Stage of HIV presentation at initial clinic visit following a community-based HIV testing campaign in rural Kenya
Identifieur interne : 000706 ( Pmc/Corpus ); précédent : 000705; suivant : 000707Stage of HIV presentation at initial clinic visit following a community-based HIV testing campaign in rural Kenya
Auteurs : John Haskew ; Kenrick Turner ; Gunnar R ; Andrew Ho ; Davies Kimanga ; Shahnaaz SharifSource :
- BMC Public Health [ 1471-2458 ] ; 2015.
Abstract
The Kenyan Ministry of Health and partners implemented a community-based integrated prevention campaign (IPC) in Western Kenya in 2008. The aim of this study was to determine whether the IPC, compared to Voluntary Counselling and Testing (VCT) services, was able to identify HIV positive individuals earlier in the clinical course of HIV infection following testing.
A total of 1,752 adults aged over 15 years who tested HIV positive through VCT services or the IPC, and subsequently registered at initial clinic visit between September 2008 and September 2010, were considered in the analysis. Multivariable logistic regression models were developed to assess the association of CD4 count and WHO clinical stage of HIV infection at first clinic appointment with age group, gender, marital status and HIV testing source.
Male gender and marital status were independently associated with late HIV presentation (WHO clinical stage 3 or 4 or CD4 count ≤350 cells/μl) at initial clinic visit. Patients testing HIV positive during the IPC had significantly higher mean CD4 count at initial clinic visit compared to individuals who tested HIV positive via VCT services. Patients testing HIV positive during the IPC had more than two times higher odds of presenting early with CD4 count greater than 350 cells/μl (adjusted OR 2.15, 95% CI 1.28 – 3.61, p = 0.004) and presenting early with WHO clinical stage 1 or 2 of HIV infection (adjusted OR 2.39, 95% CI 1.24 – 4.60, p = 0.01) at initial clinic visit compared to individuals who tested HIV positive via VCT services.
The community-based integrated prevention campaign identified HIV positive individuals earlier in the course of HIV infection, compared to Voluntary Counselling and Testing services. Community-based campaigns, such as the IPC, may be able to assist countries to achieve earlier testing and initiation of ART in the course of HIV infection. Improving referral mechanisms and strengthening linkages between HIV testing and treatment services remain a challenge and electronic medical record (EMR) systems may support monitoring of patients throughout the HIV care and treatment continuum.
Url:
DOI: 10.1186/s12889-015-1367-4
PubMed: 25604750
PubMed Central: 4335552
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<record><TEI><teiHeader><fileDesc><titleStmt><title xml:lang="en">Stage of HIV presentation at initial clinic visit following a community-based HIV testing campaign in rural Kenya</title><author><name sortKey="Haskew, John" sort="Haskew, John" uniqKey="Haskew J" first="John" last="Haskew">John Haskew</name><affiliation><nlm:aff id="Aff1">Uamuzi Bora, PO Box 2153-50100, Kakamega, Kenya</nlm:aff></affiliation></author><author><name sortKey="Turner, Kenrick" sort="Turner, Kenrick" uniqKey="Turner K" first="Kenrick" last="Turner">Kenrick Turner</name><affiliation><nlm:aff id="Aff2">British Antarctic Survey Medical Unit, Plymouth, UK</nlm:aff></affiliation></author><author><name sortKey="R, Gunnar" sort="R, Gunnar" uniqKey="R G" first="Gunnar" last="R">Gunnar R</name><affiliation><nlm:aff id="Aff1">Uamuzi Bora, PO Box 2153-50100, Kakamega, Kenya</nlm:aff></affiliation><affiliation><nlm:aff id="Aff3">University of Durham, Durham, UK</nlm:aff></affiliation></author><author><name sortKey="Ho, Andrew" sort="Ho, Andrew" uniqKey="Ho A" first="Andrew" last="Ho">Andrew Ho</name><affiliation><nlm:aff id="Aff4">East and North Hertfordshire NHS Trust, London, UK</nlm:aff></affiliation></author><author><name sortKey="Kimanga, Davies" sort="Kimanga, Davies" uniqKey="Kimanga D" first="Davies" last="Kimanga">Davies Kimanga</name><affiliation><nlm:aff id="Aff5">Elizabeth Glazer Paediatric AIDS Foundation, Nairobi, Kenya</nlm:aff></affiliation></author><author><name sortKey="Sharif, Shahnaaz" sort="Sharif, Shahnaaz" uniqKey="Sharif S" first="Shahnaaz" last="Sharif">Shahnaaz Sharif</name><affiliation><nlm:aff id="Aff6">Ministry of Health, Nairobi, Kenya</nlm:aff></affiliation></author></titleStmt><publicationStmt><idno type="wicri:source">PMC</idno><idno type="pmid">25604750</idno><idno type="pmc">4335552</idno><idno type="url">http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4335552</idno><idno type="RBID">PMC:4335552</idno><idno type="doi">10.1186/s12889-015-1367-4</idno><date when="2015">2015</date><idno type="wicri:Area/Pmc/Corpus">000706</idno><idno type="wicri:explorRef" wicri:stream="Pmc" wicri:step="Corpus" wicri:corpus="PMC">000706</idno></publicationStmt><sourceDesc><biblStruct><analytic><title xml:lang="en" level="a" type="main">Stage of HIV presentation at initial clinic visit following a community-based HIV testing campaign in rural Kenya</title><author><name sortKey="Haskew, John" sort="Haskew, John" uniqKey="Haskew J" first="John" last="Haskew">John Haskew</name><affiliation><nlm:aff id="Aff1">Uamuzi Bora, PO Box 2153-50100, Kakamega, Kenya</nlm:aff></affiliation></author><author><name sortKey="Turner, Kenrick" sort="Turner, Kenrick" uniqKey="Turner K" first="Kenrick" last="Turner">Kenrick Turner</name><affiliation><nlm:aff id="Aff2">British Antarctic Survey Medical Unit, Plymouth, UK</nlm:aff></affiliation></author><author><name sortKey="R, Gunnar" sort="R, Gunnar" uniqKey="R G" first="Gunnar" last="R">Gunnar R</name><affiliation><nlm:aff id="Aff1">Uamuzi Bora, PO Box 2153-50100, Kakamega, Kenya</nlm:aff></affiliation><affiliation><nlm:aff id="Aff3">University of Durham, Durham, UK</nlm:aff></affiliation></author><author><name sortKey="Ho, Andrew" sort="Ho, Andrew" uniqKey="Ho A" first="Andrew" last="Ho">Andrew Ho</name><affiliation><nlm:aff id="Aff4">East and North Hertfordshire NHS Trust, London, UK</nlm:aff></affiliation></author><author><name sortKey="Kimanga, Davies" sort="Kimanga, Davies" uniqKey="Kimanga D" first="Davies" last="Kimanga">Davies Kimanga</name><affiliation><nlm:aff id="Aff5">Elizabeth Glazer Paediatric AIDS Foundation, Nairobi, Kenya</nlm:aff></affiliation></author><author><name sortKey="Sharif, Shahnaaz" sort="Sharif, Shahnaaz" uniqKey="Sharif S" first="Shahnaaz" last="Sharif">Shahnaaz Sharif</name><affiliation><nlm:aff id="Aff6">Ministry of Health, Nairobi, Kenya</nlm:aff></affiliation></author></analytic><series><title level="j">BMC Public Health</title><idno type="eISSN">1471-2458</idno><imprint><date when="2015">2015</date></imprint></series></biblStruct></sourceDesc></fileDesc><profileDesc><textClass></textClass></profileDesc></teiHeader><front><div type="abstract" xml:lang="en"><sec><title>Background</title><p>The Kenyan Ministry of Health and partners implemented a community-based integrated prevention campaign (IPC) in Western Kenya in 2008. The aim of this study was to determine whether the IPC, compared to Voluntary Counselling and Testing (VCT) services, was able to identify HIV positive individuals earlier in the clinical course of HIV infection following testing.</p></sec><sec><title>Methods</title><p>A total of 1,752 adults aged over 15 years who tested HIV positive through VCT services or the IPC, and subsequently registered at initial clinic visit between September 2008 and September 2010, were considered in the analysis. Multivariable logistic regression models were developed to assess the association of CD4 count and WHO clinical stage of HIV infection at first clinic appointment with age group, gender, marital status and HIV testing source.</p></sec><sec><title>Results</title><p>Male gender and marital status were independently associated with late HIV presentation (WHO clinical stage 3 or 4 or CD4 count ≤350 cells/μl) at initial clinic visit. Patients testing HIV positive during the IPC had significantly higher mean CD4 count at initial clinic visit compared to individuals who tested HIV positive via VCT services. Patients testing HIV positive during the IPC had more than two times higher odds of presenting early with CD4 count greater than 350 cells/μl (adjusted OR 2.15, 95% CI 1.28 – 3.61, p = 0.004) and presenting early with WHO clinical stage 1 or 2 of HIV infection (adjusted OR 2.39, 95% CI 1.24 – 4.60, p = 0.01) at initial clinic visit compared to individuals who tested HIV positive via VCT services.</p></sec><sec><title>Conclusion</title><p>The community-based integrated prevention campaign identified HIV positive individuals earlier in the course of HIV infection, compared to Voluntary Counselling and Testing services. Community-based campaigns, such as the IPC, may be able to assist countries to achieve earlier testing and initiation of ART in the course of HIV infection. Improving referral mechanisms and strengthening linkages between HIV testing and treatment services remain a challenge and electronic medical record (EMR) systems may support monitoring of patients throughout the HIV care and treatment continuum.