Re-thinking Linkage to Care in the Era of Universal Test and Treat: Insights from Implementation and Behavioral Science for Achieving the Second 90

  • Michael E. HerceEmail author
  • Benjamin H. Chi
  • Rodrigo C. Liao
  • Christopher J. Hoffmann
Open Access


To successfully link to care, persons living with HIV must negotiate a complex series of processes from HIV diagnosis through initial engagement with HIV care systems and providers. Despite the complexity involved, linkage to care is often oversimplified and portrayed as a single referral step. In this article, we offer a new conceptual framework for linkage to care, tailored to the current universal test and treat era that presents linkage to care as its own nuanced pathway within the larger HIV care cascade. Conceptualizing linkage to care in this way may help better identify and specify processes posing a barrier to linkage, and allow for the development of targeted implementation and behavioral science-based approaches to address them. Such approaches are likely to be most relevant to programmatic and clinical settings with limited resources and high HIV burden.


HIV Linkage to care Test and treat 90-90-90 Implementation science 


Para vincularse a la atención médica con éxito, las personas que viven con VIH tienen que negociar una serie de pasos complicados desde el diagnóstico del VIH hasta las interacciones primeras con los sistemas y proveedores de cuidado y tratamiento del VIH. A pesar de la complejidad involucrada, muchas veces el vínculo con la atención médica es demasiado simplificado y se considera como un solo paso de remisión. En este artículo, ofrecemos una nueva definición operativa de la vinculación con la atención médica, adaptada a la era actual de prueba y tratamiento universal que establece la vinculación a la atención médica como su propio camino matizado dentro de la cascada más amplia del tratamiento de VIH. Conceptualizando la vinculación a la atención médica de esta manera puede ayudar a identificar y especificar mejor los procesos que dificulten la vinculación a la atención médica, y permitir el desarrollo de estrategias dirigidas y basadas en la ciencia de implementación y de compartamiento para abordar esos procesos obstructivos. Es probable que estas estrategias sean más relevantes para contextos programáticos y clínicos con recursos limitados y una alta prevalencia de VIH.


Global calls to realize the UNAIDS 90-90-90 targets have been transformative, mobilizing governments and the international community to ensure: (1) 90% of people living with HIV (PLHIV) know their HIV status; (2) 90% of PLHIV who know their status start and sustain antiretroviral therapy (ART); and (3) 90% of PLHIV on ART achieve viral suppression. At the heart of these targets is a global effort to “treat all” PLHIV irrespective of CD4 count or clinical stage, a strategy known as universal test and treat (UTT). When implemented at scale, UTT can promote universal access to ART and lead to profound individual and public health benefits [1, 2, 3, 4, 5, 6]. As a result, UTT has been codified in countless country treatment guidelines since WHO endorsement in 2015 [7, 8], and is currently being implemented in many clinical and programmatic settings globally in pursuit of the first and second 90s.

Despite this global progress, efforts to achieve the second 90 have been hampered by persistent challenges with linkage to care (LTC), the pathway from HIV diagnosis to initial engagement with HIV care and treatment. In 2017, 41% of all PLHIV globally, and 21% of those aware of their HIV status were not receiving ART [9]. Recent pragmatic trials from sub-Saharan Africa highlight the extent of the LTC problem in those countries most heavily burdened by HIV. Two cluster randomized trials of treatment as prevention (ANRS 12249 [TasP] and HPTN 071 [PopART]) reported only 42–48% of adults linking to care after testing HIV-positive despite receiving a variety of linkage support services [10, 11]. Other work—mostly from before the UTT era—has identified important barriers and facilitators to LTC in low and middle-income countries (LMICs) [12, 13, 14, 15], and provided behavioral models to conceptualize HIV care utilization and LTC [16, 17, 18]. What appears less explored and, thereby, incompletely understood, are the processes integral to LTC in settings implementing UTT. In this paper, we present a conceptual framework that articulates the individual processes comprising LTC, and the service delivery approaches and health-seeking behaviors needed to successfully achieve LTC in the UTT era. Our goal is to provide a clear and operationally relevant description of these processes to support the implementation of evidence-based approaches to improve LTC, with particular focus on clinical and programmatic settings in LMICs highly burdened by HIV/AIDS.

A New Approach to Framing Linkage to Care

Successful LTC should reflect more than the first visit to the ART clinic, the first ART prescription [19], or a simple handoff between HIV testing and treatment providers. Instead, a programmatically meaningful definition of “full” LTC should include, at a minimum, that a newly HIV-diagnosed individual has received health communication regarding the HIV test result with post-test counseling, has registered for care, has been evaluated for ART, has received ART education (from a clinician or counselor), and has been dispensed and initiated ART. In our framework, we also include a return follow-up visit—after the initial ART dispensation—as a step in the LTC definition. This is to provide some assessment of linkage beyond a single (and potentially fleeting) encounter with the health care system. Notably, reports of patients who collect ART for the first time but never return for follow up range from 15% to over 30% across a range of settings [20, 21, 22], calling into question whether these patients were ever truly linked to care. Including a follow-up contact with the health care system—either in the facility or the community—enhances the assessment of linkage as being fully connected or linked into care versus having simply passed by an ART prescriber, but not having committed to continuing care or taking medications.

