years 318/1,193 26.7 23.3–30.3 156 28.3 24.1–32.9 162 25.2 21.0–30.0
35–49 years 62/1,193 5.2 3.9-7.0 26 4.7 3.3–6.7 36 5.6 3.7–8.4
50 + years
Marital status 73/1,169 6.2 3.4–11.3 27 5.0 3.4–7.1 46 7.4 3.0-16.9 0.9 0.46
Married (living together) 32/1,169 2.7 1.7–4.3 11 2.0 1.0–4.0 21 3.4 2.1–5.4
Married (living separately) 169/1,169 14.5 10.5–19.7 83 15.2 10.5–21.5 86 13.8 9.3–20.0
Cohabiting 727/1,169 62.2 56.8–67.3 336 61.7 55.0-67.9 391 62.7 55.7–69.2
Dating 168/1,169 14.4 9.6–21.1 88 16.1 9.5–26.1 80 12.8 8.6–18.7
Single
Access to US$14 in emergencies 703/1,173 59.9 49.6–69.4 348 63.7 55.9–70.9 355 56.6 41.1–71.0 1.0 0.34
Very/somewhat difficult 470/1,173 40.1 30.6–50.4 198 36.3 29.1–44.1 272 43.4 29.0–59.0
Fairly/very easy
Received child support grant 531/1,169 45.4 42.4–48.5 269 50.7 44.9–53.3 262 42.2 37.9–46.6 5.8 0.03
Area of residence 441 36.9 16.1–64.1 144 26.1 8.3–58.0 297 46.2 20.2–74.5 2.0 0.18
Rural 753 63.1 35.9–83.9 407 73.9 42.0-91.7 346 53.8 25.5–79.9
Urban

have confirmed that women have better retention in care (DMD) have shown success in reducing masculinity-related
behaviors [22, 31]. For instance, a multi-center study con- barriers to engaging in HIV services [34]. A recent study
ducted in South Africa showed that men were more likely to conducted in South Africa revealed that these differentiated
be lost to follow up compared to women [32]. The reason service delivery models have the potential to increase the
for the gender differences has been attributed to masculin- retention to care and adherence to medication among men
ity – a set of local beliefs and practices that capture what in particular [35]. These models achieve this by helping
it means to be a man in a particular context [33]. In South men refashion ART-friendly masculinities – a set of attri-
Africa, gender-transformative interventions such as “One butes, behaviors, and roles associated with boys and men
Man Can”, a rights-based gender equality and health pro- that favor the uptake and use of ART [36]. Other interven-
gram intervention, and Decentralized Medication Delivery tions/ models designed to help South African men initiate

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AIDS and Behavior

Table 4 (continued)

Variable Total Retained in care Not retained in care

(N = 1,194) (RiC) (nRiC)
(N = 551) (N = 643)
n % 95% CI n % 95% CI n % 95% CI F p-value
value
Mode of transport 492/1,179 (51.3%) 26.2–59.1 206 37.6 19.4–60.1
` 286 30.7–60.8 1.0 0.38
Foot 611/1,179 51.8 35.7–67.6 309 56.4 35.6–75.2
45.3 302 32.7–63.4
Public transport 70/1,179 5.9 3.8–9.1 30 5.5 3.1–9.4
47.9 40 3.7–10.6
Private transport 6/1,179 0.5 0.2–1.2 3 0.5 0.2–1.6
6.3 3 0.1–1.8
Other 0.5
Time to get to facility 705/1,172 60.2 47.5–71.6 366 66.9 58.6–74.3 339 54.2 37.0-70.5 2.0 0.18
< 30min 405/1,172 34.6 23.5–47.6 159 29.1 22.1–37.3 246 39.4 22.9–58.6
30–60min 62/1,172 5.3 3.7–7.6 22 4.0 2.5–6.4 40 6.4 3.8–10.5
> 60min
p-value of ≤ 0.05 was considered statistically significant
p-values derived using Mann Whitney U-test for continuous data
p-values derived using Chi-squared test and considered the one stage cluster design
proportions (%) for the columns reported as n/N (except if data is missing - denominator added in the n column) and the associated 95% CI
IQR – Interquartile range; CI – Confidence Interval; US$ – United States of American Dollar; RiC – Retained in Care; nRiC – Not retained in
care
* z value reported