</p></sec></div></front><back><div1 type="bibliography"><listBibl><biblStruct></biblStruct><biblStruct></biblStruct><biblStruct></biblStruct><biblStruct><analytic><author><name sortKey="Badri, M" uniqKey="Badri M">M Badri</name></author><author><name sortKey="Lawn, Sd" uniqKey="Lawn S">SD Lawn</name></author><author><name sortKey="Wood, R" uniqKey="Wood R">R Wood</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Castilla, J" uniqKey="Castilla J">J Castilla</name></author><author><name sortKey="Sobrino, P" uniqKey="Sobrino P">P Sobrino</name></author><author><name sortKey="De La Fuente, L" uniqKey="De La Fuente L">L de la Fuente</name></author><author><name sortKey="Noguer, I" uniqKey="Noguer I">I Noguer</name></author><author><name sortKey="Guerra, L" uniqKey="Guerra L">L Guerra</name></author><author><name sortKey="Parras, F" uniqKey="Parras F">F Parras</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Sabin, Ca" uniqKey="Sabin C">CA Sabin</name></author><author><name sortKey="Smith, Cj" uniqKey="Smith C">CJ Smith</name></author><author><name sortKey="Gumley, H" uniqKey="Gumley H">H Gumley</name></author><author><name sortKey="Murphy, G" uniqKey="Murphy G">G Murphy</name></author><author><name sortKey="Lampe, Fc" uniqKey="Lampe F">FC Lampe</name></author><author><name sortKey="Phillips, An" uniqKey="Phillips A">AN Phillips</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Leisegang, R" uniqKey="Leisegang R">R Leisegang</name></author><author><name sortKey="Cleary, S" uniqKey="Cleary S">S Cleary</name></author><author><name sortKey="Hislop, M" uniqKey="Hislop M">M Hislop</name></author><author><name sortKey="Davidse, A" uniqKey="Davidse A">A Davidse</name></author><author><name sortKey="Regensberg, L" uniqKey="Regensberg L">L Regensberg</name></author><author><name sortKey="Little, F" uniqKey="Little F">F Little</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Granich, Rm" uniqKey="Granich R">RM Granich</name></author><author><name sortKey="Gilks, Cf" uniqKey="Gilks C">CF Gilks</name></author><author><name sortKey="Dye, C" uniqKey="Dye C">C Dye</name></author><author><name sortKey="De Cock, Km" uniqKey="De Cock K">KM De Cock</name></author><author><name sortKey="Williams, Bg" uniqKey="Williams B">BG Williams</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Girardi, E" uniqKey="Girardi E">E Girardi</name></author><author><name sortKey="Sabin, Ca" uniqKey="Sabin C">CA Sabin</name></author><author><name sortKey="Monforte, Ad" uniqKey="Monforte A">AD Monforte</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Bunnell, R" uniqKey="Bunnell R">R Bunnell</name></author><author><name sortKey="Mermin, J" uniqKey="Mermin J">J Mermin</name></author><author><name sortKey="De Cock, Km" uniqKey="De Cock K">KM De Cock</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Lugada, E" uniqKey="Lugada E">E Lugada</name></author><author><name sortKey="Millar, D" uniqKey="Millar D">D Millar</name></author><author><name sortKey="Haskew, J" uniqKey="Haskew J">J Haskew</name></author><author><name sortKey="Grabowsky, M" uniqKey="Grabowsky M">M Grabowsky</name></author><author><name sortKey="Garg, N" uniqKey="Garg N">N Garg</name></author><author><name sortKey="Vestergaard, M" uniqKey="Vestergaard M">M Vestergaard</name></author></analytic></biblStruct><biblStruct></biblStruct><biblStruct></biblStruct><biblStruct></biblStruct><biblStruct><analytic><author><name sortKey="Quigley, Ma" uniqKey="Quigley M">MA Quigley</name></author><author><name sortKey="Morgan, D" uniqKey="Morgan D">D Morgan</name></author><author><name sortKey="Malamba, Ss" uniqKey="Malamba S">SS Malamba</name></author><author><name sortKey="Mayanja, B" uniqKey="Mayanja B">B Mayanja</name></author><author><name sortKey="Okongo, Mj" uniqKey="Okongo M">MJ Okongo</name></author><author><name sortKey="Carpenter, Lm" uniqKey="Carpenter L">LM Carpenter</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Kigozi, Im" uniqKey="Kigozi I">IM Kigozi</name></author><author><name sortKey="Dobkin, Lm" uniqKey="Dobkin L">LM Dobkin</name></author><author><name sortKey="Geng, Eh" uniqKey="Geng E">EH Geng</name></author><author><name sortKey="Emenyonu, Ni" uniqKey="Emenyonu N">NI Emenyonu</name></author><author><name sortKey="Bangsberg, Dr" uniqKey="Bangsberg D">DR Bangsberg</name></author><author><name sortKey="Hahn, Ja" uniqKey="Hahn J">JA Hahn</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Nabyonga, J" uniqKey="Nabyonga J">J Nabyonga</name></author><author><name sortKey="Desmet, M" uniqKey="Desmet M">M Desmet</name></author><author><name sortKey="Karamagi, H" uniqKey="Karamagi H">H Karamagi</name></author><author><name sortKey="Kadama, Py" uniqKey="Kadama P">PY Kadama</name></author><author><name sortKey="Omaswa, Fg" uniqKey="Omaswa F">FG Omaswa</name></author><author><name sortKey="Walker, O" uniqKey="Walker O">O Walker</name></author></analytic></biblStruct><biblStruct></biblStruct><biblStruct><analytic><author><name sortKey="Bonjour, Ma" uniqKey="Bonjour M">MA Bonjour</name></author><author><name sortKey="Montagne, M" uniqKey="Montagne M">M Montagne</name></author><author><name sortKey="Zambrano, M" uniqKey="Zambrano M">M Zambrano</name></author><author><name sortKey="Molina, G" uniqKey="Molina G">G Molina</name></author><author><name sortKey="Lippuner, C" uniqKey="Lippuner C">C Lippuner</name></author><author><name sortKey="Wadskier, Fg" uniqKey="Wadskier F">FG Wadskier</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Ekouevi, Dk" uniqKey="Ekouevi D">DK Ekouevi</name></author><author><name sortKey="Balestre, E" uniqKey="Balestre E">E Balestre</name></author><author><name sortKey="Ba Gomis, F O" uniqKey="Ba Gomis F">F-O Ba-Gomis</name></author><author><name sortKey="Eholie, Sp" uniqKey="Eholie S">SP Eholie</name></author><author><name sortKey="Maiga, M" uniqKey="Maiga M">M Maiga</name></author><author><name sortKey="Amani Bosse, C" uniqKey="Amani Bosse C">C Amani-Bosse</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Suthar, Ab" uniqKey="Suthar A">AB Suthar</name></author><author><name sortKey="Ford, N" uniqKey="Ford N">N Ford</name></author><author><name sortKey="Bachanas, Pj" uniqKey="Bachanas P">PJ Bachanas</name></author><author><name sortKey="Wong, Vj" uniqKey="Wong V">VJ Wong</name></author><author><name sortKey="Rajan, Js" uniqKey="Rajan J">JS Rajan</name></author><author><name sortKey="Saltzman, Ak" uniqKey="Saltzman A">AK Saltzman</name></author></analytic></biblStruct><biblStruct></biblStruct><biblStruct><analytic><author><name sortKey="Puffer, Es" uniqKey="Puffer E">ES Puffer</name></author><author><name sortKey="Meade, Cs" uniqKey="Meade C">CS Meade</name></author><author><name sortKey="Drabkin, As" uniqKey="Drabkin A">AS Drabkin</name></author><author><name sortKey="Broverman, Sa" uniqKey="Broverman S">SA Broverman</name></author><author><name sortKey="Ogwang Odhiambo, Ra" uniqKey="Ogwang Odhiambo R">RA Ogwang-Odhiambo</name></author><author><name sortKey="Sikkema, Kj" uniqKey="Sikkema K">KJ Sikkema</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Rosen, S" uniqKey="Rosen S">S Rosen</name></author><author><name sortKey="Fox, Mp" uniqKey="Fox M">MP Fox</name></author></analytic></biblStruct><biblStruct></biblStruct><biblStruct><analytic><author><name sortKey="Wynberg, E" uniqKey="Wynberg E">E Wynberg</name></author><author><name sortKey="Cooke, G" uniqKey="Cooke G">G Cooke</name></author><author><name sortKey="Shroufi, A" uniqKey="Shroufi A">A Shroufi</name></author><author><name sortKey="Reid, Sd" uniqKey="Reid S">SD Reid</name></author><author><name sortKey="Ford, N" uniqKey="Ford N">N Ford</name></author></analytic></biblStruct><biblStruct></biblStruct><biblStruct><analytic><author><name sortKey="Nsigaye, R" uniqKey="Nsigaye R">R Nsigaye</name></author><author><name sortKey="Wringe, A" uniqKey="Wringe A">A Wringe</name></author><author><name sortKey="Roura, M" uniqKey="Roura M">M Roura</name></author><author><name sortKey="Kalluvya, S" uniqKey="Kalluvya S">S Kalluvya</name></author><author><name sortKey="Urassa, M" uniqKey="Urassa M">M Urassa</name></author><author><name sortKey="Busza, J" uniqKey="Busza J">J Busza</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Decroo, T" uniqKey="Decroo T">T Decroo</name></author><author><name sortKey="Panunzi, I" uniqKey="Panunzi I">I Panunzi</name></author><author><name sortKey="Das Dores, C" uniqKey="Das Dores C">C Das Dores</name></author><author><name sortKey="Maldonado, F" uniqKey="Maldonado F">F Maldonado</name></author><author><name sortKey="Biot, M" uniqKey="Biot M">M Biot</name></author><author><name sortKey="Ford, N" uniqKey="Ford N">N Ford</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Nordberg, E" uniqKey="Nordberg E">E Nordberg</name></author><author><name sortKey="Holmberg, S" uniqKey="Holmberg S">S Holmberg</name></author><author><name sortKey="Kiugu, S" uniqKey="Kiugu S">S Kiugu</name></author></analytic></biblStruct></listBibl></div1></back></TEI><pmc article-type="research-article"><pmc-dir>properties open_access</pmc-dir>
