How does HIV testing modality impact the cascade of care among persons diagnosed with HIV in Ethiopia?

Background: Despite scaling up of HIV programmes in sub-Saharan Africa, many people living with HIV (PLHIV) are unaware of their HIV status. New testing modalities, such as community-based testing, can improve test uptake, but it is uncertain whether type of testing modality affects the subsequent cascade of HIV care.
Objective: To compare linkage to care and antiretroviral treatment (ART) outcomes with regard to type of HIV testing modality.
Methods: A retrospective registry-based study was conducted at public ART clinics in an urban uptake area in Central Ethiopia. Persons aged ≥15 years newly diagnosed with HIV in 2015-2018 were eligible for inclusion. Data on patient characteristics and testing modality were analysed for associations with the following outcomes: ART initiation, retention in care at 12 months after starting ART, and viral suppression (<1000 copies/ml, recorded during the first 12 months after ART initiation), using uni- and multivariable analysis. Separate analyses disaggregated by sex were performed.
Results: Among 2885 included PLHIV (median age 32 years, 59% female), 2476 (86%) started ART, 1422/2043 (70%) were retained in care, and 953/1046 (92%) achieved viral suppression. Rates of ART initiation were lower among persons diagnosed through community-based testing (adjusted odds ratio [AOR] 0.44, 95% confidence interval [CI] 0.29-0.66) and among persons diagnosed through provider-initiated testing (AOR 0.65, 95% CI 0.44-0.97) compared with facility-based voluntary counselling and testing. In sex-disaggregated analyses, community-based testing was associated with lower rates of ART initiation among both women and men (AOR 0.47, 95% CI 0.27-0.82; AOR 0.39, 95% CI 0.19-0.78, respectively). No differences were found for retention in care or viral suppression with regard to test modality.
Conclusion: Type of HIV testing modality was associated with likelihood of ART initiation, but not with subsequent treatment outcomes among persons starting ART.