ART and remain in care include the MINA and Coach Mpilo corroborate the study by Govindasamy et al. [40], which
campaigns, which provide men with information and sup- showed an association between being employed and being
port that help them to get tested for HIV, to initiate and less likely to be linked to care, perhaps due to the difficulties
remain in care [37]. of accessing health care services after working hours.
Considering the geographic distance for participants Our study found a statistically significant difference
located in the rural areas accessing HIV testing services in between participants who remained in care at 12 months and
facilities, and the cost of public transport for the majority those who dropped out of care for several variables. Access
who used facilities in urban areas, it was not surprising to to cash was significantly associated with retention in care.
find issues of lack of transport to health facilities emerging as Our findings show that participants who had no access to a
a barrier to retention in care in this context. Our study found child support grant and those who found it very difficult to
that participants who used public transport to access health access R200 ($12) in emergency cases were less likely to
facilities were more likely to be in care after 12 months be retained in care at 12 months post ART initiation. This
than those who access health facilities by foot. Similar find- corroborates findings from a similar study [41] where per-
ings on access to health facilities have been noted in other sonnel responsible for linking clients to care had to provide
low- and middle- income countries [38, 39]. Unlike stud- transport for clients who did not have enough money to go
ies conducted in urban settings, our study demonstrated that to the health facility.
HIV patients in uThukela District Municipality do not often Participants’ sex and age played a major role in deter-
change health facilities. Although participants remained in mining whether they test for HIV, link to, or remain in care.
their testing facilities and reported feeling that they were The proportion of women that tested for HIV and retained
provided with necessary information and generally treated in care at 12 months in this study was significantly higher
well by clinic staff, some felt that clinical personnel did not than men. This corroborates studies that show that HIV-
have enough time for them when they visited the health positive men are less likely than women to access HIV care
facilities. This might have also contributed to the reasons for [42, 43], and be retained in care across sub-Saharan Africa
not remaining in care. Lankowski et al. [38], identified the [44]. However, a higher proportion of males were linked to
size of the facility and staffing-patient ratio as factors that care within three months post HIV-positive diagnosis com-
may improve linkage and retention in care. This calls for pared to females in our study. More research is needed to
recruitment of more HIV counsellors and linkage officers in understand barriers to early linkage and retention for men.
uThukela health facilities. We also found that females in the younger age and males
Other reasons for delaying the return to the clinic for HIV in the older age categories had higher rates of positivity.
care or non-retention in care included inability to take time This was consistent with the current research done in KZN
off work or inconvenient appointment dates. Our findings

