Risk Factors for Late Linkage to Care and Delayed Antiretroviral Therapy Initiation Amongst HIV Infected Adults in Sub-saharan Africa: a Systematic Review and Meta-analyses
Authors: Fuge Terefe Gone , Tsourtos George , Miller Emma 
Published: January 2022

Abstract
Background: Late linkage to care and delay in antiretroviral therapy (ART) initiation threaten the clinical and public health benefits of ART such as: preventing acquired immunodeficiency syndrome (AIDS) and non-AIDS related morbidities and mortality, as well as reducing new infections. The prevalence of both of these poor care outcomes remains high in sub-Saharan African (SSA) countries. Quantitative synthesises of the existing data are lacking, which would help ascertain the best evidence-based interventions. This review aimed to systematically synthesise the available literature on factors affecting linkage to care and ART initiation amongst HIV infected adults in SSA. Methods: Systematic searches were undertaken of the following databases: Emcare, Medline, PubMed and Web of Science. In our review, we included observational studies that analysed factors affecting linkage to HIV care and ART initiation amongst adults (age ≥19 years) in SSA, and were published between January 1, 2015 and June 1, 2021. All included studies were assessed for risk of bias using the Effective Public Health Practice Project (EPHPP) Quality Assessment Tool for Quantitative Studies. RevMan-5 software was used to conduct meta-analyses and Mantel-Haenszel statistics to pool outcomes with 95% confidence interval and <0.05 level of significance. The review protocol has been published at the International Prospective Register of Systematic Reviews (PROSPERO; Number: CRD42021264398).Results: Forty-six studies were included in the systematic review, of which 18 fulfilled requirements for meta-analysis. Health care delivery, psychosocial, behavioural and sociodemographic factors were identified as determinants of late linkage to care and delay in ART initiation. The meta-analyses showed that people of a younger age group (<35 years) were 29% (OR: 0.71; 95%CI: 0.55-0.91, I2 = 74%) and 45% (OR: 0.55; 95%CI: 0.49-0.63, I2 = 0%) less likely to be linked to care and initiate ART respectively compared to people of an older age group (≥35 years). Employed people and people who travelled for more than an hour to reach a clinic were more than 1.3 (OR: 1.32; 95%CI: 1.14-1.52, I2 = 14%) and 1.2 (OR: 1.27; 95%CI: 1.15-1.39, I2 = 57%) times more likely to be presented late for care, respectively. The likelihood of linkage to care decreased by 26% (OR: 0.74; 95%CI: 0.62-0.87, I2 = 25%) for people who were unable to disclose their HIV status and 50% (OR: 0.50; 95%CI: 0.42-0.60, I2 = 0%) for those who had a baseline CD4 count >350cells/mm3 compared to CD4 count ≤350cells/mm3, but increased by 65% (OR: 1.65; 95%CI: 1.16-2.34, I2 = 0%) for those who were diagnosed through health facility-based testing approaches compared to community-based approaches. Conclusion: This systematic review and meta-analyses identified a range of risk factors for late linkage to care and delayed ART initiation amongst HIV infected adults in SSA including: health service delivery, psychosocial, behavioural and sociodemographic circumstances. We recommend implementation of patient-centred intervention approaches to alleviate these barriers.