<front><journal-meta><journal-id journal-id-type="nlm-ta">BMC Public Health</journal-id><journal-id journal-id-type="iso-abbrev">BMC Public Health</journal-id><journal-title-group><journal-title>BMC Public Health</journal-title></journal-title-group><issn pub-type="epub">1471-2458</issn><publisher><publisher-name>BioMed Central</publisher-name><publisher-loc>London</publisher-loc></publisher></journal-meta><article-meta><article-id pub-id-type="pmid">25604750</article-id><article-id pub-id-type="pmc">4335552</article-id><article-id pub-id-type="publisher-id">1367</article-id><article-id pub-id-type="doi">10.1186/s12889-015-1367-4</article-id><article-categories><subj-group subj-group-type="heading"><subject>Research Article</subject></subj-group></article-categories><title-group><article-title>Stage of HIV presentation at initial clinic visit following a community-based HIV testing campaign in rural Kenya</article-title></title-group><contrib-group><contrib contrib-type="author" corresp="yes"><name><surname>Haskew</surname><given-names>John</given-names></name><address><email>john.haskew@uamuzibora.org</email></address><xref ref-type="aff" rid="Aff1"></xref></contrib><contrib contrib-type="author"><name><surname>Turner</surname><given-names>Kenrick</given-names></name><address><email>kenrick@kenners.org</email></address><xref ref-type="aff" rid="Aff2"></xref></contrib><contrib contrib-type="author"><name><surname>Rø</surname><given-names>Gunnar</given-names></name><address><email>gunnar.ro@uamuzibora.org</email></address><xref ref-type="aff" rid="Aff1"></xref><xref ref-type="aff" rid="Aff3"></xref></contrib><contrib contrib-type="author"><name><surname>Ho</surname><given-names>Andrew</given-names></name><address><email>andrewho@andrewho.co.uk</email></address><xref ref-type="aff" rid="Aff4"></xref></contrib><contrib contrib-type="author"><name><surname>Kimanga</surname><given-names>Davies</given-names></name><address><email>daviesomari@yahoo.com</email></address><xref ref-type="aff" rid="Aff5"></xref></contrib><contrib contrib-type="author"><name><surname>Sharif</surname><given-names>Shahnaaz</given-names></name><address><email>sksharif@outlook.com</email></address><xref ref-type="aff" rid="Aff6"></xref></contrib><aff id="Aff1"><label></label>Uamuzi Bora, PO Box 2153-50100, Kakamega, Kenya</aff><aff id="Aff2"><label></label>British Antarctic Survey Medical Unit, Plymouth, UK</aff><aff id="Aff3"><label></label>University of Durham, Durham, UK</aff><aff id="Aff4"><label></label>East and North Hertfordshire NHS Trust, London, UK</aff><aff id="Aff5"><label></label>Elizabeth Glazer Paediatric AIDS Foundation, Nairobi, Kenya</aff><aff id="Aff6"><label></label>Ministry of Health, Nairobi, Kenya</aff></contrib-group><pub-date pub-type="epub"><day>21</day><month>1</month><year>2015</year></pub-date><pub-date pub-type="pmc-release"><day>21</day><month>1</month><year>2015</year></pub-date><pub-date pub-type="collection"><year>2015</year></pub-date><volume>15</volume><elocation-id>16</elocation-id><history><date date-type="received"><day>9</day><month>3</month><year>2014</year></date><date date-type="accepted"><day>7</day><month>1</month><year>2015</year></date></history><permissions><copyright-statement>© Haskew et al.; licensee BioMed Central. 2015</copyright-statement><license license-type="open-access"><license-p>This is an Open Access article distributed under the terms of the Creative Commons Attribution License (<ext-link ext-link-type="uri" xlink:href="http://creativecommons.org/licenses/by/4.0">http://creativecommons.org/licenses/by/4.0</ext-link>), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly credited. The Creative Commons Public Domain Dedication waiver (<ext-link ext-link-type="uri" xlink:href="http://creativecommons.org/publicdomain/zero/1.0/">http://creativecommons.org/publicdomain/zero/1.0/</ext-link>) applies to the data made available in this article, unless otherwise stated.</license-p></license></permissions><abstract id="Abs1"><sec><title>Background</title><p>The Kenyan Ministry of Health and partners implemented a community-based integrated prevention campaign (IPC) in Western Kenya in 2008. The aim of this study was to determine whether the IPC, compared to Voluntary Counselling and Testing (VCT) services, was able to identify HIV positive individuals earlier in the clinical course of HIV infection following testing.</p></sec><sec><title>Methods</title><p>A total of 1,752 adults aged over 15 years who tested HIV positive through VCT services or the IPC, and subsequently registered at initial clinic visit between September 2008 and September 2010, were considered in the analysis. Multivariable logistic regression models were developed to assess the association of CD4 count and WHO clinical stage of HIV infection at first clinic appointment with age group, gender, marital status and HIV testing source.</p></sec><sec><title>Results</title><p>Male gender and marital status were independently associated with late HIV presentation (WHO clinical stage 3 or 4 or CD4 count ≤350 cells/μl) at initial clinic visit. Patients testing HIV positive during the IPC had significantly higher mean CD4 count at initial clinic visit compared to individuals who tested HIV positive via VCT services. Patients testing HIV positive during the IPC had more than two times higher odds of presenting early with CD4 count greater than 350 cells/μl (adjusted OR 2.15, 95% CI 1.28 – 3.61, p = 0.004) and presenting early with WHO clinical stage 1 or 2 of HIV infection (adjusted OR 2.39, 95% CI 1.24 – 4.60, p = 0.01) at initial clinic visit compared to individuals who tested HIV positive via VCT services.</p></sec><sec><title>Conclusion</title><p>The community-based integrated prevention campaign identified HIV positive individuals earlier in the course of HIV infection, compared to Voluntary Counselling and Testing services. Community-based campaigns, such as the IPC, may be able to assist countries to achieve earlier testing and initiation of ART in the course of HIV infection. Improving referral mechanisms and strengthening linkages between HIV testing and treatment services remain a challenge and electronic medical record (EMR) systems may support monitoring of patients throughout the HIV care and treatment continuum.</p></sec></abstract><kwd-group xml:lang="en"><title>Keywords</title><kwd>Electronic medical record</kwd><kwd>Resource-constrained settings</kwd><kwd>Community-based HIV testing</kwd><kwd>HIV testing</kwd><kwd>Linkage to care</kwd></kwd-group><custom-meta-group><custom-meta><meta-name>issue-copyright-statement</meta-name><meta-value>© The Author(s) 2015</meta-value></custom-meta></custom-meta-group></article-meta></front><body><sec id="Sec1" sec-type="introduction"><title>Background</title><p>The Joint United Nations Programme on HIV/AIDS (UNAIDS) estimates 35.3 million people worldwide are living with HIV, with an estimated 2.3 million new infections in 2012 [<xref ref-type="bibr" rid="CR1">1</xref>]. The epidemic continues to disproportionately affect sub-Saharan Africa, which is home to 70% of all new HIV infections [<xref ref-type="bibr" rid="CR1">1</xref>]. Knowledge of HIV status remains inadequate, despite significant scaling up of HIV testing services over the past decade [<xref ref-type="bibr" rid="CR1">1</xref>]. In 2011, an estimated 36% of people in the region had never been tested for HIV and less than 50% of people living with HIV in sub-Saharan Africa knew their status [<xref ref-type="bibr" rid="CR1">1</xref>,<xref ref-type="bibr" rid="CR2">2</xref>].</p><p>Due to the lack of access to HIV testing services, an estimated 25% of people who initiate ART in low- and middle-income countries have CD4 counts <100 cells/μl, and late stage of HIV presentation at the time of ART initiation is an important prognostic factor for treatment success [<xref ref-type="bibr" rid="CR3">3</xref>]. Patients with advanced HIV disease at the time of starting ART, defined by low CD4 count and World Health Organization (WHO) clinical stage 3 or 4 of infection, are less likely to respond to treatment and have a higher mortality rate compared with those who start treatment earlier [<xref ref-type="bibr" rid="CR4">4</xref>-<xref ref-type="bibr" rid="CR6">6</xref>]. In addition, those who survive suffer more morbidity and utilise more health care resources than would otherwise have been necessary, placing increased financial burden on health services [<xref ref-type="bibr" rid="CR7">7</xref>]. Late presentation also poses a higher cumulative risk of HIV transmission to others, considering that earlier presentation and access to ART can reduce viral load and risk of onward transmission [<xref ref-type="bibr" rid="CR6">6</xref>,<xref ref-type="bibr" rid="CR8">8</xref>-<xref ref-type="bibr" rid="CR10">10</xref>].</p><p>In an effort to increase access to HIV testing services, and to identify people living with HIV earlier in the course of infection, the Kenyan Ministry of Health and partners launched a community integrated prevention campaign (IPC) in Western Province, Kenya in September 2008 [<xref ref-type="bibr" rid="CR11">11</xref>]. The IPC provided HIV testing and counseling services, water filters, insecticide-treated bed nets, condoms, and for HIV-infected individuals cotrimoxazole prophylaxis and referral to care. 47,311 people attended the campaign, achieving 87% coverage among the target population over the age of 15 years in seven days and, of all those tested, 1,956 (4.1%) were found to be HIV positive and referred to Ministry of Health care and support services [<xref ref-type="bibr" rid="CR11">11</xref>].</p><p>There is a paucity of published data comparing linkage to HIV treatment services from different sources of HIV testing. The overall aim of this study was to determine whether the IPC, compared to Voluntary Counselling and Testing (VCT) services, was able to identify HIV positive individuals earlier in the clinical course of infection, defined by CD4 count and WHO clinical stage of HIV infection at first clinic visit.