Another important consideration for a programmatically useful LTC definition is the time interval from testing HIV-positive to initiating ART care and attending follow-up. In routine practice, this time can range from minutes, to days, to weeks, or even months. A variety of time intervals have been used in the literature and for programmatic reporting, mostly focused on time from testing to one of the following steps: enrollment, first clinical evaluation, ART initiation, or baseline laboratory testing [23, 24]. Historically, the time interval used (e.g., 30, 60, or 90 days) has reflected programmatic needs resulting from routine data collection activities, funder reporting requirements, limited program resources, or other pragmatic considerations. Emerging data suggest that applying 1 month as a “deadline” for establishing LTC may be a programmatically useful time point to predict future viral suppression [24] and to identify “unlinked” individuals who may benefit from more intensive LTC services [25]. For example, in Uganda, 53% of newly HIV-diagnosed patients linked to care by 1 month—defined as registering for ART at a facility—with that figure increasing only slightly to 56% by 3 months post-diagnosis [21]. After 1 month, the incremental likelihood of patients linking to care increased only marginally [24]. Passively waiting beyond a few weeks, let alone 1 month, for a newly diagnosed HIV-positive individual to link to care may undermine a program’s ability to successfully identify, and then trace, find, and engage, individuals who have not yet achieved LTC.

In the time from testing HIV-positive, to being dispensed and initiating ART, to the first follow-up visit, there are multiple steps that should occur. We summarize these steps as part of a pragmatic operational definition of LTC, which frames LTC as its own pathway within the larger HIV cascade (Fig. 1). The steps include appropriately educating or counseling a patient, facilitating transfer to the care and treatment department, investigating for co-morbid infections and assessing safety of the planned ART regimen during clinical evaluation, initiating ART and dispensing other medications, providing early support, and completing a first follow-up visit. Ideally, the LTC pathway should take no more than a few weeks to complete all steps, including same-day or rapid ART initiation (within 7 days of diagnosis) in line with WHO guidelines [26], and a first return visit. The LTC pathway is informed by the social ecological model [27, 28] and the conceptual model of implementation research [29, 30], and thus reflects a complex set of processes, each involving dynamic interplay among multiple health system-, facility-, and patient behavior-level factors (Table 1) [12].
Fig. 1

Linkage to care pathway representing the steps necessary to ensure full linkage to care and treatment

Table 1

Barriers and health system-, service delivery-, and patient behavioral factors influencing linkage to care

Linkage to care pathway step & relevance



Health service delivery

Patient behavioral


HIV testing services

Counseling and testing services necessary to accurately and safely establish an HIV diagnosis

Setting (facility, venue, community, home, etc.); maintaining test kit supply chain

Access; provider attitude toward clients; provider incentives; quality assurance and control mechanisms

Motivation for testing; believing and acting upon test results

Access; test kit quality control; ensuring confidentiality and privacy; preventing inadvertent disclosure

Post-test counseling

Educating patient about HIV/AIDS and implications of the diagnosis for the patient, their partner(s), and their family; emphasizing benefits and availability of ART; discussing importance of LTC

Adequate training, support, and remuneration for counselors

Counseling technique, focus, and content

Engagement and trust in counselor

Adequate counseling space; effective counselor supervision and training

Care transfer

Robust, facilitated transition between testing and treatment departments, ultimately culminating in registration in the national HIV program and meeting treatment provider

Complexity of navigation to care registration

Patient-centered processes; facilitation of transfer/patient accompaniment

Perception of value of HIV care; perception of costs of attending care

Patient perceptions of time and value of HIV care; patient readiness to accept treatment and initiate ART

Clinical evaluation

Initial medical review, including comprehensive history and physical exam, laboratory evaluation, investigation for co-morbid infections and assessment of safety of planned ART regimen

Number of steps or visits required; adequate infrastructure and human resources for health

Integrity of laboratory testing and processes for returning results

Patient capacity (mediated by burden of illness)

Added burden from multiple clinical encounters which may require enduring long queues; clinic space; lab infrastructure; limited human resources and provider training

ART initiation

Patient ART readiness assessment and first ART dispensing

ART supply chain and logistics

Complexity of dispensing ART

Consideration of the relevance of ART and potential side effects

Patient “not ready” to start ART; internal and external stigma

Early support

Psychosocial counseling, often focused on adherence and “positive living,” and other support to lower barriers to care engagement, including voluntary facilitated partner disclosure

Patient-centered support versus health system-centered

Availability of peer supporters, support groups, and counselors; identifying individuals who do not return for support; Adherence counseling technique, focus, and content

Overcoming concerns of disclosure and stigma to engage in available support services

Patient not identifying value; unavailable or insufficiently resourced support services; weak connections between facility- and community-level services

First follow-up

Return visit with the treatment provider to confirm and support taking ART and continuing HIV care

Goals and timing of follow-up

Availability of health workers; capacity of facility for additional patient visits

Value of follow-up to patient

Establishing systems for scheduling early follow-up and reminding patients

HIV Testing Services

The context and modality of HIV testing services (HTS) and the availability of facilitated LTC services (e.g., accompaniment to the first clinic visit) have important effects on the population reached and the proportion of those testing positive who successfully link to care. Often, this is an inverse relationship. Thus, while community, mobile, or home-based testing may reach a population less likely to undergo testing, these approaches may be associated with lower LTC than facility-based testing when offered without facilitated linkage strategies [31]. For example, in a meta-analysis of 12 studies examining home- and campaign-based HTS, only 26% (95% confidence interval [CI] 18–36%) of newly HIV-diagnosed individuals visited an ART clinic compared to 61% with facility-based testing (95% CI 39–71%) [31]. In contrast, when combined with facilitated linkage interventions, the same meta-analysis suggests that home-based HIV testing and community-based campaign testing can support LTC (defined as a first visit to the ART clinic) that is excellent (95%, 95% CI 87–98%) [31]. Linkage to care following community HTS may be contextually dependent [31]. For instance, in Malawi, just 56% of newly HIV-diagnosed adults realized LTC—defined as accessing confirmatory testing and clinic-based HIV care—following implementation of a novel community-based HIV self-testing strategy [32]. Additional studies are needed to further evaluate LTC after other innovative HTS approaches (e.g., following couples-based testing).

