Gaps in continuum for HIV care contribute to poor health outcomes and increase the risk of HIV transmission. A combination of evidence-based interventions targeting multiple steps in the continuum is needed to achieve the desired impact of HIV treatment. The Link4Health study was conducted by ICAP at Columbia University in collaboration with the Ministry of Health in Swaziland.

The Link4Health Study, a cluster-randomized controlled trial, evaluated the effectiveness of a combination intervention strategy (CIS) versus the standard of care (SOC) on the primary outcome of linkage to care within one month plus retention in care at 12 months after HIV-positive testing. Ten clusters of HIV clinics in Swaziland were randomized 1:1 to the CIS versus the SOC. The CIS included: • Point-of-care (POC) CD4+ cell count testing at time of HIV-positive test

• Accelerated antiretroviral therapy (ART) initiation for treatment-eligible individuals
• Mobile phone appointment reminders
• Health educational packages
• Non-cash financial incentives

A total of 2,197 adults 18 years of age or older who newly tested HIV-positive were enrolled from August 2013–November 2014, with 1,096 randomly assigned to CIS arm and 1,101 to the SOC arm. All participants were followed for 12 months. Median age was 31 years (interquartile range [IQR] 26–39) and 59 percent were women. An intention-to-treat analysis including 2,197 participants showed that 64 percent (705/1096) of participants at CIS sites achieved the primary outcome versus 43 percent (477/1,101) at SOC sites (absolute difference 21%, adjusted relative risk [RR] 1.52, 95% CI 1.19–1.96, p = 0.002). Participants in CIS versus SOC sites also had improved secondary outcomes, including a higher proportion assessed for ART-eligibility (100% versus 84%, p = 0.004), shorter time from HIV testing to ART initiation among eligible patients (seven versus 14 days, p<0.0001), and higher 12-month retention (66% versus 45%, RR 1.48, 95% CI 1.18–1.86, p = 0.002). No difference was noted in viral load suppression among those on ART for at least 6 months (RR 0.97, 95% CI: 0.88–1.07, p = 0.55).

A combination of behavioral, structural, and biomedical interventions aimed at multiple steps in the HIV care continuum was associated with a 50 percent increase in the combined outcome of prompt linkage to care and 12-month retention. This strategy offers promise for enhanced treatment outcomes and decreased HIV transmission.