Linkage to HIV care and early retention in care rates in the Universal Test-and-Treat era: a population-based prospective study in KwaZulu-Natal, South Africa

Introduction: HIV care, linkage, and retention are key weaknesses in South Africa’s national antiretroviral therapy (ART) program, with the greatest loss of patients in the HIV treatment pathway occurring before ART initiation. Very few studies have investigated the proportion of people newly diagnosed with HIV linked-to and retained-in-care in the ‘Universal Test-and-Treat’ era. This study investigated linkage-to and early-retention-in-care (LTRIC) rates among adults newly diagnosed with HIV in a high-HIV prevalent rural district. Methods: We conducted an observational prospective cohort study from December 2017 to August 2019 to investigate LTRIC rates for adults with a new HIV diagnosis in uThukela district, South Africa. Patient-level survey and clinical data were collected using a one-stage-cluster design from 18 healthcare facilities and triangulated between HIV and laboratory databases and registered deaths from Department of Home Affairs. We used Chi-square tests to assess associations between categorical variables, and results were stratified by HIV status, sex, and age. Confidence intervals (CI) and p-value of £0.05 were reported to consider statistical significance. Results: Of the 5,637 participants recruited from December 2017 to June 2018, 21.2% [1,194/5,637; CI: 15.8-26.5] had confirmed HIV. Of the HIV-positive participants, 70.9% were women, and 46.5% were aged 25–34 years. Although 82.7% of participants (987/1,194) were linked-to-care within 3 months, only 46.1% (551/1,194; CI: 31.0-61.3) remained-in-care 12 months after initiating ART and 5.2% (62/1,194; CI: 4.0-6.6) were deceased. While a significantly higher proportion of men were linked-to-care at 3 months compared to women [85.1% (292/343); CI: 80.4-88.9 vs. 81.7 (695/851); CI: 75.0-86.9, p=0.03], a significantly proportion of women [49.5% (419/847); CI: 34.3-64.7] remained-in-care at 12 months than men [38.0% (132/347); CI: 24.6-53.6, p=0.01). Nearly half of the participants retained-in-care were aged 35–49 years (49.1%). Post-secondary education (p=0.05) and child support grants (p=0.03) were independently significantly associated with retention. Conclusion: We found high initial linkage-to-care rates, but less than 50% of participants remained-in-care at 12 months. Significant effort is required to retain PLHIV in care, especially during the first year after ART initiation. Our findings suggest that interventions could target women aged 18–34 years; more research is needed to understand barriers to LTRIC for men.