From HIV diagnosis to treatment: evaluation of a referral system to promote and monitor access to antiretroviral therapy in rural Tanzania

Background
Individuals diagnosed with HIV in developing countries are not always successfully linked to onward treatment services, resulting in missed opportunities for timely initiation of antiretroviral therapy, or prophylaxis for opportunistic infections. In collaboration with local stakeholders, we designed and assessed a referral system to link persons diagnosed at a voluntary counselling and testing (VCT) clinic in a rural district in northern Tanzania with a government-run HIV treatment clinic in a nearby city.

Methods
Two-part referral forms, with unique matching numbers on each side were implemented to facilitate access to the HIV clinic, and were subsequently reconciled to monitor the proportion of diagnosed clients who registered for these services, stratified by sex and referral period. Delays between referral and registration at the HIV clinic were calculated, and lists of non-attendees were generated to facilitate tracing among those who had given prior consent for follow up.

Transportation allowances and a “community escort” from a local home-based care organization were introduced for patients attending the HIV clinic, with supportive counselling services provided by the VCT counsellors and home-based care volunteers. Focus group discussions and in-depth interviews were conducted with health care workers and patients to assess the acceptability of the referral procedures.

Results
Referral uptake at the HIV clinic averaged 72% among men and 66% among women during the first three years of the national antiretroviral therapy (ART) programme, and gradually increased following the introduction of the transportation allowances and community escorts, but declined following a national VCT campaign. Most patients reported that the referral system facilitated their arrival at the HIV clinic, but expressed a desire for HIV treatment services to be in closer proximity to their homes. The referral forms proved to be an efficient and accepted method for assessing the effectiveness of the VCT clinic as an entry point for ART.

Conclusion
The referral system reduced delays in seeking care, and enabled the monitoring of access to HIV treatment among diagnosed persons. Similar systems to monitor referral uptake and linkages between HIV services could be readily implemented in other settings.

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HIV testing services have expanded rapidly in many developing countries in order to reach ambitious targets for antiretroviral therapy (ART) coverage [1]. However, the potential for testing services to act as a gateway to HIV treatment can be met only if individuals diagnosed with HIV are subsequently linked to onward care and treatment services in a timely manner. Delays in registering at HIV treatment clinic services following an HIV diagnosis can lead to late initiation of prophylactic treatment against opportunistic infections or ART, potentially resulting in poorer prognoses for patients and an additional clinical burden on overstretched health services [2].

In many settings, HIV services are currently organized such that there are a great deal more HIV testing points than treatment clinics, with diagnosed persons from several testing sites theoretically linking to each HIV treatment centre. The World Health Organization has repeatedly acknowledged the importance of strengthening links between HIV testing and HIV treatment sites, stating that explicit mechanisms are necessary to promote referral to onward medical and psychosocial support for those testing positive [3,4]. Simple methods for monitoring onward referral rates are particularly important in the context of provider-initiated testing and counselling and prevention of mother to child transmission services, and for monitoring subsequent access to HIV-related services, thus ensuring that ethical concerns about routine testing strategies are addressed [5].

Although international guidelines have emphasized that improved referral mechanisms are essential for promoting and monitoring entry to HIV services [6,7], few referral tools have been developed, and as a result there is a paucity of data on the number of persons who are successfully linked with treatment services following an HIV diagnosis. Nevertheless, emerging evidence from projects involved in referring HIV-diagnosed persons to HIV clinics in Tanzania has suggested rates of referral uptake as low as 14%, representing missed opportunities for timely HIV care and ART initiation [8]. Similarly low rates of referral uptake at HIV clinics have been noted following diagnoses made at voluntary counselling and testing (VCT) services that are provided through mobile outreach clinics [9]. In this case, diagnoses are made conveniently close to patients’ homes, but the HIV treatment clinic may be far away, and after the mobile VCT service has moved on, there is no-one left for patients to consult. Indeed, in terms of accessing treatment following an HIV diagnosis, transportation costs have been identified as an important barrier to reaching these services [10,11], with allowances rarely provided at the point of diagnosis.

The effectiveness of referral systems between the various echelons of the health system in sub-Saharan African countries has been explored in relation to other conditions, with several studies focusing on reasons for non-adherence to referral advice or analyses of health systems inefficiencies when patients are treated at higher level facilities than necessary [12-15]. However, few studies have reported rates of referral uptake, with the exception of two studies of “down referrals” of HIV and TB patients from hospitals to health centres, which indicated an overall attrition rate between facilities of approximately 30% [16,17]. The most commonly cited reasons for poorly functioning referral systems include systemic factors, such as inadequate training, poor quality referral letters or a lack of feedback between facilities [13,16,17]. Furthermore, patient-level factors, including economic or opportunity costs and preferences for, or proximity to, certain facilities, have also been shown to influence uptake of referral advice [12,13,15].

Until effective referral systems for HIV treatment are more widely implemented, it is difficult to evaluate how effective or equitable different HIV testing sites are in terms of enabling access to onward care and treatment services [18], or to devise locally relevant, low-cost interventions to improve referral uptake. In order to maximize the benefits of HIV testing, simple and robust referral systems are therefore needed to promote timely access to treatment services for infected patients, enable delays and equity in the uptake of referral appointments to be monitored, and facilitate communication between different HIV service providers so that low rates of referral uptake can be documented and acted upon.

In this context, we piloted a new method for monitoring referral rates between a VCT clinic in a rural area in north-west Tanzania and a government-run HIV treatment clinic in a zonal referral hospital, 20 km away in Mwanza City. We also documented the role of transport allowances and a volunteer escort from a local home-based care (HBC) organization on rates of referral uptake. This paper describes the implementation of this referral system and reports on the lessons learned that enabled us to improve access to HIV treatment in the community, and that can be readily adopted elsewhere.