In the quest for HIV epidemic control, enabling people living with HIV to get into care, keeping them there, and helping them achieve viral load suppression after starting antiretroviral therapy (ART) are three key objectives for the global health community.

In 2011, ICAP at Columbia University began the Link4Health study in Swaziland to evaluate the effectiveness of an innovative combination intervention strategy on the linkage of HIV-positive persons to HIV care and their retention in care. The Combination Intervention Strategy (CIS) included five practical interventions that targeted multiple steps across the HIV care cascade. These included point-of-care CD4+ cell count testing at the time of an HIV positive test, accelerated ART initiation for eligible patients, mobile phone appointment reminders, health educational packages, and non-cash financial incentives. Ten clusters of HIV clinics were randomized by chance to CIS or to standard of care.

The study was conducted in collaboration with the Ministry of Health in Swaziland and with funding from the U.S. President’s Emergency Plan for AIDS Relief (PEPFAR) though the National Institutes of Health (NIH). After following participants for 12 months, the study found that approximately 50% more CIS participants had achieved linkage to care within one month of testing AND retention in care at 1 year compared to those following the traditional standard of care: 64% versus 45%.

There were secondary benefits as well for the CIS group, including faster linkage to care and shorter time from testing to ART initiation. The study did not find significant differences in viral suppression or mortality at 12-months after testing HIV positive, however.

The Kingdom of Swaziland has one of the most severe HIV epidemics and HIV-related illness is the leading cause of death in the country. When the Link4Health study began, an estimated 32 percent of adults aged 18-49 were infected and the incidence was at 2.4%. In that year, about 95,000 adults had been started on ART. As recent data from ICAPsupported PHIA project showed, by 2016, the number of adults on ART had increased to over 170,000 and annual the annual incidence rate dropped to 1.4%. However, the prevalence of the disease among adults remains high at 31 percent. This makes ensuring sustainable linkage to care and retention on ART an ongoing priority for Swaziland—as it is for other countries affected by the epidemic.

The combination strategy used in this the Link4Health study could be easily adapted to other resource-limited settings and may be relevant to the challenges faced in engaging HIV-positive vulnerable and key populations, providing a promising avenue to explore in the ongoing pursuit of a world without AIDS.

Read the full study here.

Read the recent PLoS Medicine article:
Effectiveness of a combination strategy for linkage and retention in adult HIV care in Swaziland: The Link4Health cluster randomized trial.
McNairy ML, Lamb MR, Gachuhi AB, Nuwagaba-Biribonwoha H, Burke S, Mazibuko S, Okello V, Ehrenkranz P, Sahabo R, El-Sadr WM.

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