Monitoring progress towards the first UNAIDS target:
                understanding the impact of people living with HIV who re-test
                during HIV-testing campaigns in rural Mozambique

INTRODUCTION: Awareness of HIV-infection goes beyond diagnosis,
                and encompasses understanding, acceptance, disclosure and
                initiation of the HIV-care. We aimed to characterize the
                HIV-positive population that underwent repeat HIV-testing
                without disclosing their serostatus and the impact on estimates
                of the first UNAIDS 90 target. METHODS: This analysis was nested
                in a prospective cohort established in southern Mozambique which
                conducted three HIV-testing modalities: voluntary counselling
                and testing (VCT), provider-initiated counselling and testing
                (PICT) and home-based testing (HBT). Participants were given the
                opportunity to self-report their status to lay counsellors and
                HIV-positive diagnoses were verified for previous enrolment in
                care. This study included 1955 individuals diagnosed with HIV
                through VCT/PICT and 11,746 participants of a HBT campaign.
                Those who did not report their serostatus prior to testing, and
                were found to have a previous HIV-diagnosis, were defined as
                non-disclosures. Venue-stratified descriptive analyses were
                performed and factors associated with non-disclosure were
                estimated through log-binomial regression. RESULTS: In the first
                round of 2500 adults randomized for HBT, 1725 were eligible for
                testing and 18.7% self-reported their HIV-positivity. Of those
                tested with a positive result, 38.9% were found to be
                non-disclosures. Similar prevalence of non-disclosures was found
                in clinical-testing modalities, 29.4% (95% CI 26.7 to 32.3) for
                PICT strategy and 13.0% (95% CI 10.9 to 15.3) for VCT. Prior
                history of missed visits (adjusted prevalence ratio (APR) 4.2,
                95% CI 2.6 to 6.8), younger age (APR 2.5, 95% CI 1.4 to 4.4) and
                no prior history of treatment ((APR) 1.4, 95% CI 1.0 to 2.1)
                were significantly associated with non-disclosure as compared to
                patients who self-reported. When considering non-disclosures as
                people living with HIV (PLWHIV) aware of their HIV-status, the
                proportion of PLWHIV aware increased from 78.3% (95% CI 74.2 to
                81.6) to 86.8% (95% CI 83.4 to 89.6). CONCLUSION: More than
                one-third of individuals testing HIV-positive did not disclose
                their previous positive HIV-diagnosis to counsellors. This
                proportion varied according to testing modality and age. In the
                absence of an efficient and non-anonymous tracking system for
                HIV-testers, repeat testing of non-disclosures leads to wasted
                resources and may distort programmatic indicators. Developing
                interventions that ensure appropriate psychosocial support are
                needed to encourage this population to disclose their status and
                optimize scarce resources