</p></sec><sec id="Sec2" sec-type="materials|methods"><title>Methods</title><sec id="Sec3"><title>Study population and design</title><p>Data for this study included all patients who attended the HIV clinic of Kakamega Provincial General Hospital, Western Kenya for their first clinic visit between January 2004 and September 2010. In 2012, HIV prevalence in Western Kenya is 4.7%, compared to a national average of 5.6% [<xref ref-type="bibr" rid="CR12">12</xref>].</p><p>Data were obtained from the Uamuzi Bora Electronic Medical Record (EMR) system [<xref ref-type="bibr" rid="CR13">13</xref>], an open-source web-based database that replicates information collected in the national paper-based HIV outpatient record, which includes socio-demographic information, patient source of testing, treatment history, and clinical and laboratory results. The EMR system was designed to enable the Ministry of Health to maintain accurate HIV medical records, track patients and monitor outcomes more effectively.</p><p>Clinical and demographic data from the initial clinic visit were extracted for use in the analysis, including age, gender, source of HIV testing, date of diagnosis, date of first clinic appointment, clinical data from first clinic appointment (WHO clinical stage of infection) and date started ART. Quality control checks were performed during data entry into the EMR database from the paper record, during which electronic records were compared variable by variable with the original paper record.</p><p>In September 2010, 6,657 HIV positive patients were registered in the EMR system, including 108 adults who tested HIV positive during the IPC and 3,651 patients who tested HIV positive via VCT services.</p></sec><sec id="Sec4"><title>Statistical analysis</title><p>All analyses were carried out using STATA version 12.1 (Stata Corp; College Station, TX). Primary outcomes considered for analysis were CD4 count and WHO clinical stage of HIV infection at initial clinic visit.</p><p>Early or late presentation of HIV (by CD4 count or WHO clinical stage of HIV infection) was defined according to thresholds for initiation of antiretroviral therapy (ART) as indicated in the 2011 fourth edition of the Guidelines for antiretroviral therapy in Kenya [<xref ref-type="bibr" rid="CR14">14</xref>]. This guideline recommends ART to be started in all HIV-positive adults and adolescents with WHO clinical stage 1 or 2 and a CD4 count ≤ 350 cells/μl or with WHO clinical stage 3 or 4 regardless of CD4 count. CD4 count was coded as a numeric value at initial clinic visit and as a binary variable, defined as early presentation (CD4 > 350 cells/μl) or late presentation (CD4 ≤ 350 cells/μl) according to the 2011 Guidelines for antiretroviral therapy in Kenya [<xref ref-type="bibr" rid="CR14">14</xref>]. WHO clinical stage of HIV infection was categorised as early presentation (stages 1 or 2) or late presentation (stages 3 or 4) according to 2011 Guidelines for antiretroviral therapy in Kenya [<xref ref-type="bibr" rid="CR14">14</xref>]. Age group, gender, marital status and HIV testing source were considered independent variables in the analysis.</p><p>A total of 3,759 adults testing HIV positive through VCT services (n = 3,651) or the IPC (n = 108) were initially considered in the analysis. VCT patients prior to 1 September 2008 were excluded from analysis (n = 1,944), because the IPC was undertaken in September 2008 and improvements in provision of HIV testing and treatment services since the first patients were registered at the clinic in 2004 could bias results. All children under the age of 15 years were also excluded from VCT services (n = 63) because the IPC only included individuals over the age of fifteen, leaving a total sample size of 1,752 considered for analysis (1,644 from VCT, 108 from IPC). Patients with missing data for WHO clinical stage and CD4 count were compared to patients with complete data using Pearson χ2 tests to check for differences in distribution of socio-demographic variables and to assess for the likelihood of bias.</p><p>A multivariable logistic regression model was developed to identify independent correlates of late presentation. The model was built in a step-wise fashion, initially including HIV testing source and potential confounders showing a strong association with the outcome (p < 0.1) in univariable analysis. The variable most strongly related (lowest p-value) to the outcome in univariable analysis was the first to be included in the logistic regression model. A likelihood ratio test was then carried out on the model with and without this variable. The variable with the next smallest <italic>P</italic>-value from the univariable analyses was then added into the model. Variables were added until no further variables improved the fit of the model (p > 0.05). Any variables with p > 0.05 were tested to ensure they had no effect on the final multivariable model. Adjusted multivariable odds ratios, 95% confidence intervals and p-values are presented.</p></sec><sec id="Sec5"><title>Ethical issues</title><p>The study was approved by the institutional review board at Kakamega Provincial General Hospital and the Director of Public Health, Ministry of Health, Kenya.</p></sec></sec><sec id="Sec6" sec-type="results"><title>Results</title><sec id="Sec7"><title>Missing data</title><p>Of 1,752 patient records initially included in the analysis, just over one half did not record CD4 count and one quarter of patient records did not record WHO clinical stage on the initial visit form (Table <xref rid="Tab1" ref-type="table">1</xref>). Patients who had CD4 count and WHO clinical stage information were compared with those who had none using Pearson χ<sup>2</sup> trend tests and significant difference (p < 0.05) was found between different patient sources of HIV testing source (Table <xref rid="Tab1" ref-type="table">1</xref>). Patients with missing CD4 count and WHO clinical stage were therefore removed from subsequent analysis when comparing IPC to VCT services (Tables <xref rid="Tab2" ref-type="table">2</xref> and <xref rid="Tab3" ref-type="table">3</xref>).<table-wrap id="Tab1"><label>Table 1</label><caption><p><bold>Socio-demographic characteristics of patients with and without initial WHO clinical stage and CD4 count recorded</bold></p></caption><table frame="hsides" rules="groups"><thead><tr valign="top"><th><bold>Characteristic</bold></th><th><bold>N. (%) with initial WHO stage</bold></th><th><bold>N. (%) missing initial WHO stage</bold></th><th><bold>Pearson χ</bold><sup><bold>2</bold></sup></th><th><bold><italic>P</italic></bold></th><th><bold>N. (%) with initial CD4 count</bold></th><th><bold>N. (%) missing initial CD4 count</bold></th><th><bold>Pearson χ</bold><sup><bold>2</bold></sup></th><th><bold><italic>P</italic></bold></th></tr></thead><tbody><tr valign="top"><td>Total</td><td>1,314 (75.0%)</td><td>438 (25.0%)</td><td></td><td></td><td>861 (49.1%)</td><td>891 (50.9%)</td><td></td><td></td></tr><tr valign="top"><td>Patient testing source</td><td></td><td></td><td>4.263</td><td>0.04</td><td></td><td></td><td>14.14</td><td>0.000</td></tr><tr valign="top"><td>IPC</td><td>90 (86.5%)</td><td>18 (16.7%)</td><td></td><td></td><td>72 (66.7%)</td><td>36 (33.3%)</td><td></td><td></td></tr><tr valign="top"><td>VCT</td><td>1,224 (74.5%)</td><td>420 (25.5%)</td><td></td><td></td><td>789 (48.0%)</td><td>855 (52.0%)</td><td></td><td></td></tr><tr valign="top"><td>Age group</td><td></td><td></td><td>1.416</td><td>0.23</td><td></td><td></td><td>0.087</td><td>0.77</td></tr><tr valign="top"><td>50 years and under</td><td>1,106 (74.5%)</td><td>379 (25.5%)</td><td></td><td></td><td>732 (49.3%)</td><td>753 (50.7%)</td><td></td><td></td></tr><tr valign="top"><td>Over 50 years</td><td>208 (77.9%)</td><td>59 (22.1%)</td><td></td><td></td><td>129 (48.3%)</td><td>138 (51.7%)</td><td></td><td></td></tr><tr valign="top"><td>Gender</td><td></td><td></td><td>0.515</td><td>0.47</td><td></td><td></td><td>1.406</td><td>0.24</td></tr><tr valign="top"><td>Female</td><td>833 (74.4%)</td><td>286 (25.6%)</td><td></td><td></td><td>538 (48.1%)</td><td>581 (51.9%)</td><td></td><td></td></tr><tr valign="top"><td>Male</td><td>481 (76.0%)</td><td>152 (24.0%)</td><td></td><td></td><td>323 (51.0%)</td><td>310 (49.0%)</td><td></td><td></td></tr><tr valign="top"><td>Marital status<sup>*</sup></td><td></td><td></td><td>8.468</td><td>0.01</td><td></td><td></td><td>1.06</td><td>0.59</td></tr><tr valign="top"><td>Married</td><td>691 (76.5%)</td><td>212 (23.5%)</td><td></td><td></td><td>444 (49.2%)</td><td>459 (50.8%)</td><td></td><td></td></tr><tr valign="top"><td>Never married</td><td>125 (66.5%)</td><td>63 (33.5%)</td><td></td><td></td><td>85 (45.2%)</td><td>103 (54.8%)</td><td></td><td></td></tr><tr valign="top"><td>Divorced/widowed</td><td>368 (75.6%)</td><td>119 (24.4%)</td><td></td><td></td><td>240 (49.3%)</td><td>247 (50.7%)</td><td></td><td></td></tr></tbody></table><table-wrap-foot><p><sup>*</sup>174 missing values.