HITS: a community-randomized trial to increase linkage to care in rural South Africa

  

Introduction: HIV elimination in South Africa requires innovative approaches to ensure men test for HIV and start treatment to reduce onwards transmission. We investigated the effectiveness of intrinsic and extrinsic motivators to increase uptake of HIV testing and linkage to care in a 2x2 factorial cluster randomized controlled trial, “Home-Based Intervention to Test and Start” (HITS), in rural South Africa. Conditional financial incentives significantly increased home-based HIV testing uptake among men. Here, we report the effect of the intervention on linkage to care. 

Methods:  Between February and December 2018, in the uMkhanyakude district of KwaZulu-Natal, we randomly assigned 45 communities to one of four arms: (i) conditional financial incentives for home-based HIV testing and linkage to care within 6 weeks (R50 [$3] food voucher each); (ii) male-targeted HIV-specific decision-support app based on self-determination theory; (iii) both conditional financial incentives and EPIC-HIV; and (iv) standard of care (SoC). EPIC-HIV was individually offered to men via a tablet at the point of HIV test offer (EPIC-HIV1) or 1 month after home-based HIV testing if individuals who tested positive had not linked to care (EPIC-HIV2). We examined linkage to care (new initiation or re-start of ART after >2 months of care interruption) at local clinics within 6 weeks of a home visit. Intention-to-treat (ITT) analysis was performed using modified Poisson regression with adjustment for clustering of standard errors at the community level. 

Results: Among all 13,838 men ≥15 years living in the 45 communities, 20.7% (n=2,865) received home-based HIV testing, which resulted in 122 HIV-positive tests including 104 individuals who were newly diagnosed through the trial. The probability of having an HIV-positive test was significantly higher in all intervention arms. A total of 92 individuals, including 35 who received home-based positive tests, initiated ART or resumed care within 6 weeks of a home visit. In the ITT analysis, the probability of linkage to care was significantly higher in the EPIC-HIV only arm (risk ratio [RR]=1.86; 95% CI:1.19–2.92), compared to SoC. There was no increase in linkage to care within 6 weeks in the financial incentives only arm (RR=1.19, 95% CI:0.55–2.54) or the combined arm (RR=1.11, 95% CI:0.56–2.20), compared to SoC.

Conclusions: During a single round of interventions to improve linkage to care, a theory-based decision-support intervention increased linkage to care among men.