Determinants of time from HIV infection to linkage-to-care in rural KwaZulu-Natal, South Africa

Maheu-Giroux, Mathieu; Tanser, Frank; Boily, Marie-Claude; Pillay, Deenan; Joseph, Serene A.; Bärnighausen, Till

Objective: To estimate time from HIV infection to linkage-to-care and its determinants. Linkage-to-care is usually assessed using the date of HIV diagnosis as the starting point for exposure time. However, timing of diagnosis is likely endogenous to linkage, leading to bias in linkage estimation.

Design: We used longitudinal HIV serosurvey data from a large population-based HIV incidence cohort in KwaZulu-Natal (2004–2013) to estimate time of HIV infection. We linked these data to patient records from a public-sector HIV treatment and care program to determine time from infection to linkage (defined using the date of the first CD4+ cell count).

Methods: We used Cox proportional hazards models to estimate time from infection to linkage and the effects of the following covariates on this time: sex, age, education, food security, socioeconomic status, area of residence, distance to clinics, knowledge of HIV status, and whether other household members have initiated antiretroviral therapy.

Results: We estimated that it would take an average of 4.9 years for 50% of HIV seroconverters to be linked to care (95% confidence intervals: 4.2–5.7). Among all cohort members who were linked to care, the median CD4+ cell count at linkage was 350 cells/μl (95% confidence interval: 330–380). Men and participants aged less than 30 years were found to have the slowest rates of linkage-to-care. Time to linkage became shorter over calendar time.

Conclusion: Average time from HIV infection to linkage-to-care is long and needs to be reduced to ensure that HIV treatment-as-prevention policies are effective. Targeted interventions for men and young individuals have the largest potential to improve linkage rates.

April 4, 2017
Year of publication
Resource types
Journal and research articles
linkage to care, HIV diagnosis, exposure time, ART initiation, treatment, ART, antiretroviral therapy, South Africa, linkage estimation, CD4 cell count, treatment as prevention (TasP), linkage rates

Similar Resources

This issue of the Southern African HIV Clinicians Society's "HIV Nursing Matters" online magazine focuses on vulnerable populations, including TB in prisons and intimate partner violence in the context of HIV.

This issue of the Southern African HIV Clinicians Society's "HIV Nursing Matters" online magazine focuses on key populations.


The goal of virtual elimination of horizontal and mother-to-child HIV transmission in South Africa (SA) has been proposed, but there have been few systematic investigations of which interventions are likely to be most critical to reducing HIV incidence.

Many countries are working to reduce or eliminate mother-to-child transmission (MTCT) of HIV. Prevention efforts have been conceptualized as steps in a cascade but cascade completion rates during and after pregnancy are low.

Antiretroviral therapy (ART) that enables suppression of HIV replication has been successfully rolled out at large scale to HIV-positive patients in low-income and middle-income countries.

Initiation of antiretroviral therapy (ART) following diagnosis of HIV infection at birth is an emerging area of paediatric HIV care. We present outcomes of HIV-infected infants identified at birth at Rahima Moosa Mother and Child Hospital in Johannesburg, South Africa.

Across sub-Saharan Africa, prevention of mother-to-child transmission services are encountering increasing numbers of women already established on antiretroviral therapy (ART) when entering antenatal care.

Female sex workers (FSW) in sub-Saharan Africa have a higher prevalence of HIV than other women of reproductive age. Social, legal, and structural barriers influence their access to care. Little is known about the HIV diagnosis and care cascade in most countries in southern Africa.


Attrition along the HIV care continuum slows gains in mitigating the South African HIV epidemic. Understanding population-level gaps in HIV identification, linkage, retention in care and viral suppression is critical to target programming.

Identifying gaps in HIV testing and treatment is essential to design specific strategies targeting those not accessing HIV services. We assessed the prevalence and factors associated with being HIV untested, unaware, untreated, and virally unsuppressed in KwaZulu-Natal, South Africa.