1. RISK FACTORS, BARRIERS AND FACILITATORS FOR LINKAGE AND RETENTION IN PRE-ART CARE Darshini Govindasamy Health Economics and Epidemiology Research Office, SA Katharina Kranzer London School of Hygiene and Tropical Medicine, UK

2. HIV continuum of care HIV test Continuous lifelong ART Assessment for ART eligibility: Clinical staging CD4 count ART initiation Retention in pre- ART care until eligible not yet eligible eligible HIV infection HIV testing Pre-ART careART care Not in care Kranzer et al 2012

3. HIV continuum of care HIV test Continuous lifelong ART Assessment for ART eligibility: Clinical staging CD4 count ART initiation Retention in pre- ART care until eligible not yet eligible eligible HIV infection HIV testing Pre-ART careART care Not in care Kranzer et al 2012

4. Search limited to sub-Saharan Africa studies published before May 2011 Total number of studies: 42 Semi-qualitative studies: 19 Quantitative 17 Qualitative 6 Systematic review

5. Barriers to retention in pre-ART care Govindasamy, Ford, Kranzer 2012 Health systems Long waiting times Shortage of HCWs Economic Transport cost Distance Food shortage Unable to take time of work Medical TB treatment Psychosocial Stigma Fear of disclosure Fear of drug toxicities Perceived good health

6. Predictors of attrition Govindasamy, Ford, Kranzer 2012 Health systems Shortage of HCWs Economic Transport cost Distance Medical TB treatment Pregnancy Advanced immunodeficiency Severe malnutrition Other Male sex Younger age Lower levels of education

7. Predictors of attrition Govindasamy, Ford, Kranzer 2012 Health systems Shortage of HCWs Economic Transport cost Distance Medical TB treatment Pregnancy Advanced immunodeficiency Severe malnutrition Other Male sex Younger age Lower levels of education

8. Men Lower test uptake Lower ART coverage More advanced immunodeficiency at diagnosis and ART initiation Higher mortality Lower adherence Higher risk of loss to follow-up on ART Johnson 2013, Cornell 2012, Druyts 2013, Peltzer 2009, Kranzer 2013, Johnson 2012, Muula 2009, Remien 2009

9. How to address gender inequality Men do not become pregnant Men are less health seeking Health care staff are predominantly women Health care services are targeted at women and children Health care services AIMED at men or "men friendly" health care services

10. Areas for interventions Govindasamy, Ford, Kranzer 2012

11. Systematic review of interventions to improve linkage to and retention in pre-ART care Govindasamy, Kranzer 2013 N=11129 potentially eligible citations identified through: Search strategy on electronic databases (n=11 048) Keyword search on electronic conference abstract databases (n=45) References obtained from experts (n=36) 24 studies retained for analysis (19 published articles + 1 unpublished article from experts + 2 conference abstracts + 2 conference abstracts from experts) N=67 of full text articles assessed for eligibility (54 published articles + 1 unpublished article from experts + 10 conference abstracts + 2 conference abstracts from experts)

12. Intervention studies - design and populations Govindasamy, Kranzer 2013  Before after studies: n=11 Observational studies with control group(s): n=6 Individuals randomized controlled trials: n=4 Cluster randomized controlled trials: n=3  Adults: n=11  Children: n=1  Adolescents: n=1  Pregnant women: n=8  Inpatients: n=1  TB patients: n=1  IVDU: n=1

13. Intervention studies - design and populations Govindasamy, Kranzer 2013  Before after studies: N=11 Observational studies with control group(s): n=6 Individuals randomized controlled trials: n=4 Cluster randomized controlled trials: n=3  Adults: n=11  Children: n=1  Adolescents: n=1  Pregnant women: n=8  Inpatients: n=1  TB patients: n=1  IVDU: n=1 Few studies with rigorous design

14. Intervention studies - design and populations Govindasamy, Kranzer 2013  Before after studies: N=11 Observational studies with control group(s): n=6 Individuals randomized controlled trials: n=4 Cluster randomized controlled trials: n=3  Adults: n=11  Children: n=1  Adolescents: n=1  Pregnant women: n=8  Inpatients: n=1  TB patients: n=1  IVDU: n=1 Few studies with rigorous design Few studies in special risk groups

15. Pregnant women

16. Interventions and outcomes in special groups InterventionNumber of studies ParticipantsDesignOutcome Food incentives1ChildrenBefore/after study Improved clinic attendance (RR 2.9) Health system intervention 1TB patientsBefore/after study Increased ART initiation (HR 2.6) Food vouchers1IVDURCTTime to initiation: 7 days (intervention) 58 days (control) Point of care CD4 count testing 1adolescentsBefore/after study Time between HIV-testing and eligibility assessment: 14 days (control) and 0 days (intervention)

17. Interventions and outcomes in adults InterventionNo of studies DesignOutcome Monthly visits with refill of cotrimoxazole 1Before/after studyImproved retention in pre-ART care (RR 2.6) Health system intervention 1Before/after studyIncreased ART initiation (HR 2.7) Point of care or immediate CD4 count testing 31 before/after study 1 Individual RCT 1 Observation study with control group Increased retention and ART initiation (RR 2) PICT1Observation study with control groupNo effect on ART initiation (RR 0.9) Task shifting and decentralisation 1Cluster RCTNo effect on retention (RR 1.0) Intensive counselling1Individual RCTIncreased pre-ART enrolment (RR 1.8) Home-based ART initiation 1Cluster RCTIncreased ART initiation rate (RR 2.9)

18. Interventions addressing the barriers Health systems Long waiting times Shortage of HCWs Economic Transport cost Distance Food shortage Unable to take time of work Medical TB treatment Psychosocial Stigma Fear of disclosure Fear of drug toxicities Perceived good health

19. Interventions addressing the barriers Health systems Long waiting times Shortage of HCWs Economic Transport cost Distance Food shortage Unable to take time of work Medical TB treatment Psychosocial Stigma Fear of disclosure Fear of drug toxicities Perceived good health

20. Thank you!