13
 AIDS and Behavior

through the Centre for the AIDS Program of Research in accessing care such as access to cash, lack of transportation
South Africa (CAPRISA). to health facilities, gender, and age.
Young women test more for HIV compared to young
men. This may be attributed to the fact that they have more
Strengths and limitations opportunities for testing when accessing family planning or
maternal and child health (MCH) services. While integrated
We found the availability of a medical clinic visit evidenced family planning or MCH services may have improved
by a record in Tier.Net, which was synonymous with ART testing for women of reproductive age, there is a need to
initiation, to be useful in determining linkage to care. How- improve testing for older women and younger men. Our
ever, in some instances, after receiving counseling and findings suggest that interventions could target men aged
blood samples drawn at a treatment facility, the individual 18–34 years to encourage HIV testing and linkage to care.
might indicate that they are not ready to initiate treatment More research is needed to understand barriers to care link-
even though there was UTT. age and retention for men.
Our determination of retention in care was confirmed
via the presence of viral load measurements and the con- Acknowledgments  We would like to extend our word of appreciation
to the uThukela district manager, Dr T. Zulu as well as the deputy
firmation of deceased status with the Department of Home district manager of monitoring and evaluation, Mr. M. Asvat for their
Affairs. Identifying viral loads and the subsequent viral unending support to the project. We would also like to acknowledge
suppression after one year of linkage to care through the the Health Systems Trust (HST) team in Ladysmith, our collaborating
NHLS is superior to other methods such as pharmacy refills partners, for the advisory role they played in setting up the project
as well as throughout the project. We also thank the hospital Chief
and clinic attendance records reported as retention in care Executive Officers, clinic managers and counsellors of participating
because viral load measurements capture PLHIV who had facilities for their support during the fieldwork. And, finally, to all the
transferred out from one facility to another. participants, thank you for participating in this project. We also appre-
This cohort study has provided an overview of the demo- ciate the co-operation of the staff in the sub-district offices and selected
facilities and would like to thank Ms T. Makowa, and the fieldwork
graphics and context of the participants, and it shows a high team for data collection. We also thank Ms. B. Zani and Ms T. Ramraj,
linkage rate as evidence by ART initiation in the context who contributed to and assisted with editing of the report.
of UTT amongst the HIV-positive cohort. This could have
been influenced by our field team, who provided educational Authors’ contributions  EN and DB conceptualized the study. EN and
materials about linkages and support to the participants. FCM drafted the manuscript. EN, WB, CL, MC, RL, and DB provided
methodological support, while EN, WB, FCM, NJ, DP, SM, MC, and
This study is of great relevance within the context of the DB provided critical contributions towards developing and refining the
South African health priorities, and the findings will provide manuscript. All authors read and approved the final manuscript.
insight to guide decision makers, especially the National
Department of Health (NDoH) on ways to strengthen strate- Funding  This work was supported by the U.S. President’s Emergency
gies geared towards improving linkage to and retention in Plan for AIDS Relief (PEPFAR) through the Centers for Disease Con-
trol and Prevention, under the terms of Cooperative Agreement Num-
HIV care. Although the study focused on one district with a ber 1U2GGH001150.
high HIV prevalence, most of the findings maybe applicable
to other settings. Data Availability The datasets generated and/or analyzed during the
A limitation to our study though is that we did not inves- current study are available from the corresponding author on reason-
able request.
tigate the presence of a CD4 count, which is a good tracker
for each time the participant interacts with the health sys- Code Availability  Not Applicable.
tem. The study also, did not capture the details of interven-
tions that are being implemented in our study sites to show
Declaration
which interventions enhanced linkage to care.
Conflicts of interest/Competing interests  None declared.

Conclusion Ethics approval  This project was reviewed in accordance with CDC
human research protection procedures and was determined to be re-
search, but CDC investigators did not interact with human subjects or
This study has shown higher rates of linkage to care com- have access to identifiable data or specimens for research purposes. It
pared to regional estimates, but less than 50% of the partici- was approved by the South African Medical Research Council (SAM-
pants remained in care at 12 months, pointing to challenges RC) ethics committee in October 2016 (EC021-7/2016). Additional
with access to continuing care. We have also described approvals were received from the KwaZulu-Natal provincial Depart-
ment of Health and uThukela district in October 2017.
socio-demographic characteristics, and some drivers of
Consent to participate  All participants completed a consent form be-