</p></table-wrap-foot></table-wrap><table-wrap id="Tab2"><label>Table 2</label><caption><p><bold>Socio-demographic, clinical characteristics and univariable/multivariable associations with late HIV disease presentation (WHO clinical stage 3 or 4) at initial clinic visit</bold></p></caption><table frame="hsides" rules="groups"><thead><tr valign="top"><th><bold>Characteristics</bold></th><th><bold>Early presentation (WHO stage 1/2) N. (%)*</bold></th><th><bold>Late presentation (WHO stage 3/4) N. (%)*</bold></th><th><bold>Unadj OR (95% CI)</bold></th><th><bold><italic>P</italic></bold></th><th><bold>Adj OR</bold><sup><bold>^</bold></sup><bold>(95% CI)</bold></th><th><bold><italic>P</italic></bold></th></tr></thead><tbody><tr valign="top"><td>All participants</td><td>955 (72.7%)</td><td>359 (27.3%)</td><td></td><td></td><td></td><td></td></tr><tr valign="top"><td>HIV testing source</td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr valign="top"><td>IPC</td><td>75 (83.3%)</td><td>15 (16.7%)</td><td>1</td><td></td><td></td><td></td></tr><tr valign="top"><td>VCT</td><td>880 (71.9%)</td><td>344 (28.1%)</td><td>1.95 (1.11 – 3.45)</td><td>0.02</td><td>2.39 (1.24 – 4.60)</td><td>0.01</td></tr><tr valign="top"><td>Age</td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr valign="top"><td>50 years and under</td><td>809 (73.1%)</td><td>297 (26.9%)</td><td>1</td><td></td><td>1</td><td></td></tr><tr valign="top"><td>Over 50 years</td><td>146 (70.2%)</td><td>62 (29.8%)</td><td>0.46 (0.28 – 0.74)</td><td>0.002</td><td>1.10 (0.77 – 1.57)</td><td>0.61</td></tr><tr valign="top"><td>Gender</td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr valign="top"><td>Female</td><td>623 (74.5%)</td><td>210 (25.2%)</td><td>1</td><td></td><td>1</td><td></td></tr><tr valign="top"><td>Male</td><td>332 (69.0%)</td><td>149 (31.0%)</td><td>1.33 (1.04 – 1.71)</td><td>0.02</td><td>1.38 (1.04 – 1.83)</td><td>0.02</td></tr><tr valign="top"><td>Marital status<sup>†</sup></td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr valign="top"><td>Married</td><td>524 (75.8%)</td><td>167 (24.2%)</td><td>1</td><td></td><td>1</td><td></td></tr><tr valign="top"><td>Never married</td><td>95 (76.0%)</td><td>30 (24.0%)</td><td>0.99 (0.63 – 1.55)</td><td>0.97</td><td>1.02 (0.65 – 1.59)</td><td>0.95</td></tr><tr valign="top"><td>Divorced/widowed</td><td>252 (68.5%)</td><td>116 (31.5%)</td><td>1.44 (1.09 – 1.91)</td><td>0.01</td><td>1.55 (1.15 – 2.08)</td><td>0.004</td></tr></tbody></table><table-wrap-foot><p>*Patients missing WHO stage removed from analysis (n = 438).</p><p><sup>†</sup>130 missing values.</p><p><sup>^</sup>Adjusted for age, gender, marital status.</p></table-wrap-foot></table-wrap><table-wrap id="Tab3"><label>Table 3</label><caption><p><bold>Socio-demographic, clinical characteristics and univariable/multivariable associations with late HIV disease presentation (CD4 count ≤ 350 cells/μl) at initial clinic visit</bold></p></caption><table frame="hsides" rules="groups"><thead><tr valign="top"><th><bold>Characteristics</bold></th><th><bold>Early presentation (CD4 > 350 cells/μl) N. (%)*</bold></th><th><bold>Late presentation (CD4 ≤ 350 cells/μl) N. (%)*</bold></th><th><bold>Unadj OR (95% CI)</bold></th><th><bold><italic>P</italic></bold></th><th><bold>Adj OR</bold><sup><bold>^</bold></sup><bold>(95% CI)</bold></th><th><bold><italic>P</italic></bold></th></tr></thead><tbody><tr valign="top"><td>All Participants</td><td>297 (34.5%)</td><td>564 (65.5%)</td><td></td><td></td><td></td><td></td></tr><tr valign="top"><td>HIV Testing Source</td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr valign="top"><td>IPC</td><td>34 (47.2%)</td><td>38 (52.8%)</td><td>1</td><td></td><td></td><td></td></tr><tr valign="top"><td>VCT</td><td>263 (33.3%)</td><td>526 (66.7%)</td><td>1.79 (1.10 – 2.90)</td><td>0.002</td><td>2.15 (1.28 – 3.60)</td><td>0.005</td></tr><tr valign="top"><td>Age</td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr valign="top"><td>50 years and under</td><td>264 (35.3%)</td><td>468 (64.7%)</td><td>1</td><td></td><td>1</td><td></td></tr><tr valign="top"><td>Over 50 years</td><td>33 (33.1%)</td><td>96 (66.9%)</td><td>1.64 (1.07 – 2.51)</td><td>0.002</td><td>1.72 (1.09 – 2.74)</td><td>0.02</td></tr><tr valign="top"><td>Gender</td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr valign="top"><td>Female</td><td>190 (51.5%)</td><td>348 (48.5%)</td><td>1</td><td></td><td>1</td><td></td></tr><tr valign="top"><td>Male</td><td>107 (47.7%)</td><td>216 (52.3%)</td><td>1.10 (0.82 – 1.48)</td><td>0.51</td><td>1.01 (0.73 – 1.40)</td><td>0.94</td></tr><tr valign="top"><td>Marital status<sup>†</sup></td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr valign="top"><td>Married</td><td>150 (33.8%)</td><td>294 (66.2%)</td><td>1</td><td></td><td>1</td><td></td></tr><tr valign="top"><td>Never married</td><td>35 (41.2%)</td><td>50 (58.8%)</td><td>0.73 (0.45 – 1.17)</td><td>0.19</td><td>0.71 (0.44 – 1.16)</td><td>0.17</td></tr><tr valign="top"><td>Divorced/widowed</td><td>79 (32.9%)</td><td>161 (67.1%)</td><td>1.04 (0.75 – 1.45)</td><td>0.82</td><td>0.96 (0.68 – 1.37)</td><td>0.83</td></tr></tbody></table><table-wrap-foot><p>*Patients missing CD4 count removed from analysis (n = 891).</p><p><sup>†</sup>92 missing values.</p><p><sup>^</sup>Adjusted for age, gender, marital status.</p></table-wrap-foot></table-wrap></p></sec><sec id="Sec8"><title>Descriptive analysis</title><p>Of 1,752 patients included in analysis, 108 were from the IPC and 1,644 from VCT services. The median age was 38.6 years (range 38.0 – 39.1 years). The sample was nearly two-thirds female and more than half of the sample reported being married (Table <xref rid="Tab4" ref-type="table">4</xref>). Nearly two-thirds of patients presented to the clinic with CD4 ≤ 350 cells/μl (mean CD4 304.0 cells/μl) and more than one quarter of patients presented in WHO clinical stage 3 or 4 (Table <xref rid="Tab4" ref-type="table">4</xref>).<table-wrap id="Tab4"><label>Table 4</label><caption><p><bold>Socio-demographic and clinical characteristics of patients, by HIV testing source (IPC or VCT)</bold></p></caption><table frame="hsides" rules="groups"><thead><tr valign="top"><th><bold>Characteristics</bold></th><th><bold>IPC N. (%)</bold></th><th><bold>VCT N. (%)</bold></th><th><bold>Total N. (%)</bold></th></tr></thead><tbody><tr valign="top"><td>All participants</td><td>108 (6.2%)</td><td>1,644 (93.8%)</td><td>1,752 (100%)</td></tr><tr valign="top"><td>WHO clinical stage at initial clinic visit<sup>*</sup></td><td></td><td></td><td></td></tr><tr valign="top"><td>1 or 2</td><td>75 (7.8%)</td><td>880 (92.2%)</td><td>955 (100.0%)</td></tr><tr valign="top"><td>3 or 4</td><td>15 (4.2%)</td><td>344 (95.8%)</td><td>359 (100.0%)</td></tr><tr valign="top"><td>CD4 count at initial clinic visit<sup>**</sup></td><td></td><td></td><td></td></tr><tr valign="top"><td>>350 cells/mm<sup>3</sup></td><td>45 (10.4%)</td><td>386 (89.6%)</td><td>431 (100.0%)</td></tr><tr valign="top"><td>≤350 cells/mm<sup>3</sup></td><td>27 (6.3%)</td><td>403 (93.7%)</td><td>430 (100.0%)</td></tr><tr valign="top"><td>Mean CD4 count at initial clinic visit (cells/μl)</td><td>368.0</td><td>298.1</td><td>304.0</td></tr><tr valign="top"><td>95% CI (cells/μl)</td><td>(305.0 – 431.0)</td><td>(280.1 – 316.2)</td><td>(286.6 – 321.4)</td></tr><tr valign="top"><td>Age</td><td></td><td></td><td></td></tr><tr valign="top"><td>50 years and under</td><td>80 (5.4%)</td><td>1,405 (94.6%)</td><td>1,485 (100.0%)</td></tr><tr valign="top"><td>Over 50 years</td><td>28 (10.5%)</td><td>239 (89.5%)</td><td>267 (100.0%)</td></tr><tr valign="top"><td>Gender</td><td></td><td></td><td></td></tr><tr valign="top"><td>Female</td><td>73 (6.5%)</td><td>1,046 (93.5%)</td><td>1,119 (100.0%)</td></tr><tr valign="top"><td>Male</td><td>35 (5.5%)</td><td>598 (94.5%)</td><td>633 (100.0%)</td></tr><tr valign="top"><td>Marital status<sup>***</sup></td><td></td><td></td><td></td></tr><tr valign="top"><td>Married</td><td>73 (8.1%)</td><td>830 (91.9%)</td><td>903 (100.0%)</td></tr><tr valign="top"><td>Never married</td><td>4 (2.1%)</td><td>184 (97.9%)</td><td>188 (100.0%)</td></tr><tr valign="top"><td>Divorced/widowed</td><td>23 (4.7%)</td><td>464 (95.3%)</td><td>487 (100.0%)</td></tr></tbody></table><table-wrap-foot><p><sup>*</sup>438, <sup>**</sup>891, <sup>***</sup>174 missing values.</p></table-wrap-foot></table-wrap></p></sec><sec id="Sec9"><title>Multivariable analysis</title><p>A multivariable analysis was conducted including all variables studied in the univariable analysis. Patients who tested HIV positive via VCT services had more than two times higher odds of presenting to initial clinic visit in WHO clinical stage 3 or 4 of HIV infection than those who tested HIV positive during the IPC (adjusted OR 2.39, 95% CI 1.24 – 4.60, p = 0.01) (Table <xref rid="Tab2" ref-type="table">2</xref>). Patients who tested HIV positive via VCT services had more than two times higher odds of presenting to initial clinic visit with CD4 ≤ 350 cells/μl than those who tested HIV positive during the IPC (adjusted OR 2.15, 95% CI 1.28 – 3.61, p = 0.005) (Table <xref rid="Tab3" ref-type="table">3</xref>). Mean CD4 count at initial clinic visit among patients testing HIV positive via VCT was significantly lower than those who tested HIV positive during the IPC (Table <xref rid="Tab5" ref-type="table">5</xref>).<table-wrap id="Tab5"><label>Table 5</label><caption><p><bold>Two sample t test with equal variances comparing mean CD4 count between IPC and VCT testing sources</bold></p></caption><table frame="hsides" rules="groups"><thead><tr valign="top"><th><bold>HIV testing source</bold></th><th><bold>Obs</bold></th><th><bold>Mean CD4 count (cells/μl) (95% CI)</bold></th></tr></thead><tbody><tr valign="top"><td>IPC</td><td>72</td><td>368.0 (304.0 – 432.0)</td></tr><tr valign="top"><td>VCT</td><td>789</td><td>298.1 (280.0 – 316.2)</td></tr><tr valign="top"><td>Total</td><td>861</td><td>304.0 (286.6 – 321.4)</td></tr></tbody></table><table-wrap-foot><p>t = 2.184, d.f = 859, p = 0.03.