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1 Health Economics and Epidemiology Research Office, Johannesburg, South Africa

Rapid point-of-care CD4 testing at mobile HIV testing sites to increase linkage to care: An evaluation of a pilot program in South Africa. Bruce Larson 2 , Kate Bistline 1 , Buyiswa Ndibong 1 , Thembi Xulu³, Alana Brennan¹², Lawrence Long¹, Matt Fox², Sydney Rosen 2.

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1 Health Economics and Epidemiology Research Office, Johannesburg, South Africa

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  1. Rapid point-of-care CD4 testing at mobile HIV testing sites to increase linkage to care: An evaluation of a pilot program in South Africa Bruce Larson2, Kate Bistline1, Buyiswa Ndibong1, Thembi Xulu³, Alana Brennan¹², Lawrence Long¹, Matt Fox², Sydney Rosen2 1Health Economics and Epidemiology Research Office, Johannesburg, South Africa 2Boston University Center for International Health and Development , Boston, USA 3Right to Care, Johannesburg, South Africa

  2. Introduction • Early identification of HIV-infected individuals and improved linkage to care is a prerequisite for South Africa to achieve its goals for care and treatment. • While mobile HIV counseling and testing (HCT) is well suited for early identification, little information exists on post-HCT linkage to care.

  3. The Pilot Intervention • A mobile HCT program around Johannesburg (ACCESS VCT) piloted integration of point-of-care (POC) CD4 testing into routine practice to improve linkage to HIV care and treatment. • The POC CD4 technology was the Pima™ Analyzer, provided to the site by Alere through a collaboration with USAID and the PEPFAR Program.

  4. Study Objective • Primary objective: • Does integration of POC CD4 testing into routine HCT services in a mobile program improve linkage to HIV care? • Primary outcome: • The proportion of patients testing HIV positive in the mobile HCT program who complete the first visit to their referral site within 8 weeks of testing positive.

  5. Methods • Access VCT provides HCT in mobile settings around Johannesburg (nurses provide HCT services). • During May – October 2010, multiple nurses offered HCT services at each mobile site (a day of operation across multiple locations). • Each day, a subset of nurses also offered the POC CD4 test to positive patients. • For each patient offered the POC CD4 test, the same nurse provided HIV testing and CD4 testing. • Using patient-provided phone numbers, the HCT program made three efforts to reach all positive patients after 8 weeks to ask if they completed their referral visit to an HIV clinic, the first step in the initiation of HIV care.

  6. Results

  7. Cohort Characteristics

  8. Next Figure: patients reached by phone

  9. Mobile HCT Patients tested HIV positive(n = 508) 59.6% female Standard Practice: HCT + referral for CD4 (n = 197) Pilot Practice: HCT + Rapid CD4 + referral (n = 311) Received PIMA CD4 count (n = 263) median [IQR] = 414[251-586] n=45 with CD4 < 200 Declined PIMA (n = 32) Pima Technical Failure (n = 16) Not Called (n = 1) Not reached by phone (n = 74) Not reached by phone (n = 96) Answered phone call (n = 122) Answered phone call (n = 167) Conclusion: For both groups, about 63% reached by phone after 8 weeks Risk difference “answered phone call” RD = 1.6% (95% CI: -10.5% - 7.4%)

  10. Next Figure: completed referral visit

  11. Standard practice and answered phone call (n = 122) Received PIMA CD4 count and answered phone call (n = 167) Completed 1st referral visit ≤8 weeks (n = 108, 64.7%) Completed 1st referral visit ≤8 weeks (n = 47, 38.5%) Risk difference “Completed referral visit within 8 weeks” RD = 26.14% (95% CI: 14.8% - 37.4%) Conclusion: Substantially greater % of patients completed 1st referral visit among group receiving rapid CD4 at HCT Note: Outcomes for 16 patients with technical failures similar to those not offered POC CD4 (11 of 16 contacted, 4 of 11 completed referral visit)

  12. Conclusions • POC CD4 testing can be integrated into routine HCT mobile program. • About 90% of patients offered the POC test accepted the opportunity. • No significant difference in patient characteristics between those offered the POC CD4 test and those not offered. • mobile HCT program is successful in early identification of patients (i.e., median POC CD4 = 414).

  13. Conclusions • For both study groups, about 63% were reached by phone after 8 weeks. • A substantially larger percentage of patients receiving the POC CD4 test at HCT completed their first referral visit within 8 weeks of testing. • Increase in referral completion from 38.5% to 64.7% (a 68% improvement)

  14. Next Steps • Record systems need to track patients from mobile HCT to care and treatment sites if: • linkage to care to be evaluated further; and • interventions to be developed and evaluated. • Evaluate costs per test and cost-effectiveness.

  15. Thanks • Patients • Access VCT • Right to Care (Busi Makhanya) • Alere (Glynis Davis) • National and Provincial Departments of Health • USAID/South Africa (Melinda Wilson, Clint Cavanaugh) • PEPFAR

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