A combination intervention strategy to improve linkage to and retention in HIV care following diagnosis in Mozambique: A cluster-randomized study

Background: concerning gaps in the hiv care continuum compromise individual and population health. we evaluated a combination intervention strategy (cis) targeting prevalent barriers to timely linkage and sustained retention in hiv care in mozambique. methods and findings: in this cluster-randomized trial,10 primary health facilities in the city of maputo and inhambane province were randomly assigned to provide the cis or the standard of care (soc). the cis included point-of-care cd4 testing at the time of diagnosis,accelerated art initiation,and short message service (sms) health messages and appointment reminders. a pre–post intervention 2-sample design was nested within the cis arm to assess the effectiveness of cis+,an enhanced version of the cis that additionally included conditional non-cash financial incentives for linkage and retention. the primary outcome was a combined outcome of linkage to care within 1 month and retention at 12 months after diagnosis. from april 22,2013,to june 30,2015,we enrolled 2,004 out of 5,327 adults ≥18 years of age diagnosed with hiv in the voluntary counseling and testing clinics of participating health facilities: 744 (37%) in the cis group,493 (25%) in the cis+ group,and 767 (38%) in the soc group. fifty-seven percent of the cis group achieved the primary outcome versus 35% in the soc group (relative risk [rr]cis vs soc= 1.58,95% ci 1.05–2.39). eighty-nine percent of the cis group linked to care on the day of diagnosis versus 16% of the soc group (rrcis vs soc= 9.13,95% ci 1.65–50.40). there was no significant benefit of adding financial incentives to the cis in terms of the combined outcome (55% of the cis+ group achieved the primary outcome,rrcis+ vs cis= 0.96,95% ci 0.81–1.16). key limitations include the use of existing medical records to assess outcomes,the inability to isolate the effect of each component of the cis,non-concurrent enrollment of the cis+ group,and exclusion of many patients newly diagnosed with hiv. conclusions: the cis showed promise for making much needed gains in the hiv care continuum in our study,particularly in the critical first step of timely linkage to care following diagnosis. © 2017 elul et al.