Post-test Counseling

Post-test counseling has long been a cornerstone of HTS; however, its effectiveness for facilitating LTC has not been rigorously evaluated. Many existing practices for post-test counseling provide HIV-related information that may only be tangentially related to LTC [33, 34]. For example, many national post-test counseling guidelines have historically emphasized healthy lifestyle practices and prevention of HIV transmission through condom use or status disclosure. Until very recently, less attention has been paid to LTC, immediate ART initiation, and messages around achieving an undetectable viral load (e.g., undetectable = untransmittable) [34]. In the UTT era, there is a need to determine the optimal counseling communication technique and content, and the effectiveness of post-test counseling for supporting LTC [35]. In this regard, applying health belief and transtheoretical health behavior models may help adapt existing post-test counseling approaches to enhance LTC [28, 36, 37]. Approaches informed by both models may help counselors better provide client-centered counseling and align the value of LTC with patient goals and values. This may guide a patient in overcoming specific barriers to LTC, and could be particularly important for asymptomatic patients or those with high levels of fatalism or denial.

Longitudinal or “follow-up” counseling that focuses on LTC and occurs subsequent to HTS (and post-test counseling) has been evaluated in multiple studies, yielding modest LTC improvements in South Africa (38% vs. 31%) and Uganda (51% vs. 33%) when compared to standard care [25, 38]. Follow-up counseling generally encourages patients to access care and initiate ART, and is delivered over multiple counseling sessions that explicitly emphasize the importance of early LTC. Importantly, such longitudinal counseling typically takes a client-centered approach to address individual concerns and needs [39]. This process may not be an essential step in the LTC pathway for all patients, but may be important to achieve LTC for a select group. For example, follow-up counseling can be targeted toward patients in denial of an HIV diagnosis, those who do not accept ART on the day of testing, or PLHIV who fail to initiate ART within a specified time frame [40]. If, where, and how follow-up counseling should be positioned within the LTC pathway and existing HIV service delivery platforms needs further evaluation.

Care Transfer from Testing to Treatment

After HIV testing and counseling, a structured process should take place in which the newly diagnosed patient seamlessly transfers between testing and care settings. This transfer may take several forms. The simplest scenario occurs when the HTS provider is also the ART prescriber. There may also be direct transitions to ART assessment and dispensing following post-test counseling when HTS and ART services are co-located and ART providers are immediately available to assess a patient. Even in this case, multiple challenges may complicate a seemingly simple process, including time constraints for the provider or patient, the patient’s desire to receive HIV care elsewhere (i.e. transfer openly or “silently”), high patient volumes competing for the provider’s time, or local practices regarding ART preparedness and safety assessments. Despite such challenges, ART initiation during the HTS encounter has been delivered successfully in rural Lesotho and in antenatal care in multiple LMICs [22, 41, 42]. In other settings, HTS team members may accompany a patient to initiate ART at a facility located elsewhere from where testing occurred [43, 44]. Such personalized accompaniment from the testing to the treatment venue warrants further study as a strategy to strengthen care transfer. Common to each of these approaches is a client-centered approach to service delivery. Considering the client needs before health system convenience is likely to improve success with all ART initiation approaches. Overall, success with facilitating care transfer from HTS to ART providers has been demonstrated by reducing the number of, and time required for, steps in the transfer process [22, 44, 45, 46].

Clinical Evaluation

Clinical evaluation is required prior to ART initiation. The goals of this evaluation include: inspiring confidence in ART care; obtaining a complete medical history, including ART history to identify and optimize care for any returning patients re-initiating treatment after prolonged ART interruption or care disengagement (e.g., the so-called “side door” to the HIV cascade) [47]; conducting baseline laboratory testing to assess for co-morbid conditions (e.g. chronic kidney disease) and to determine the severity of HIV disease (e.g., baseline CD4 cell count testing); and screening for sub-clinical opportunistic infections (OIs) and other potentially life-threatening conditions that could be exacerbated by the planned ART regimen, such as cryptococcal meningitis and tuberculosis (TB). This evaluation can be a barrier to LTC if it necessitates multiple clinical contacts and excessive delays [13], as ART can be successfully initiated prior to having laboratory results in LMICs [48]. Local context, including the availability of point-of-care (POC) testing, may influence the prioritization, timing, and speed of baseline laboratory evaluation during ART initiation [49, 50].

As the leading cause of morbidity and mortality among PLHIV in LMICs, assessment for TB is an essential part of the clinical evaluation, but one that may add complexity to the LTC pathway due to the lack of a simple, rapid, and affordable POC diagnostic tool in most clinical settings [26, 51]. Reducing or eliminating the patient-level complexity and duration of evaluation for TB and other OIs may improve LTC [52]. Rapid near POC testing with Xpert MTB/RIF [53], POC testing with TB-LAM [54], co-locating TB and HIV diagnostic and treatment services [55], and telephonic delivery of test results to providers and patients (before or after ART initiation) have all shown promise for streamlining TB and HIV care integration [56].

Antimicrobial prophylaxis can prevent TB and other co-morbid infections, does not adversely affect viral load suppression despite the added pill burden [57], and should be smoothly integrated within ART care to facilitate LTC rather than create additional barriers. While isoniazid preventive therapy and cotrimoxazole are the most commonly prescribed, recent evidence supports the use of shorter course TB preventive regimens [58, 59], as well as some combination of fluconazole, azithromycin, and albendazole provision in patients with advanced immunosuppression [57]. Seamlessly integrating OI preventive therapy and new laboratory testing modalities within the baseline clinical evaluation may require adopting human-centered design approaches to ensure maximally efficient patient care services responsive to clinic workflow, available human resources for health, and other health system constraints [60].