</p></table-wrap-foot></table-wrap></p><p>Male gender and being divorced or widowed were independently associated with presenting late to initial clinic visit at WHO clinical stage 3 or 4 (Table <xref rid="Tab2" ref-type="table">2</xref>). Age over 50 years was independently associated with presenting late to initial clinic visit with CD4 ≤ 350 cells/μl (Table <xref rid="Tab3" ref-type="table">3</xref>).</p></sec></sec><sec id="Sec10" sec-type="discussion"><title>Discussion</title><p>Age, gender and current marital status are all associated with late HIV presentation (WHO clinical stage 3 or 4 or CD4 ≤ 350 cells/μl) at first clinic appointment, which supports the findings of previous studies. Men had 1.4 times higher odds of presenting to clinic late in the course of HIV infection compared to women, and gender differences have been observed in other studies with regard to presentation to HIV clinic [<xref ref-type="bibr" rid="CR15">15</xref>,<xref ref-type="bibr" rid="CR16">16</xref>], as well as general outpatient health service utilisation [<xref ref-type="bibr" rid="CR17">17</xref>,<xref ref-type="bibr" rid="CR18">18</xref>]. Age over 50 years was also significantly associated with late HIV presentation, as shown in other studies [<xref ref-type="bibr" rid="CR19">19</xref>], which may be due to a lack of knowledge of the disease and services available, or a low self-perceived risk of HIV in older age groups [<xref ref-type="bibr" rid="CR9">9</xref>]. Increasing age has also been shown to have a negative impact on retention in care and overall treatment outcomes [<xref ref-type="bibr" rid="CR20">20</xref>]. Not being married was associated with late presentation, as reported in previous studies [<xref ref-type="bibr" rid="CR15">15</xref>].</p><p>More than two-thirds of patients who tested HIV positive via VCT services presented to initial clinic with CD4 ≤ 350 cells/μl and one-quarter of patients who tested HIV positive via VCT services presented to initial clinic with WHO clinical stage 3 or 4 of HIV infection, which is comparable to other studies in sub-Saharan Africa [<xref ref-type="bibr" rid="CR16">16</xref>]. A significantly lower proportion of patients who tested HIV positive during the community-based IPC presented to their initial clinic visit late in the course of infection. The IPC may have identified patients earlier in the clinical course of HIV infection in the community because these individuals may be asymptomatic and have less perceived risk than those who self-attended VCT services. Community-based campaigns of HIV testing may therefore be able to reach individuals who are unaware of their HIV status and still at an early stage of infection. [<xref ref-type="bibr" rid="CR21">21</xref>] While the rate of people ever having been tested for HIV has increased in Kenya, nearly half of people living with HIV still do not know they are infected [<xref ref-type="bibr" rid="CR12">12</xref>]. These individuals may not be symptomatic, may not have adequate knowledge or understanding of HIV signs and symptoms, and/or may have low self-perceived risk and understanding of HIV transmission [<xref ref-type="bibr" rid="CR22">22</xref>,<xref ref-type="bibr" rid="CR23">23</xref>].</p><p>It is important to acknowledge the limitations of this study. Other important potential confounders such as socioeconomic status, HIV status of the spouse and time required to travel to clinic were not included in the paper-based patient record or EMR system and therefore could not be included and adjusted for in the analysis. Comparative analysis of the entire dataset and inclusion of all patients testing HIV positive via VCT services was also not possible due to missing data in the dataset. Missing data more broadly reflects the fact that many medical records are rarely kept up to date and complete in sub-Saharan Africa, making their use problematic for rigorous analysis and follow-up of outcomes [<xref ref-type="bibr" rid="CR24">24</xref>].</p><p>During the IPC in September 2008, a significantly higher median CD4 count was recorded at the point of testing compared to those testing HIV positive from the IPC at initial clinic visit during this study, suggesting a lack of timely linkage between testing and care [<xref ref-type="bibr" rid="CR11">11</xref>]. Improved referral mechanisms, particularly from community-based settings, are therefore also required to ensure timely and accountable linkage between testing and treatment services to ensure the gains of earlier testing are realised [<xref ref-type="bibr" rid="CR2">2</xref>,<xref ref-type="bibr" rid="CR3">3</xref>,<xref ref-type="bibr" rid="CR25">25</xref>]. Few referral tools have been developed however and effective linkage between HIV testing and initiation of ART remains a challenge [<xref ref-type="bibr" rid="CR24">24</xref>,<xref ref-type="bibr" rid="CR26">26</xref>]. Little systematic data exist on the proportion of people living with HIV who are linked to care [<xref ref-type="bibr" rid="CR26">26</xref>,<xref ref-type="bibr" rid="CR27">27</xref>] and, once linked to care, there are mixed findings regarding retention in care. In a systematic review by Rosen et al., no study was able to follow patients from testing to treatment if they were not already eligible for ART when diagnosed [<xref ref-type="bibr" rid="CR24">24</xref>]. Reasons for poor linkage between HIV testing and treatment services are multi-factorial and include systemic factors such as inadequate training, lack of access to timely and reliable data (electronic or paper based) and individual patient factors such as financial costs and proximity or preference for certain health facilities [<xref ref-type="bibr" rid="CR28">28</xref>-<xref ref-type="bibr" rid="CR30">30</xref>]. Electronic medical record (EMR) systems could support linkage of patients from testing to treatment services and should be evaluated further in real-time program settings. EMR systems may also help to improve the quality of data collected, as well as support provision of clinical care and ensure individuals are monitored and retained throughout the HIV care and treatment continuum.</p></sec><sec id="Sec11" sec-type="conclusions"><title>Conclusions</title><p>The community-based IPC identified HIV positive individuals earlier in the course of HIV infection, compared to voluntary counselling and testing services. The IPC may have identified patients earlier in the clinical course of HIV infection in the community because these individuals may be asymptomatic and have less perceived risk than those who self-attended VCT services. Such community-based campaigns of HIV testing may be able to assist countries to achieve earlier testing and initiation of ART in the course of HIV infection. A significantly higher median CD4 count was recorded at the point of testing during the IPC compared to those testing HIV positive from the IPC at initial clinic visit. Improving referral mechanisms and strengthening linkages between HIV testing and treatment services remain a challenge and electronic medical record (EMR) systems may support monitoring of patients throughout the HIV care and treatment continuum.</p></sec></body><back><fn-group><fn><p><bold>Competing interests</bold></p><p>JH worked as a consultant for Vestergaard Frandsen during planning and implementation of the IPC in 2008. Vestergaard Frandsen paid travel costs to Kenya for JH, GR and KT during implementation of the EMR system. This does not alter the authors’ adherence to policies on sharing data and materials. No authors were paid for analysis or writing of the manuscript.</p></fn><fn><p><bold>Authors’ contributions</bold></p><p>All authors contributed to the paper. JH conceived and designed the study. JH, KT, GR designed and implemented the EMR system. JH analysed the data. JH, KT, GR wrote the paper. All authors reviewed the final draft of the manuscript. All authors read and approved the final manuscript.</p></fn></fn-group><ack><p>Thanks to the staff and patients of Kakamega Provincial General Hospital and to Job Mabonga and staff in the Provincial Medical Records Office, Western Kenya for their assistance and co-operation in implementation of this study.</p><sec id="d30e1922"><title>Funding</title><p>Vestergaard Frandsen fund Uamuzi Bora EMR system implementation in Kakamega Provincial General Hospital. Vestergaard Frandsen had no role in study design, data collection and analysis, decision to publish, preparation of the manuscript, nor exerted any editorial control.</p></sec></ack><ref-list id="Bib1"><title>References</title><ref id="CR1"><label>1.</label><mixed-citation publication-type="other">UNAIDS. (2013). Global Report: UNAIDS report on the global AIDS epidemic 2013. Joint United Nations Programme on HIV/AIDS (UNAIDS).</mixed-citation></ref><ref id="CR2"><label>2.</label><mixed-citation publication-type="other">WHO. (2010). Towards Universal access: Scaling up priority HIV/AIDS interventions in the health sector. Progress Report 2010. World Health Organization WHO), Joint United Nations Programme on HIV/AIDS (UNAIDS), UN Childrens' Agency (UNICEF). Retrieved from <ext-link ext-link-type="uri" xlink:href="http://www.who.int/">http://www.who.int/</ext-link></mixed-citation></ref><ref id="CR3"><label>3.</label><mixed-citation publication-type="other">UNAIDS. (2012). Treatment 2015. Joint United Nations Programme on HIV/AIDS (UNAIDS).