Same-Day CD4 Testing to Improve Uptake of HIV Care and Treatment in South Africa: Point-of-Care Is Not Enough

Background. We evaluated whether a pilot program providing point-of-care (POC), but not rapid, CD4 testing (BD FACSCount) immediately after testing HIV-positive improved retention in care. Methods. We conducted a retrospective record review at the Themba Lethu Clinic in Johannesburg, South Africa. We compared all walk-in patients testing HIV-positive during February, July 2010 (pilot POC period) to patients testing positive during January 2008–February 2009 (baseline period). The outcome for those with a cells/mm3 when testing HIV-positive was initiating ART weeks after HIV testing. Results. 771 patients had CD4 results from the day of HIV testing (421 pilots, 350 baselines). ART initiation within 16 weeks was 49% in the pilot period and 46% in the baseline period. While all 421 patients during the pilot period should have been offered the POC test, patient records indicate that only 73% of them were actually offered it, and among these patients only 63% accepted the offer. Conclusions. Offering CD4 testing using a point-of-care, but not rapid, technology and without other health system changes had minor impacts on the uptake of HIV care and treatment. Point-of-care technologies alone may not be enough to improve linkage to care and treatment after HIV testing. 1. Introduction A growing body of studies from resource limited settings documents poor patient retention in HIV care after HIV counseling and testing (HCT) [1]. Although comparing retention in preantiretroviral care across sites and countries is complicated by varying definitions and methods of measurement [2], it is clear that a large percentage of people testing HIV-positive at HCT sites do not return to collect CD4 test results, do not return on schedule for pre-ART monitoring and care, and/or do not initiate ART as soon as they become eligible [1, 3–6]. At Themba Lethu Clinic, which is a public-sector HIV/AIDS treatment facility at the Helen Joseph Hospital in Johannesburg, South Africa, for example, a retrospective review of patient records demonstrated that 65% of HIV-positive walk-in patients to the HCT program did not return for their CD4 test results within 12 weeks [3]. Among this cohort, nearly two-thirds (64%) of them were already eligible for ART on the day of HCT, based on having a CD4 count ≤ 200？cells/mm3 Because so many patients do not return for their CD4 count results, one improvement to the existing HCT practices that may reduce losses to HIV care and treatment after diagnosis is the use of point-of-care (POC) CD4 testing immediately after HCT [1, 6–10]. This strategy has the