ART Initiation

There are multiple potential benefits of initiating ART on the same day as diagnosis, including promotion of early LTC and reduction in the number of health service contacts prior to ART initiation [44, 61]. In Lesotho, for example, offering home-based ART initiation on the day of testing increased LTC by 25.6% (95% CI 13.8–36.3%) at 3 months compared to usual care [22]. Health system encouragement of “same day” treatment may also serve to reinforce the health benefits of early ART, just as is done for many other infectious diseases. Disadvantages of starting ART on the day of testing may include increased risk of failing to attend a first follow-up visit and resulting failure to establish full LTC. If ART is started without proper patient preparation, it is possible that its use may be sporadic, which in turn could lead to HIV drug resistance, especially with regimens containing efavirenz or nevirapine. Patient-centered approaches to measuring ART readiness—as has been done in some settings [61]—may help identify patients requiring additional counseling and support to ensure long-term adherence. These approaches likely need further refinement to be generally useful and should not unduly delay ART initiation among those who are ready to start and likely to remain adherent over time.

Early Support

Careful consideration must be given after ART initiation to services to help patients adjust to new realities of managing a chronic illness. Insights from social cognitive theory suggest that there is a dynamic relationship between a patient’s behavior toward managing their illness and their environmental and physiologic milieu, which interact in myriad ways to affect longitudinal engagement in care and, ultimately, health outcomes [28]. Empowering patients with skills to positively influence their environment, build self-efficacy, and overcome personal and structural barriers to care can help patients develop positive support networks, fully engage with healthcare providers, and take their medications regularly [62].

Pragmatically addressing the social determinants of health, including poverty, malnutrition, and social isolation through socioeconomic interventions, patient-enabling strategies to facilitate service access, nutritional supplementation, and community health worker or peer navigation services may also assist some patients to more fully establish care during the early stages of their treatment and develop a stronger bond with the care system [63, 64]. How early peer-based support may generate other downstream programmatic benefits, such as by promoting voluntary partner disclosure for HIV index testing or creating patient demand for viral load testing, require future investigation. Group support models, such as community adherences groups and patient ART initiation “clubs”, and other differentiated service delivery (DSD) models may decrease barriers and opportunity costs of care while potentially increasing value of care engagement. Such approaches may prove feasible and effective for patients in some settings [65, 66]. DSD models initially designed for stably in-care patients should be further studied and adapted to the needs of new and returning patients to better support them as they face the first days and weeks of (re-)treatment.

Underlying many early support interventions is a focus on providing adherence counseling. Adherence counseling can be delivered in group, community, or facility settings by lay counselors, peers, community health workers, nurses, or clinicians, depending on the local context. While multiple adherence counseling sessions have been required for patients to start ART and promote adherence in many programs (e.g., 3 counseling sessions over 3 weeks before ART can be initiated), additional research is needed to elucidate the optimal form and timing of adherence counseling within the LTC pathway. Notably, there are few data on the effectiveness of, or best practices for, adherence counseling.

Early Follow-Up

Early follow-up shortly after ART initiation is thought to be important. This is a period during which ART adherence can be re-enforced, ART side effects managed (prior to a patient self-discontinuing treatment), and patient strategies introduced for managing internalized stigma and coping with living with HIV. While the exact timing for optimal early follow-up is unknown, operational data from routine care settings suggest that scheduling a first follow-up visit a few months after ART initiation is too long to wait and may undermine patient care engagement [21]. Moreover, the ideal modality for early follow-up (e.g., provider-patient clinic encounter, pharmacy visit, community- or home-based visit, group meeting, or phone call) is also unclear. Finally, while interventions such as flexible clinic hours and text message appointment reminders hold promise for facilitating early ART use [67], optimal strategies to promote early follow-up and how early follow-up influences later retention in care are areas of uncertainty.

Monitoring and Measuring Linkage to Care

A universal operational definition for LTC responsive to the UTT era is urgently needed to allow comparison of LTC outcomes over time within and across programs. We propose a programmatic definition for “full” LTC that presents the proportion of newly diagnosed HIV-positive individuals who successfully register in the national treatment program, undergo baseline clinical and laboratory evaluation, collect a first ART prescription, initiate ART, and return for a first follow-up visit—all within a well-specified time frame (e.g., no more than 2 to 4 weeks from HIV diagnosis). Such a definition may be applied at an individual level to identify patients who have not achieved full LTC or at a program level to prompt corrective action when a program’s LTC “rate” fails to meet a pre-specified target. To be most effective, LTC data must be tracked for individual patients as they progress through each step in the LTC pathway, with a particular focus on ART initiation [19], so providers and program managers can identify areas of attrition and develop ways to address them. The use of a paper-based linkage register that captures every new HIV diagnosis within a facility’s catchment area and documents patient HTS, ART, and laboratory identifying numbers from disparate data sources in one data recording tool may be a low-cost approach for improving individual-level LTC reporting. Newer strategies to link diverse HIV program data, such as biometrics and SIM chip- or barcode-enabled patient cards encoding a national health identifier, merit further evaluation and scale up [68]. Using such individually linked health information across data platforms is the most promising strategy to provide true patient-level descriptions of LTC. Critically, these linked data need to identify in as real-time as possible: (1) patients who have not fully linked and may benefit from a specific enhanced LTC strategy; and (2) clinic-level trends to guide quality improvement activities. Implementing partners and funding agencies should move away from reporting uncoupled cross-sectional estimates of LTC (e.g., total number of PLHIV newly initiating ART divided by the total number of new HIV diagnoses in a reporting period), which do not track individual patients along the LTC pathway and may overestimate rates of successful linkage. Instead, employing longitudinal information, programs should adopt sequential time-defined patient-level “cohort” reporting, which can be used to assess LTC changes over time and to monitor LTC in populations who may be less likely to achieve full LTC (e.g., adolescents) [69]. Where universal national health identifiers are not available, cohort-based reporting within a geographic area (e.g., district or province) may be assisted by electronic health record data capture at all service entry points along the LTC pathway [70] and the use of probabilistic patient matching algorithms to identify silent transfers, “side door” LTC pathway entry [47], and minimize duplicate patient records [71].