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AIDS and Behavior

fore participating in the study. Confidentiality and privacy were main- 2017. ISSN 2078–5135. [Available from: http://www.samj.org.
tained using study codes instead of the participant’s details in all our za/index.php/samj/article/view/12136. Date accessed: 26 Nov.
records. 2021.] doi:https://doi.org/10.7196/SAMJ.2017.v107i12.12358.
10. Fox MP, Sydney R. Retention of Adult Patients on Antiretrovi-
Consent for publication  Not Applicable. ral Therapy in Low-and Middle-Income Countries: Systematic
Review and Meta-analysis 2008–2013. J Acquir Immune Defic
Disclaimer  The findings and conclusions in this paper are those of the Syndr. 2015;69:98–108.
authors and do not necessarily represent the official position of the 11. Fox MP, Rosen S. A new cascade of HIV care for the era of
CDC or other funding agencies. “treat all”. PLOS Medicine 14(4): e1002268. DOI: https://doi.
org/10.1371/journal.pmed.1002268.
12. Haber N, Pillay D, Porter K, et al. Constructing the cascade of
Open Access  This article is licensed under a Creative Commons HIV care. Curr Opin HIV AIDS. 2016;11:102–8.
Attribution 4.0 International License, which permits use, sharing, 13. Hayes RJ, Bennett S. Simple sample size calculation for cluster-
adaptation, distribution and reproduction in any medium or format, randomized trials. 1999. International journal of epidemiology.
as long as you give appropriate credit to the original author(s) and the 1999;28(2):319 – 26.
source, provide a link to the Creative Commons licence, and indicate 14. StataCorp LLC. Statistics/Data Analysis (STATA) 16.0. Special
if changes were made. The images or other third party material in this Edition. College Station, Texas 77845 USA. http://www.stata.
article are included in the article’s Creative Commons licence, unless com.
indicated otherwise in a credit line to the material. If material is not 15. Myburgh H, Murphy JP, van Huyssteen M, et al. Implementa-
included in the article’s Creative Commons licence and your intended tion of an Electronic Monitoring and Evaluation System for the
use is not permitted by statutory regulation or exceeds the permitted Antiretroviral Treatment Programme in the Cape Winelands
use, you will need to obtain permission directly from the copyright District, South Africa: A Qualitative Evaluation. PLoS ONE.
holder. To view a copy of this licence, visit http://creativecommons. 2015;10:e0127223.
org/licenses/by/4.0/. 16. Fox MP, Bor J, Brennan AT, et al. Estimating retention in HIV
care accounting for patient transfers: A national laboratory cohort
study in South Africa. PLoS Med. 2018;15:30–43.
References 17. Kayigamba FR, Bakker MI, Fikse H, et al. Patient Enrolment
into HIV Care and Treatment within 90 Days of HIV Diagnosis
in Eight Rwandan Health Facilities: A Review of Facility-Based
1. Unaids. Fast-Track Ending the AIDS epidemic by 2030. : Registers. PLoS ONE. 2012;7:e36792.
UNAIDS. 2014 [Available from: http://www.unaids.org/en/ 18. Rosen S, Fox MP. Retention in HIV Care between Testing and
resources/documents/2014/JC2686_WAD2014report. Date Treatment in Sub-Saharan Africa: A Systematic Review. PLoS
accessed: 28 May 2020]. Med. 2011;8:e1001056.
2. World Health Organization. Consolidated Guidelines on the Use 19. Rachlis B, Burchell AN, Gardner S, et al. Social determinants of
of Antiretroviral Drugs for Treating and Preventing HIV Infec- health and retention in HIV care in a clinical cohort in Ontario,
