Mapping an HIV Treatment Program to Identify Barriers to Linkage in HIV Care in Resource Limited Settings

Aims: To develop a practical method to evaluate and address failures to linkage to care for HIV treatment so as to achieve better access to antiretroviral therapy in resource limited settings.
Study Design: A mixed methods analysis to identify and quantify failure to linkage to care involving intensive program mapping, retrospective quantification of retention data, and statistical analysis.
Place and Duration of Study: AIC Kijabe Hospital, Kijabe Kenya. Data were collected from January 1 to December 31, 2011. Data collection and analysis was conducted in February 2012.
Methodology: First a series of successive interviews of all levels of care providers was used to create a program map and identify linkage points. Following this, data registries were identified and cases at each linkage point were quantified. Simple statistical analysis of retention data were then completed and trends analyzed by Kaplan-Meier survival analysis.
Results: Less than 20% of eligible cases testing positive for HIV were enrolled in the treatment program. Most cases enrolled received CD4 testing (78.9%). Most eligible enrolled patients were initiated on ART (82.2%). Patients referred from VCT (voluntary testing) were more likely to be enrolled, receive CD4 testing, and be initiated on therapy. Cases enrolled in the program within 7 days of HIV diagnosis had improved time to initiation of therapy (43 days vs 79 days, p<.001). Cases who received a CD4 test within seven days of diagnosis also had improved time to initiation of therapy (47 vs 77 days, p=.01).
Conclusion: This method proved effective to identify, prioritize, and problem solve to improve linkages to care in our setting. Further evaluation should include prospective studies to identify facilitators to linkage and test interventions.