Successful LTC requires a patient to navigate a series of processes, from testing HIV positive through post-test counseling, care transfer, clinical evaluation, ART initiation, and initial follow-up. Identifying the process that is the greatest barrier to successful LTC—at health system, service delivery, or patient behavior levels—is a critical first step. Once identified, the barrier can be specified, characterized, and measured to spark program improvement. With this clear understanding in hand, targeted and context appropriate health system strategies or patient-level interventions can be designed to address the deficient process or processes within the LTC pathway. Critical examination of LTC as its own pathway will help to illuminate how and where intervention are, and are not, working and enable the design of new implementation strategies to achieve the second 90.


Compliance with Ethical Standards

Conflict of interest

The authors declare that they have no conflict of interest.

Research Involving Human Participants

This commentary did not involve any contact or procedures involving human participants.


  1. 1.
    UNAIDS. 90-90-90: An ambitious treatment target to help end the AIDS epidemic. Geneva, Switzerland: Joint United Nations Programme on HIV/AIDS (UNAIDS); 2014.Google Scholar
  2. 2.
    UNAIDS. Fast-Track: Ending the AIDS Epidemic by 2030. Geneva, Switzerland: Joint United Nations Programme on HIV/AIDS (UNAIDS); 2014.Google Scholar
  3. 3.
    Cohen MS, Chen YQ, McCauley M, Gamble T, Hosseinipour MC, Kumarasamy N, et al. Prevention of HIV-1 infection with early antiretroviral therapy. N Engl J Med. 2011;365(6):493–505.CrossRefPubMedPubMedCentralGoogle Scholar
  4. 4.
    Tanser F, Barnighausen T, Grapsa E, Zaidi J, Newell ML. High coverage of ART associated with decline in risk of HIV acquisition in rural KwaZulu-Natal, South Africa. Science. 2013;339(6122):966–71.CrossRefPubMedPubMedCentralGoogle Scholar
  5. 5.
    The INSIGHT START Study Group. Initiation of antiretroviral therapy in early asymptomatic HIV infection. N Engl J Med. 2015;373(9):795–807.CrossRefPubMedCentralGoogle Scholar
  6. 6.
    Granich RM, Gilks CF, Dye C, De Cock KM, Williams BG. Universal voluntary HIV testing with immediate antiretroviral therapy as a strategy for elimination of HIV transmission: a mathematical model. Lancet. 2009;373(9657):48–57.CrossRefPubMedGoogle Scholar
  7. 7.
    WHO. Consolidated guidelines on the use of antiretroviral drugs for treating and preventing HIV infection: recommendations for a public health approach. Geneva: World Health Organization (WHO); 2016.Google Scholar
  8. 8.
    WHO. Guideline on when to start antiretroviral therapy and on pre-exposure prophylaxis for HIV. Geneva: World Health Organization (WHO); 2015.Google Scholar
  9. 9.
    UNAIDS. Global AIDS update 2018: miles to go. Geneva: Joint United Nations Programme on HIV/AIDS (UNAIDS); 2018.Google Scholar
  10. 10.
    Iwuji CC, Orne-Gliemann J, Larmarange J, Okesola N, Tanser F, Thiebaut R, et al. Uptake of home-based HIV testing, linkage to care, and community attitudes about ART in Rural KwaZulu-Natal, South Africa: descriptive results from the first phase of the ANRS 12249 TasP cluster-randomised trial. PLoS Med. 2016;13(8):e1002107.CrossRefPubMedPubMedCentralGoogle Scholar
  11. 11.
    Hayes R, Floyd S, Schaap A, Shanaube K, Bock P, Sabapathy K, et al. A universal testing and treatment intervention to improve HIV control: one-year results from intervention communities in Zambia in the HPTN 071 (PopART) cluster-randomised trial. PLOS Med. 2017;14(5):e1002292.CrossRefPubMedPubMedCentralGoogle Scholar
  12. 12.
    Tso LS, Best J, Beanland R, Doherty M, Lackey M, Ma Q, et al. Facilitators and barriers in HIV linkage to care interventions: a qualitative evidence review. AIDS (London, England). 2016;30(10):1639–53.CrossRefGoogle Scholar
  13. 13.
    Mabuto T, Charalambous S, Kennedy C, Hoffmann CJ. Perceptions of value and cost of HIV care engagement following diagnosis in South Africa. AIDS Behav. 2018;22(11):3751–62.CrossRefPubMedGoogle Scholar
  14. 14.
    Inguane CA, Gloyd S, Manuel JL, Brown C, Wong V, Augusto O, et al. Assessment of linkages from HIV testing to enrolment and retention in HIV care in Central Mozambique. J Int AIDS Soc. 2016;19(5 Suppl 4):20846.PubMedPubMedCentralGoogle Scholar
  15. 15.
    Dorward J, Mabuto T, Charalambous S, Fielding KL, Hoffmann CJ. Factors associated with poor linkage to HIV care in South Africa: secondary analysis of data from the Thol’impilo trial. J Acquir Immune Defic Syndr (1999). 2017;76(5):453–60.CrossRefGoogle Scholar
  16. 16.
    Phillips KA, Morrison KR, Andersen R, Aday LA. Understanding the context of healthcare utilization: assessing environmental and provider-related variables in the behavioral model of utilization. Health Serv Res. 1998;33(3 Pt 1):571–96.PubMedPubMedCentralGoogle Scholar
  17. 17.
    Gelberg L, Andersen RM, Leake BD. The behavioral model for vulnerable populations: application to medical care use and outcomes for homeless people. Health Serv Res. 2000;34(6):1273–302.PubMedPubMedCentralGoogle Scholar