tion. Geneva: World Health Organization, http://www.ncbi.nlm. Canada. AIDS Care - Psychol Socio-Medical Asp AIDS/HIV.
nih.gov/pubmed/27466667.Date accessed: 28 May 2020). 2017;29:828–37.
3. Department of Health. Implementation of the Universal Test and 20. Harris PA, Taylor R, Thielke R, et al. Research electronic data
Treat Strategy fpr HIV Positive Patients and Differentieated care capture (REDCap)-A metadata-driven methodology and work-
for Stable Patients. Pretoria: Department of Health, http://www. flow process for providing translational research informatics sup-
sahivsoc.org/Files/22 8 16 Circular UTT Decongestion CCMT port. J Biomed Inform. 2009;42:377–81.
Directorate (2).pdf (2016, accessed 13 January 2017). 21. Rao JNK, Scott AJ. On chi-squared tests for multiway contin-
4. Human Sciences Research Council. South African National HIV gency tables with cell proportions estimated from survey data.
prevalence, Incidence, Behaviour and Communication Survey,. Ann Stat. 1984;12:46–60.
2017, http://www.hsrc.ac.za/uploads/pageContent/9234/FINAL 22. Johnson LF, Dorrington RE, Moolla H. Progress towards the
Presentation for 17 July launch.pdf (2018, accessed 3 September 2020 targets for HIV diagnosis and antiretroviral treatment in
2018). South Africa. South Afr J HIV Med. 2017;18:8 pages.
5. Frank TD, Carter A, Jahagirdar D, et al. Global, regional, and 23. Francois Venter WD, Fischer A, Lalla-Edward ST, et al. Improv-
national incidence, prevalence, and mortality of HIV, 1980–2017, ing linkage to and retention in care in newly diagnosed HIV-
and forecasts to 2030, for 195 countries and territories: a system- Positive patients using smartphones in South Africa: Randomized
atic analysis for the Global Burden of Diseases, Injuries, and Risk controlled trial. J Med Internet Res; 21. Epub ahead of print 1
Factors Study 2017. Lancet HIV. 2019;6:e831–59. April 2019. DOI: https://doi.org/10.2196/12652.
6. Perriat D, Balzer L, Hayes R, et al. Comparative assessment of 24. Rosen S, Fox MP, Larson BA, et al. Accelerating the Uptake and
five trials of universal HIV testing and treatment in sub-Saha- Timing of Antiretroviral Therapy Initiation in Sub-Saharan Africa:
ran Africa. J Int AIDS Soc; 21. Epub ahead of print 2018. DOI: An Operations Research Agenda. PLoS Med. 2016;13:1002106.
https://doi.org/10.1002/jia2.25048. 25. Sanga ES, Mukumbang FC, Mushi AK, et al. Understanding fac-
7. Stricker SM, Fox KA, Baggaley R, et al. Retention in Care and tors influencing linkage to HIV care in a rural setting, Mbeya,
Adherence to ART are Critical Elements of HIV Care Interven- Tanzania: qualitative findings of a mixed methods study. DOI:
tions. AIDS Behav. 2014;18:465–75. https://doi.org/10.1186/s12889-019-6691-7.
8. Haber N, Tanser F, Phd P, et al. From HIV infection to thera- 26. Sabapathy K, Mubekapi-Musadaidzwa C, Mulubwa C, et al. Pre-
peutic response: a population-based longitudinal HIV cascade- dictors of timely linkage-to-ART within universal test and treat
of-care study in KwaZulu-Natal, South Africa. Lancet HIV. in the HPTN 071 (PopART) trial in Zambia and South Africa:
2017;4:e223–30. findings from a nested case-control study. J Int AIDS Soc.
9. Fomundam HN, Tesfay AR, Mushipe SA, et al. Prevalence and 2017;20:e25037.
predictors of late presentation for HIV care in South Africa. South 27. Iwuji CC, Orne-Gliemann J, Larmarange J, et al. Universal test
African Medical Journal, [S.l.], v. 107, n. 12, p.1058–1064, nov. and treat and the HIV epidemic in rural South Africa: a phase

