Processes and dynamics of linkage to care from mobile/outreach and facility-based HIV testing models in hard-to-reach settings in rural Tanzania. Qualitative findings of a mixed methods study

Background

Like other countries, Tanzania instituted mobile and outreach testing approaches to address low HIV testing rates at health facilities and enhance linkage to care. Available evidence from hard-to-reach rural settings of Mbeya region, Tanzania suggests that clients testing HIV+?at facility-based sites are more likely to link to care, and to link sooner, than those testing at mobile sites. This paper (1) describes the populations accessing HIV testing at mobile/outreach and facility-based testing sites, and (2) compares processes and dynamics from testing to linkage to care between these two testing models from the same study context.

Methods

An explanatory sequential mixed-method study (a) reviewed records of all clients (n?=?11,773) testing at 8 mobile and 8 facility-based testing sites over 6 months; (b), reviewed guidelines; (c) observed HIV testing sites (n?=?10) and Care and Treatment Centers (CTCs) (n?=?8); (d) applied questionnaires at 0, 3 and 6 months to a cohort of 1012 HIV newly-diagnosed clients from the 16 sites; and (e) conducted focus group discussions (n?=?8) and in-depth qualitative interviews with cohort members (n?=?10) and health care providers (n?=?20).

Results

More clients tested at mobile/outreach than facility-based sites (56% vs 44% of 11,733, p?

Conclusions

Rural mobile/outreach HIV testing sites reach more people than facility based sites but they reach a different clientèle which is less likely to be HIV +ve and appears to be less “linkage-ready”. Despite more proactive care and confidentiality at mobile sites, linkage to care is worse than for clients who tested at facility-based sites. Our findings highlight a combination of (a) patient-level factors, including stigma; and (b) well-established procedures and routines for each step between testing and initiation of treatment in facility-based sites. Long waiting times at treatment sites are a further barrier that must be addressed.