  18. 18.
    Hoffmann CJ, Mabuto T, McCarthy K, Maulsby C, Holtgrave DR. A framework to inform strategies to improve the HIV care continuum in low- and middle-income countries. AIDS Educ Prev: Off Public Int Soc AIDS Educ. 2016;28(4):351–64.CrossRefGoogle Scholar
  19. 19.
    Fox MP, Rosen S. A new cascade of HIV care for the era of “treat all”. PLoS Med. 2017;14(4):e1002268.CrossRefPubMedPubMedCentralGoogle Scholar
  20. 20.
    Tenthani L, Haas AD, Tweya H, Jahn A, van Oosterhout JJ, Chimbwandira F, et al. Retention in care under universal antiretroviral therapy for HIV-infected pregnant and breastfeeding women (‘Option B + ’) in Malawi. AIDS (London, England). 2014;28(4):589–98.CrossRefPubMedCentralGoogle Scholar
  21. 21.
    Boeke CE, Nabitaka V, Rowan A, Guerra K, Kabbale A, Asire B, et al. Assessing linkage to and retention in care among HIV patients in Uganda and identifying opportunities for health systems strengthening: a descriptive study. BMC Infect Dis. 2018;18(1):138.CrossRefPubMedPubMedCentralGoogle Scholar
  22. 22.
    Labhardt ND, Ringera I, Lejone TI, Klimkait T, Muhairwe J, Amstutz A, et al. Effect of offering same-day ART vs usual health facility referral during home-based HIV testing on linkage to care and viral suppression among adults with HIV in Lesotho. JAMA. 2018;319(11):1103–12.CrossRefPubMedPubMedCentralGoogle Scholar
  23. 23.
    MacCarthy S, Hoffmann M, Ferguson L, Nunn A, Irvin R, Bangsberg D, et al. The HIV care cascade: models, measures and moving forward. J Int AIDS Soc. 2015;18:19395.CrossRefPubMedPubMedCentralGoogle Scholar
  24. 24.
    Hall HI, Tang T, Johnson AS, Espinoza L, Harris N, McCray E. Timing of linkage to care after HIV diagnosis and time to viral suppression. J Acquir Immune Defic Syndr (1999). 2016;72(2):e57–60.CrossRefGoogle Scholar
  25. 25.
    Ruzagira E, Grosskurth H, Kamali A, Baisley K. Brief counselling after home-based HIV counselling and testing strongly increases linkage to care: a cluster-randomized trial in Uganda. J Int AIDS Soc. 2017;20(2):e25014.CrossRefPubMedCentralGoogle Scholar
  26. 26.
    WHO. Guidelines for managing advanced HIV disease and rapid initiation of antiretroviral therapy. Geneva: World Health Organization (WHO); 2017.Google Scholar
  27. 27.
    McLeroy KR, Bibeau D, Steckler A, Glanz K. An ecological perspective on health promotion programs. Health Educ Q. 1988;15(4):351–77.CrossRefPubMedGoogle Scholar
  28. 28.
    Glanz K, Bishop DB. The role of behavioral science theory in development and implementation of public health interventions. Annu Rev Public Health. 2010;31:399–418.CrossRefGoogle Scholar
  29. 29.
    Proctor EK, Landsverk J, Aarons G, Chambers D, Glisson C, Mittman B. Implementation research in mental health services: an emerging science with conceptual, methodological, and training challenges. Adm Policy Ment Health. 2009;36(1):24–34.CrossRefPubMedGoogle Scholar
  30. 30.
    Tabak RG, Khoong EC, Chambers DA, Brownson RC. Bridging research and practice: models for dissemination and implementation research. Am J Prev Med. 2012;43(3):337–50.CrossRefPubMedPubMedCentralGoogle Scholar
  31. 31.
    Sharma M, Ying R, Tarr G, Barnabas R. Systematic review and meta-analysis of community and facility-based HIV testing to address linkage to care gaps in sub-Saharan Africa. Nature. 2015;528(7580):S77–85.CrossRefPubMedPubMedCentralGoogle Scholar
  32. 32.
    Choko AT, MacPherson P, Webb EL, Willey BA, Feasy H, Sambakunsi R, et al. Uptake, accuracy, safety, and linkage into care over two years of promoting annual self-testing for HIV in Blantyre, Malawi: a community-based prospective study. PLoS Med. 2015;12(9):e1001873.CrossRefPubMedPubMedCentralGoogle Scholar
  33. 33.
    Fisher JD, Fisher WA, Williams SS, Malloy TE. Empirical tests of an information-motivation-behavioral skills model of AIDS-preventive behavior with gay men and heterosexual university students. Health Psychol: Off J Div Health Psychol, Am Psychol Assoc. 1994;13(3):238–50.CrossRefGoogle Scholar
  34. 34.
    WHO. Consolidated guidelines on HIV testing services: 5Cs: Consent, Confidentiality, Counselling, Correct Results and Connection. Geneva: World Health Organization (WHO); 2015.Google Scholar
  35. 35.
    Leon N, Mathews C, Lewin S, Osler M, Boulle A, Lombard C. A comparison of linkage to HIV care after provider-initiated HIV testing and counselling (PITC) versus voluntary HIV counselling and testing (VCT) for patients with sexually transmitted infections in Cape Town, South Africa. BMC Health Serv Res. 2014;14:350.CrossRefPubMedPubMedCentralGoogle Scholar
  36. 36.
    Cummings KM, Jette AM, Rosenstock IM. Construct validation of the health belief model. Health Educ Monogr. 1978;6(4):394–405.PubMedGoogle Scholar
  37. 37.
    Glanz K, Rimer BK, Viswanath K, editors. Health behavior and health education: theory, research, and practice. San Francisco: Jossey-Bass; 2008.Google Scholar
  38. 38.
