1. Understanding time needed to link to care and start ART
IAS Paris July 2017 Janet Seeley

2. Background
HPTN-052 – after the release of interim results ART was offered to all participants in the delayed-ART arm, regardless of CD4+ count
17% of participants in these participants had not taken up the offer after one year because
believed CD4+ count too high
too healthy to start treatment
fear of side effects
(Cohen et al. 2016)

3. Sisonke Home-Based Counselling and Testing RCT team found that linkage to care influenced by
a complex interplay of emotions
motivational factors
living situation
relationship dynamics
responsibilities and personal resources
(Naik et al. 2017)

4. Testing and Linkage to ART in HPTN 071
Tests conducted in households by Community HIV-care Providers (CHiPs)
CHiPs support linkage to government health facilities
CHiPs return to household to check if linkage has been made
ART provided through routine government health facilities

5. Qualitative Cohort: Methods
Zambia: Cohort of 62 individuals
South Africa: Cohort of 88 ‘families’
Key interest groups recruited
Data collection: Jul 2016 – Nov 2017
Ethnographic/participatory research methods
Data collection focused on
Household composition; place and space; how they get by; love, sex and romance; relationships of power; hopes, ambitions, fears

6. Qualitative Cohort: PLHIV
Total
Zambia 31
South Africa 50 81
Gender
Cisgender women
Cisgender men
Transgender
women 18 13 34 3 52 26
Age
25+ 11 20 16 34 27 54
Treatment
On ART
Not on ART
17 (2*) 14
35 (7*) 15
52 (9*) 29
* early treatment outside guidelines

7. Time from CHiP referral to ART initiation – Zambia and South Africa, overall
Round 2, Arm A

8. Time from CHiP referral to ART initiation – by gender
Round 2, Arm A
In Zambia, time to initiate ART after referral to care in Round 2 was faster for men than women
In South Africa, time to initiate ART after referral to care in Round 2 was faster for women than men

9. Time from CHiP referral to ART initiation – Zambia and South Africa, by community
Round 2, Arm A
In both Zambia and South Africa, there were differences among communities for the time to initiate ART after referral to HIV care

10. The difference that makes a difference (Bond, Chiti et al. 2016)
Slower uptake
Zambia
Cross-border trade
High levels of transience
Several options for ART
Distinctive client flow for PLHIV
South Africa
Overburdened health system
Negative reputation of clinic
Administrative challenges (clinic)
‘Gateway’ community
Faster uptake
Zambia
Educated and middle class more dominant
More stable
Historically fewer HIV programmes
Organised/less congested clinic
South Africa
Strong NGO support
Smaller community
Fewer new ART initiations – smaller clinic
Clients relatively close to clinic

11. When it makes sense to individuals to start promptly
In sero-discordant couples
When pregnant
When feeling ill
Family history of HIV (and death)
Co-morbidity (e.g. TB)
Adolescents (guardian initiated, sometimes without knowledge of adolescent) – this may make sense for the guardian… but not to the adolescent.

12. Why some people need time
Putting things in place (disclosure, support)
Practicalities (livelihood demands)
Acceptance/readiness (denial/anger)
Navigating relationships
Alcohol/drug use
Food security
Feeling fine, managing without treatment
Using alternative treatment and/or strategies

13. Challenges in the health system
Staff readiness, stress and attitude
Waiting times/congestion
Worries over risks of being seen at a clinic (stigma)
Change in guidelines
legacy of CD4, low knowledge of TasP/UTT
Occasional discrepant HIV result
Challenges in restarting after defaulting

14. Conclusion
Sometimes it makes sense to a person to start treatment promptly, but not always
One-size does not fit all
Take into account social realities
Clients have concerns and fears about the
scaling up of treatment and
the burden on the health system