13
 AIDS and Behavior

4, open-label, community cluster randomised trial. Lancet HIV. 37. The Aurum Institute. Men’s Health Month: Aurum partners to
2018;5:e116–25. implement campaigns supporting men living with HIV. [Avail-
28. Pascoe SJ, Fox MP, Huber AN, et al. Differentiated HIV care in able from: https://www.auruminstitute.org/component/content/
South Africa: the effect of fast-track treatment initiation coun- article/28-blog/aurum-news/455-men-s-health-month-mina-and-
selling on ART initiation and viral suppression as partial results c o a c h - m p i l o - f i g h t - t h e - s t i g m a - f o r- m e n - l i v i n g - w i t h -
of an impact evaluation on the impact of a package of services hiv?Itemid=101. Date accessed: 26 Nov. 2021.].
to improve HIV treatment adherence. J Int AIDS Soc; 22. Epub 38. Lankowski AJ, Siedner MJ, Bangsberg DR, Tsai AC. Impact
ahead of print 5 November 2019. DOI: https://doi.org/10.1002/ of Geographic and Transportation-Related Barriers on HIV
jia2.25409. Outcomes in Sub-Saharan Africa: A Systematic Review. AIDS
29. Alhaj M, Amberbir A, Singogo E, et al. Retention on antiretro- Behav. 2014;18(7):1199–223.
viral therapy during Universal Test and Treat implementation in 39. Bogart LM, Chetty S, Sypek GJ, Sticklor A, L. Barriers to Care
Zomba district, Malawi: a retrospective cohort study. J Int AIDS among People Living with HIV in South Africa: Contrasts
Soc. 2019;22:e25239. between Patient and Healthcare Provider Perspectives. AIDS
30. Dorward J, Mabuto T, Charalambous S, et al. Factors Associated Care. 2013;25(7):843–53.
With Poor Linkage to HIV Care in South Africa. JAIDS J Acquir 40. Govindasamy D, van Schaik N, Kranzer K, Wood R, Mathews
Immune Defic Syndr. 2017;76:453–60. C, Bekker LG. Linkage to HIV Care from a Mobile Testing Unit
31. Schneider H, Govender V, Harris B, et al. Gender differences in in South Africa by Different CD4 Count Strata. J Acquir Immune
experiences of ART services in South Africa: a mixed methods Defic Syndr. 2011;58(3):344–52.
study. Trop Med Int Heal. 2012;17:820–6. 41. Shamu S, Slabbert J, Guloba G, Blom D, Khupakonke S, et al.
32. Cornell M, Schomaker M, Garone DB, et al. Gender Differences Linkage to care of HIV positive clients in a community based
in Survival among Adult Patients Starting Antiretroviral Ther- HIV counselling and testing programme: A success story of non-
apy in South Africa: A Multicentre Cohort Study. PLoS Med. governmental organisations in a South African district. PLoS
2012;9:e1001304. ONE. 2019;14(1):e0210826. https://doi.org/10.1371/journal.
33. Colvin CJ. Strategies for engaging men in HIV services. Lancet pone.0210826.
HIV. 2019;6:e191–200. 42. Staveteig S, Wang S, Head SK, Bradley SE, Nybro E. Demo-
34. Fleming PJ, Colvin C, Peacock D, et al. What role can gender- graphic patterns of HIV testing uptake in sub-Saharan Africa. ICF
transformative programming for men play in increasing men’s International Calverton, MD; 2013.
HIV testing and engagement in HIV care and treatment in South 43. Hirasen K, Fox MP, Hendrickson CJ, Sineke T, Onoya D. HIV
Africa? Cult Health Sex. 2016;18:1251–64. treatment outcomes among patients initiated on antiretroviral
35. Fox MP, Pascoe S, Huber AN, et al. Adherence Clubs and Decen- therapy pre and post-universal test and treat guidelines in South
tralized Medication Delivery to Support Patient Retention and Africa. Therapeutics and clinical risk management. 2020;16:169.
Sustained Viral Suppression in Care: Results from A Cluster 44. UNAIDS. Blind spot: reaching out to men and boys. Addressing
Randomized Evaluation of Differentiated ART delivery models a blind spot in the response to HIV. Geneva: UNAIDS; 2017.
in South Africa. PLOS Med. 2019;16:e1002874.
36. Mukumbang FC. Leaving No Man Behind: How Differentiated Publisher’s Note  Springer Nature remains neutral with regard to juris-
Service Delivery Models Increase Men’s Engagement in HIV dictional claims in published maps and institutional affiliations.
Care. Epub ahead of print 2020. DOI: https://doi.org/10.34172/
ijhpm.2020.32.

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