    Hoffmann CJ, Mabuto T, Ginindza S, Fielding KL, Kubeka G, Dowdy DW, et al. Strategies to accelerate HIV care and antiretroviral therapy initiation after HIV diagnosis: a randomized trial. J Acquir Immune Defic Syndr (1999). 2017;75(5):540–7.CrossRefGoogle Scholar
  39. 39.
    Kanekar AS. HIV/AIDS counseling skills and strategies: can testing and counseling curb the epidemic? Int J Prev Med. 2011;2(1):10–4.PubMedPubMedCentralGoogle Scholar
  40. 40.
    Sabapathy K, Mubekapi-Musadaidzwa C, Mulubwa C, Schaap A, Hoddinott G, Stangl A, et al. Predictors of timely linkage-to-ART within universal test and treat in the HPTN 071 (PopART) trial in Zambia and South Africa: findings from a nested case-control study. J Int AIDS Soc. 2017. Scholar
  41. 41.
    van Lettow M, Bedell R, Mayuni I, Mateyu G, Landes M, Chan AK, et al. Towards elimination of mother-to-child transmission of HIV: performance of different models of care for initiating lifelong antiretroviral therapy for pregnant women in Malawi (option B +). J Int AIDS Soc. 2014;17:18994.CrossRefPubMedPubMedCentralGoogle Scholar
  42. 42.
    Killam WP, Tambatamba BC, Chintu N, Rouse D, Stringer E, Bweupe M, et al. Antiretroviral therapy in antenatal care to increase treatment initiation in HIV-infected pregnant women: a stepped-wedge evaluation. AIDS (London, England). 2010;24(1):85–91.CrossRefGoogle Scholar
  43. 43.
    Reif LK, Rivera V, Louis B, Bertrand R, Peck M, Anglade B, et al. Community-based HIV and health testing for high-risk adolescents and youth. AIDS Patient Care STDs. 2016;30(8):371–8.CrossRefPubMedPubMedCentralGoogle Scholar
  44. 44.
    Schwarcz S, Hsu LC, Scheer S. Disparities and trends in viral suppression during a transition to a “test and treat” approach to the HIV epidemic, San Francisco, 2008-2012. J Acquir Immune Defic Syndr (1999). 2015;70(5):529–37.CrossRefGoogle Scholar
  45. 45.
    Rosen S, Maskew M, Fox MP, Nyoni C, Mongwenyana C, Malete G, et al. Initiating antiretroviral therapy for HIV at a patient’s first clinic visit: the RapIT randomized controlled trial. PLoS Med. 2016;13(5):e1002015.CrossRefPubMedPubMedCentralGoogle Scholar
  46. 46.
    MacPherson P, Lalloo DG, Webb EL, Maheswaran H, Choko AT, Makombe SD, et al. Effect of optional home initiation of HIV care following HIV self-testing on antiretroviral therapy initiation among adults in Malawi: a randomized clinical trial. JAMA. 2014;312(4):372–9.CrossRefPubMedPubMedCentralGoogle Scholar
  47. 47.
    Hallett TB, Eaton JW. A side door into care cascade for HIV-infected patients? J Acquir Immune Defic Syndr. 1999;2013(63 Suppl 2):S228–32.Google Scholar
  48. 48.
    Schouten EJ, Jahn A, Midiani D, Makombe SD, Mnthambala A, Chirwa Z, et al. Prevention of mother-to-child transmission of HIV and the health-related Millennium Development Goals: time for a public health approach. Lancet. 2011;378(9787):282–4.CrossRefPubMedGoogle Scholar
  49. 49.
    Gous NM, Scott LE, Potgieter J, Ntabeni L, Sanne I, Stevens WS. Implementation and operational research: implementation of multiple point-of-care testing in 2 HIV antiretroviral treatment clinics in South Africa. J Acquir Immune Defic Syndr (1999). 2016;71(2):e34–43.CrossRefGoogle Scholar
  50. 50.
    Rick F, Niyibizi AA, Shroufi A, Onami K, Steele SJ, Kuleile M, et al. Cryptococcal antigen screening by lay cadres using a rapid test at the point of care: a feasibility study in rural Lesotho. PLoS ONE. 2017;12(9):e0183656.CrossRefPubMedPubMedCentralGoogle Scholar
  51. 51.
    Walzl G, McNerney R, du Plessis N, Bates M, McHugh TD, Chegou NN, et al. Tuberculosis: advances and challenges in development of new diagnostics and biomarkers. Lancet Infect Dis. 2018;18(7):e199–210.CrossRefPubMedGoogle Scholar
  52. 52.
    Bassett IV, Coleman SM, Giddy J, Bogart LM, Chaisson CE, Ross D, et al. Sizanani: a randomized trial of health system navigators to improve linkage to HIV and TB care in South Africa. J Acquir Immune Defic Syndr (1999). 2016;73(2):154–60.CrossRefGoogle Scholar
  53. 53.
    Lawn SD, Brooks SV, Kranzer K, Nicol MP, Whitelaw A, Vogt M, et al. Screening for HIV-associated tuberculosis and rifampicin resistance before antiretroviral therapy using the Xpert MTB/RIF assay: a prospective study. PLoS Med. 2011;8(7):e1001067.CrossRefPubMedPubMedCentralGoogle Scholar
  54. 54.
    Lawn SD, Kerkhoff AD, Vogt M, Wood R. Diagnostic accuracy of a low-cost, urine antigen, point-of-care screening assay for HIV-associated pulmonary tuberculosis before antiretroviral therapy: a descriptive study. Lancet Infect Dis. 2012;12(3):201–9.CrossRefPubMedPubMedCentralGoogle Scholar
  55. 55.
    Legido-Quigley H, Montgomery CM, Khan P, Atun R, Fakoya A, Getahun H, et al. Integrating tuberculosis and HIV services in low- and middle-income countries: a systematic review. Trop Med Int Health: TM & IH. 2013;18(2):199–211.CrossRefGoogle Scholar
  56. 56.
    Maraba N, Hoffmann CJ, Chihota VN, Chang LW, Ismail N, Candy S, et al. Using mHealth to improve tuberculosis case identification and treatment initiation in South Africa: results from a pilot study. PLoS ONE. 2018;13(7):e0199687.CrossRefPubMedPubMedCentralGoogle Scholar
