Background:  Linkage to care rates after HIV diagnosis in Sub-Saharan Africa are unacceptably low. Delays and drop-outs can occur before ART start due to multiple steps in care delivery. We sought to improve linkage to care and remove barriers to ART initiation after HIV voluntary counseling and testing (VCT) with rapid referral, point-of-care CD4 count testing, and TB screening.

Methods:  We performed HIV VCT at a 5-day, multi-disease health campaign in a rural Ugandan community of 6000, supported by local staff and the Ministry of Health. We provided HIV⁺ adults with on-site, point-of-care CD4 count (PIMA) testing and TB screening (sputum Xpert MTB/RIF assay), and referred them to a local HIV clinic using 2 strategies. HIV⁺ adults with CD4 >100/µL received routine referral to the clinic within 3 months. HIV⁺ adults with CD4 ≤100/µL received an enhanced strategy of rapid referral (<2 weeks post-campaign), expedited pre-ART counseling, and immediate ART initiation at the first visit. All participants received a transport stipend and were introduced to a clinic nurse. We examined predictors of linkage to care in the 3 months after the campaign and conducted home visits to evaluate reasons for failing to link.

Results:  The linkage study comprised 140 HIV⁺ adult participants. We made routine referrals for 132 adults, 75 (57%) of whom linked to care within 3 months. We made enhanced referrals for 7 adults with advanced AIDS and a pregnant woman (CD4 = 278). Of these, 6 (75%) linked to care within 10 (median 2.5) days of the campaign and started ART immediately; all 6 screened negative for TB by Xpert assay and clinician assessment. All 6 reported adherence to ART 4 weeks after linking to care. For the 132 adults, new HIV diagnosis was associated with reduced odds of linkage (OR 0.1, 0.04 to 0.25, p <0.001), after adjusting for age, sex, CD4, and distance from clinic. Among new diagnoses, median CD4 was higher in adults who did not link than those who did (513 vs 315, p = 0.007). In home visit interviews, participants who failed to link reported insufficient transport funds and accessed care at other sites as key reasons for not linking.

Conclusions:  An enhanced linkage approach after a community testing drive led to rapid ART initiation in adults with advanced HIV. In contrast, even with robust measures to promote linkage, routine linkage-to-care efforts were insufficient (57%) in adults with higher CD4 cell counts. Improved linkage strategies across a broad spectrum of CD4 counts are needed.