</mixed-citation></ref><ref id="CR4"><label>4.</label><element-citation publication-type="journal"><person-group person-group-type="author"><name><surname>Badri</surname><given-names>M</given-names></name><name><surname>Lawn</surname><given-names>SD</given-names></name><name><surname>Wood</surname><given-names>R</given-names></name></person-group><article-title>Short-term risk of AIDS or death in people infected with HIV-1 before antiretroviral therapy in South Africa: a longitudinal study</article-title><source>Lancet</source><year>2006</year><volume>368</volume><fpage>1254</fpage><lpage>9</lpage><pub-id pub-id-type="doi">10.1016/S0140-6736(06)69117-4</pub-id><pub-id pub-id-type="pmid">17027731</pub-id></element-citation></ref><ref id="CR5"><label>5.</label><element-citation publication-type="journal"><person-group person-group-type="author"><name><surname>Castilla</surname><given-names>J</given-names></name><name><surname>Sobrino</surname><given-names>P</given-names></name><name><surname>de la Fuente</surname><given-names>L</given-names></name><name><surname>Noguer</surname><given-names>I</given-names></name><name><surname>Guerra</surname><given-names>L</given-names></name><name><surname>Parras</surname><given-names>F</given-names></name></person-group><article-title>Late diagnosis of HIV infection in the era of highly active antiretroviral therapy: consequences for AIDS incidence</article-title><source>Aids</source><year>2002</year><volume>16</volume><fpage>1945</fpage><pub-id pub-id-type="doi">10.1097/00002030-200209270-00012</pub-id><pub-id pub-id-type="pmid">12351955</pub-id></element-citation></ref><ref id="CR6"><label>6.</label><element-citation publication-type="journal"><person-group person-group-type="author"><name><surname>Sabin</surname><given-names>CA</given-names></name><name><surname>Smith</surname><given-names>CJ</given-names></name><name><surname>Gumley</surname><given-names>H</given-names></name><name><surname>Murphy</surname><given-names>G</given-names></name><name><surname>Lampe</surname><given-names>FC</given-names></name><name><surname>Phillips</surname><given-names>AN</given-names></name><etal></etal></person-group><article-title>Late presenters in the era of highly active antiretroviral therapy: uptake of and responses to antiretroviral therapy</article-title><source>Aids</source><year>2004</year><volume>18</volume><fpage>2145</fpage><pub-id pub-id-type="doi">10.1097/00002030-200411050-00006</pub-id><pub-id pub-id-type="pmid">15577647</pub-id></element-citation></ref><ref id="CR7"><label>7.</label><element-citation publication-type="journal"><person-group person-group-type="author"><name><surname>Leisegang</surname><given-names>R</given-names></name><name><surname>Cleary</surname><given-names>S</given-names></name><name><surname>Hislop</surname><given-names>M</given-names></name><name><surname>Davidse</surname><given-names>A</given-names></name><name><surname>Regensberg</surname><given-names>L</given-names></name><name><surname>Little</surname><given-names>F</given-names></name><etal></etal></person-group><article-title>Early and late direct costs in a Southern African antiretroviral treatment programme: a retrospective cohort analysis</article-title><source>Plos Med</source><year>2009</year><volume>6</volume><fpage>e1000189</fpage><pub-id pub-id-type="doi">10.1371/journal.pmed.1000189</pub-id><pub-id pub-id-type="pmid">19956658</pub-id></element-citation></ref><ref id="CR8"><label>8.</label><element-citation publication-type="journal"><person-group person-group-type="author"><name><surname>Granich</surname><given-names>RM</given-names></name><name><surname>Gilks</surname><given-names>CF</given-names></name><name><surname>Dye</surname><given-names>C</given-names></name><name><surname>De Cock</surname><given-names>KM</given-names></name><name><surname>Williams</surname><given-names>BG</given-names></name></person-group><article-title>Universal voluntary HIV testing with immediate antiretroviral therapy as a strategy for elimination of HIV transmission: a mathematical model</article-title><source>Lancet</source><year>2009</year><volume>373</volume><fpage>48</fpage><lpage>57</lpage><pub-id pub-id-type="doi">10.1016/S0140-6736(08)61697-9</pub-id><pub-id pub-id-type="pmid">19038438</pub-id></element-citation></ref><ref id="CR9"><label>9.</label><element-citation publication-type="journal"><person-group person-group-type="author"><name><surname>Girardi</surname><given-names>E</given-names></name><name><surname>Sabin</surname><given-names>CA</given-names></name><name><surname>Monforte</surname><given-names>AD</given-names></name></person-group><article-title>Late diagnosis of HIV infection: epidemiological features, consequences and strategies to encourage earlier testing</article-title><source>J Acquir Immune Defic Syndr</source><year>2007</year><volume>46</volume><issue>Suppl 1</issue><fpage>S3</fpage><lpage>8</lpage><pub-id pub-id-type="doi">10.1097/01.qai.0000286597.57066.2b</pub-id><pub-id pub-id-type="pmid">17713423</pub-id></element-citation></ref><ref id="CR10"><label>10.</label><element-citation publication-type="journal"><person-group person-group-type="author"><name><surname>Bunnell</surname><given-names>R</given-names></name><name><surname>Mermin</surname><given-names>J</given-names></name><name><surname>De Cock</surname><given-names>KM</given-names></name></person-group><article-title>HIV prevention for a threatened continent: implementing positive prevention in Africa</article-title><source>Jama</source><year>2006</year><volume>296</volume><fpage>855</fpage><lpage>8</lpage><pub-id pub-id-type="doi">10.1001/jama.296.7.855</pub-id><pub-id pub-id-type="pmid">16905790</pub-id></element-citation></ref><ref id="CR11"><label>11.</label><element-citation publication-type="journal"><person-group person-group-type="author"><name><surname>Lugada</surname><given-names>E</given-names></name><name><surname>Millar</surname><given-names>D</given-names></name><name><surname>Haskew</surname><given-names>J</given-names></name><name><surname>Grabowsky</surname><given-names>M</given-names></name><name><surname>Garg</surname><given-names>N</given-names></name><name><surname>Vestergaard</surname><given-names>M</given-names></name><etal></etal></person-group><article-title>Rapid implementation of an integrated large-scale HIV counseling and testing, malaria, and diarrhea prevention campaign in rural Kenya</article-title><source>PLoS One</source><year>2010</year><volume>5</volume><fpage>e12435</fpage><pub-id pub-id-type="doi">10.1371/journal.pone.0012435</pub-id><pub-id pub-id-type="pmid">20865049</pub-id></element-citation></ref><ref id="CR12"><label>12.</label><mixed-citation publication-type="other">NASCOP. (2013). Kenya AIDS Indicator Survey 2012. National AIDS and STI Control Program, Ministry of Health Kenya.</mixed-citation></ref><ref id="CR13"><label>13.</label><mixed-citation publication-type="other">Uamuzi Bora, About Uamuzi Bora [<ext-link ext-link-type="uri" xlink:href="https://www.uamuzibora.org">https://www.uamuzibora.org</ext-link>], (2014).</mixed-citation></ref><ref id="CR14"><label>14.</label><mixed-citation publication-type="other">Ministry of Medical Services, NASCOP. (2011). Guidelines for antiretroviral therapy in Kenya. 4th edition 2011. Ministry of Medical Services, National AIDS and STI Control Program</mixed-citation></ref><ref id="CR15"><label>15.</label><element-citation publication-type="journal"><person-group person-group-type="author"><name><surname>Quigley</surname><given-names>MA</given-names></name><name><surname>Morgan</surname><given-names>D</given-names></name><name><surname>Malamba</surname><given-names>SS</given-names></name><name><surname>Mayanja</surname><given-names>B</given-names></name><name><surname>Okongo</surname><given-names>MJ</given-names></name><name><surname>Carpenter</surname><given-names>LM</given-names></name><etal></etal></person-group><article-title>Case–control study of risk factors for incident HIV infection in rural Uganda</article-title><source>J Acquir Immune Defic Syndr</source><year>2000</year><volume>23</volume><fpage>418</fpage><pub-id pub-id-type="doi">10.1097/00126334-200004150-00009</pub-id><pub-id pub-id-type="pmid">10866235</pub-id></element-citation></ref><ref id="CR16"><label>16.</label><element-citation publication-type="journal"><person-group person-group-type="author"><name><surname>Kigozi</surname><given-names>IM</given-names></name><name><surname>Dobkin</surname><given-names>LM</given-names></name><name><surname>Geng</surname><given-names>EH</given-names></name><name><surname>Emenyonu</surname><given-names>NI</given-names></name><name><surname>Bangsberg</surname><given-names>DR</given-names></name><name><surname>Hahn</surname><given-names>JA</given-names></name></person-group><article-title>Late-disease stage at presentation to an HIV clinic in the era of free antiretroviral therapy in Sub-Saharan Africa</article-title><source>J Acquir Immune Defic Syndr</source><year>2009</year><volume>52</volume><fpage>280</fpage><lpage>9</lpage><pub-id pub-id-type="doi">10.1097/QAI.0b013e3181ab6eab</pub-id><pub-id pub-id-type="pmid">19521248</pub-id></element-citation></ref><ref id="CR17"><label>17.