  57. 57.
    Hakim J, Musiime V, Szubert AJ, Mallewa J, Siika A, Agutu C, et al. Enhanced Prophylaxis plus antiretroviral therapy for advanced HIV infection in Africa. N Engl J Med. 2017;377(3):233–45.CrossRefPubMedPubMedCentralGoogle Scholar
  58. 58.
    Menzies D, Adjobimey M, Ruslami R, Trajman A, Sow O, Kim H, et al. Four months of Rifampin or nine months of isoniazid for latent Tuberculosis in adults. N Engl J Med. 2018;379(5):440–53.CrossRefPubMedGoogle Scholar
  59. 59.
    Borisov AS, Bamrah Morris S, Njie GJ, Winston CA, Burton D, Goldberg S, et al. Update of recommendations for use of once-weekly isoniazid-Rifapentine Regimen to treat latent mycobacterium tuberculosis infection. MMWR Morb Mortal Wkly Rep. 2018;67(25):723–6.CrossRefPubMedPubMedCentralGoogle Scholar
  60. 60.
    Catalani C, Green E, Owiti P, Keny A, Diero L, Yeung A, et al. A clinical decision support system for integrating tuberculosis and HIV care in Kenya: a human-centered design approach. PLoS ONE. 2014;9(8):e103205.CrossRefPubMedPubMedCentralGoogle Scholar
  61. 61.
    Koenig SP, Dorvil N, Devieux JG, Hedt-Gauthier BL, Riviere C, Faustin M, et al. Same-day HIV testing with initiation of antiretroviral therapy versus standard care for persons living with HIV: a randomized unblinded trial. PLoS Med. 2017;14(7):e1002357.CrossRefPubMedPubMedCentralGoogle Scholar
  62. 62.
    Gifford AL, Sengupta S. Self-management health education for chronic HIV infection. AIDS Care. 1999;11(1):115–30.CrossRefPubMedGoogle Scholar
  63. 63.
    Koenig SP, Leandre F, Farmer PE. Scaling-up HIV treatment programmes in resource-limited settings: the rural Haiti experience. AIDS (London, England). 2004;18(Suppl 3):S21–5.CrossRefGoogle Scholar
  64. 64.
    Rich ML, Miller AC, Niyigena P, Franke MF, Niyonzima JB, Socci A, et al. Excellent clinical outcomes and high retention in care among adults in a community-based HIV treatment program in rural Rwanda. J Acquir Immune Defic Syndr (1999). 2012;59(3):e35–42.CrossRefGoogle Scholar
  65. 65.
    Decroo T, Telfer B, Biot M, Maikere J, Dezembro S, Cumba LI, et al. Distribution of antiretroviral treatment through self-forming groups of patients in Tete Province, Mozambique. J Acquir Immune Defic Syndr (1999). 2011;56(2):e39–44.CrossRefGoogle Scholar
  66. 66.
    Luque-Fernandez MA, Van Cutsem G, Goemaere E, Hilderbrand K, Schomaker M, Mantangana N, et al. Effectiveness of patient adherence groups as a model of care for stable patients on antiretroviral therapy in Khayelitsha, Cape Town, South Africa. PLoS ONE. 2013;8(2):e56088.CrossRefPubMedPubMedCentralGoogle Scholar
  67. 67.
    Petersen M, Balzer L, Kwarsiima D, Sang N, Chamie G, Ayieko J, et al. Association of implementation of a universal testing and treatment intervention with HIV diagnosis, receipt of antiretroviral therapy, and viral suppression in East Africa. JAMA. 2017;317(21):2196–206.CrossRefPubMedPubMedCentralGoogle Scholar
  68. 68.
    Beck EJ, Shields JM, Tanna G, Henning G, de Vega I, Andrews G, et al. Developing and implementing national health identifiers in resource limited countries: why, what, who, when and how? Glob Health Action. 2018;11(1):1440782.CrossRefPubMedPubMedCentralGoogle Scholar
  69. 69.
    Wong VJ, Murray KR, Phelps BR, Vermund SH, McCarraher DR. Adolescents, young people, and the 90–90–90 goals. AIDS (London, England). 2017;31:S191–4.CrossRefPubMedCentralGoogle Scholar
  70. 70.
    Braitstein P, Einterz RM, Sidle JE, Kimaiyo S, Tierney W. “Talkin’ about a revolution”: how electronic health records can facilitate the scale-up of HIV care and treatment and catalyze primary care in resource-constrained settings. J Acquir Immune Defic Syndr (1999). 1999;2009(52 Suppl 1):S54–7.Google Scholar
  71. 71.
    Waruru A, Natukunda A, Nyagah LM, Kellogg TA, Zielinski-Gutierrez E, Waruiru W, et al. Where no universal health care identifier exists: comparison and determination of the utility of score-based persons matching algorithms using demographic data. JMIR Public Health Surviv. 2018;4(4):e10436.CrossRefGoogle Scholar

Copyright information

© The Author(s) 2019
corrected publication 2019

Open AccessThis article is distributed under the terms of the Creative Commons Attribution 4.0 International License (, which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made.

Authors and Affiliations

  • Michael E. Herce
    • 1
    Email author
  • Benjamin H. Chi
    • 2
  • Rodrigo C. Liao
    • 3
  • Christopher J. Hoffmann
    • 4
  1. 1.Division of Infectious Diseases, Department of MedicineUniversity of North Carolina School of MedicineChapel HillUSA
  2. 2.Division of Global Women’s Health, Department of Obstetrics & GynecologyUniversity of North Carolina School of MedicineChapel HillUSA
  3. 3.Department of Health BehaviorUNC Gillings School of Global Public HealthChapel HillUSA
  4. 4.Department of MedicineJohns Hopkins University School of Medicine and School of Public HealthBaltimoreUSA

Personalised recommendations