</label><element-citation publication-type="journal"><person-group person-group-type="author"><name><surname>Nabyonga</surname><given-names>J</given-names></name><name><surname>Desmet</surname><given-names>M</given-names></name><name><surname>Karamagi</surname><given-names>H</given-names></name><name><surname>Kadama</surname><given-names>PY</given-names></name><name><surname>Omaswa</surname><given-names>FG</given-names></name><name><surname>Walker</surname><given-names>O</given-names></name></person-group><article-title>Abolition of cost-sharing is pro-poor: evidence from Uganda</article-title><source>Health Policy Plan</source><year>2005</year><volume>20</volume><fpage>100</fpage><lpage>8</lpage><pub-id pub-id-type="doi">10.1093/heapol/czi012</pub-id><pub-id pub-id-type="pmid">15746218</pub-id></element-citation></ref><ref id="CR18"><label>18.</label><mixed-citation publication-type="other">Bertakis, K., Azari, R., & Helms, L. (2000). Gender differences in the utilization of health care services. Journal Family Practice.</mixed-citation></ref><ref id="CR19"><label>19.</label><element-citation publication-type="journal"><person-group person-group-type="author"><name><surname>Bonjour</surname><given-names>MA</given-names></name><name><surname>Montagne</surname><given-names>M</given-names></name><name><surname>Zambrano</surname><given-names>M</given-names></name><name><surname>Molina</surname><given-names>G</given-names></name><name><surname>Lippuner</surname><given-names>C</given-names></name><name><surname>Wadskier</surname><given-names>FG</given-names></name><etal></etal></person-group><article-title>Determinants of late disease-stage presentation at diagnosis of HIV infection in Venezuela: a case-case comparison</article-title><source>AIDS Res Ther</source><year>2008</year><volume>5</volume><fpage>6</fpage><pub-id pub-id-type="doi">10.1186/1742-6405-5-6</pub-id><pub-id pub-id-type="pmid">18416849</pub-id></element-citation></ref><ref id="CR20"><label>20.</label><element-citation publication-type="journal"><person-group person-group-type="author"><name><surname>Ekouevi</surname><given-names>DK</given-names></name><name><surname>Balestre</surname><given-names>E</given-names></name><name><surname>Ba-Gomis</surname><given-names>F-O</given-names></name><name><surname>Eholie</surname><given-names>SP</given-names></name><name><surname>Maiga</surname><given-names>M</given-names></name><name><surname>Amani-Bosse</surname><given-names>C</given-names></name><etal></etal></person-group><article-title>Low retention of HIV-infected patients on antiretroviral therapy in 11 clinical centres in West Africa</article-title><source>Tropical Med Int Health</source><year>2010</year><volume>15</volume><fpage>34</fpage><lpage>42</lpage><pub-id pub-id-type="doi">10.1111/j.1365-3156.2010.02505.x</pub-id></element-citation></ref><ref id="CR21"><label>21.</label><element-citation publication-type="journal"><person-group person-group-type="author"><name><surname>Suthar</surname><given-names>AB</given-names></name><name><surname>Ford</surname><given-names>N</given-names></name><name><surname>Bachanas</surname><given-names>PJ</given-names></name><name><surname>Wong</surname><given-names>VJ</given-names></name><name><surname>Rajan</surname><given-names>JS</given-names></name><name><surname>Saltzman</surname><given-names>AK</given-names></name><etal></etal></person-group><article-title>Towards universal voluntary HIV testing and counselling: a systematic review and meta-analysis of community-based approaches</article-title><source>Plos Med.</source><year>2013</year><volume>10</volume><fpage>e1001496</fpage><pub-id pub-id-type="doi">10.1371/journal.pmed.1001496</pub-id><pub-id pub-id-type="pmid">23966838</pub-id></element-citation></ref><ref id="CR22"><label>22.</label><mixed-citation publication-type="other">Ngatu NR, Hirota R, Eitoku M, Muzembo BA, Nishimori M, Kuramochi M, et al. Perception of the risk of sexual transmission of HIV among Congolese and Japanese university students, Environ Health Prev Med. 2011. doi:10.1007/s12199-011-0232-z.</mixed-citation></ref><ref id="CR23"><label>23.</label><element-citation publication-type="journal"><person-group person-group-type="author"><name><surname>Puffer</surname><given-names>ES</given-names></name><name><surname>Meade</surname><given-names>CS</given-names></name><name><surname>Drabkin</surname><given-names>AS</given-names></name><name><surname>Broverman</surname><given-names>SA</given-names></name><name><surname>Ogwang-Odhiambo</surname><given-names>RA</given-names></name><name><surname>Sikkema</surname><given-names>KJ</given-names></name></person-group><article-title>Individual- and family-level psychosocial correlates of HIV risk behavior among youth in rural Kenya</article-title><source>AIDS Behav</source><year>2011</year><volume>15</volume><fpage>1264</fpage><lpage>74</lpage><pub-id pub-id-type="doi">10.1007/s10461-010-9823-8</pub-id><pub-id pub-id-type="pmid">20945157</pub-id></element-citation></ref><ref id="CR24"><label>24.</label><element-citation publication-type="journal"><person-group person-group-type="author"><name><surname>Rosen</surname><given-names>S</given-names></name><name><surname>Fox</surname><given-names>MP</given-names></name></person-group><article-title>Retention in HIV care between testing and treatment in Sub-Saharan africa: a systematic review</article-title><source>Plos Med</source><year>2011</year><volume>8</volume><fpage>e1001056</fpage><pub-id pub-id-type="doi">10.1371/journal.pmed.1001056</pub-id><pub-id pub-id-type="pmid">21811403</pub-id></element-citation></ref><ref id="CR25"><label>25.</label><mixed-citation publication-type="other">UNAIDS. (2011, August 19). Getting To Zero: UNAIDS 2011-2015 Strategy. Unaids.org. Retrieved February 1, 2014, from <ext-link ext-link-type="uri" xlink:href="http://www.unaids.int">http://www.unaids.int</ext-link></mixed-citation></ref><ref id="CR26"><label>26.</label><element-citation publication-type="journal"><person-group person-group-type="author"><name><surname>Wynberg</surname><given-names>E</given-names></name><name><surname>Cooke</surname><given-names>G</given-names></name><name><surname>Shroufi</surname><given-names>A</given-names></name><name><surname>Reid</surname><given-names>SD</given-names></name><name><surname>Ford</surname><given-names>N</given-names></name></person-group><article-title>Impact of point-of-care CD4 testing on linkage to HIV care: a systematic review</article-title><source>J Int AIDS Soc</source><year>2014</year><volume>17</volume><fpage>18809</fpage><pub-id pub-id-type="doi">10.7448/IAS.17.1.18809</pub-id><pub-id pub-id-type="pmid">24447595</pub-id></element-citation></ref><ref id="CR27"><label>27.</label><mixed-citation publication-type="other">Kranzer K, Govindasamy D, Ford N, Johnston V, Lawn S D. Quantifying and addressing losses along the continuum of care for people living with HIV infection in sub-Saharan Africa: a systematic review, J Int AIDS Soc. 15, 2013. doi:10.7448/ias.15.2.17383.</mixed-citation></ref><ref id="CR28"><label>28.</label><element-citation publication-type="journal"><person-group person-group-type="author"><name><surname>Nsigaye</surname><given-names>R</given-names></name><name><surname>Wringe</surname><given-names>A</given-names></name><name><surname>Roura</surname><given-names>M</given-names></name><name><surname>Kalluvya</surname><given-names>S</given-names></name><name><surname>Urassa</surname><given-names>M</given-names></name><name><surname>Busza</surname><given-names>J</given-names></name><etal></etal></person-group><article-title>From HIV diagnosis to treatment: evaluation of a referral system to promote and monitor access to antiretroviral therapy in rural Tanzania</article-title><source>J Int AIDS Soc</source><year>2009</year><volume>12</volume><fpage>31</fpage><pub-id pub-id-type="doi">10.1186/1758-2652-12-31</pub-id><pub-id pub-id-type="pmid">19906291</pub-id></element-citation></ref><ref id="CR29"><label>29.</label><element-citation publication-type="journal"><person-group person-group-type="author"><name><surname>Decroo</surname><given-names>T</given-names></name><name><surname>Panunzi</surname><given-names>I</given-names></name><name><surname>Das Dores</surname><given-names>C</given-names></name><name><surname>Maldonado</surname><given-names>F</given-names></name><name><surname>Biot</surname><given-names>M</given-names></name><name><surname>Ford</surname><given-names>N</given-names></name><etal></etal></person-group><article-title>Lessons learned during down referral of antiretroviral treatment in Tete, Mozambique</article-title><source>J Int AIDS Soc</source><year>2009</year><volume>12</volume><fpage>6</fpage><pub-id pub-id-type="doi">10.1186/1758-2652-12-6</pub-id><pub-id pub-id-type="pmid">19419543</pub-id></element-citation></ref><ref id="CR30"><label>30.</label><element-citation publication-type="journal"><person-group person-group-type="author"><name><surname>Nordberg</surname><given-names>E</given-names></name><name><surname>Holmberg</surname><given-names>S</given-names></name><name><surname>Kiugu</surname><given-names>S</given-names></name></person-group><article-title>Exploring the interface between first and second level of care: referrals in rural Africa</article-title><source>Trop Med Int Health</source><year>1996</year><volume>1</volume><fpage>107</fpage><lpage>11</lpage><pub-id pub-id-type="doi">10.1046/j.1365-3156.1996.d01-2.x</pub-id><pub-id pub-id-type="pmid">8673814</pub-id></element-citation></ref></ref-list></back></pmc></record>Pour manipuler ce document sous Unix (Dilib)
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