Research Article: Linkage to HIV care following diagnosis in the WHO European Region: A systematic review and meta-analysis, 2006-2017

Date Published: February 16, 2018

Publisher: Public Library of Science

Author(s): Sara Croxford, Zheng Yin, Fiona Burns, Andrew Copas, Katy Town, Sarika Desai, Andrew Skingsley, Valerie Delpech, Alan Winston.


Timely linkage to care after HIV diagnosis is crucial as delayed access can result in poor patient outcomes. The aim of this systematic review was to synthesise the evidence to achieve a better understanding of what proportion of patients are linked to care and what factors impact linkage.

Systematic searches were run in six databases up to the end of February 2017. The grey literature was also reviewed. Inclusion criteria were: sample size ≥50 people (aged ≥15), from the WHO European Region, published 2006–2017 and in English. Linkage to care was defined as a patient seen for HIV care after diagnosis. Study selection, data extraction and quality assurance were performed by two independent reviewers. Random-effects meta-analysis was carried out to summarise linkage to care within three months of diagnosis.

Twenty-four studies were included; 22 presented linkage to care data and seven examined factors for linkage. Linkage among 89,006 people in 19 countries was captured. Meta-analysis, restricted to 12 studies and measuring prompt linkage within three months, gave a pooled estimate of 85% (95% CI: 75%-93%). Prompt linkage was higher in studies including only people in care (94%; 95% CI: 91%-97%) than in those of all new diagnoses (71%; 95% CI: 50%-87%). Heterogeneity was high across and within strata (>99%). Factors associated with delaying or not linking to care included: acquiring HIV through heterosexual contact/injecting drug use, younger age at diagnosis, lower levels of education, feeling well at diagnosis and diagnosis outside an STI clinic.

Overall, linkage to care was high, though estimates were lower in studies with a high proportion of people who inject drugs. The high heterogeneity between studies made it challenging to synthesise findings. Studies should adopt a standardised definition with a three month cut-off to measure prompt linkage to care to ensure comparability.

Partial Text

Linking people who test HIV-positive to appropriate specialist services is a key step in the HIV patient pathway. Delayed linkage to HIV care is associated with delayed receipt of antiretroviral medications, faster disease progression and increased mortality.[1, 2] In addition to the impact on the health of the individual, engagement in HIV care plays an important public health role in reducing the onward transmission of HIV.[3]

A protocol was developed prior to commencement of the systematic review and published on PROSPERO, an international prospective register of systematic reviews.[7]

In this systematic review, 24 studies were identified that used a standardised definition to measure linkage to care following HIV diagnosis since 2006 in the WHO European Region. Twenty-two studies provided an independent point estimate of linkage to care, with 14 studies measuring prompt linkage within three months. Seven studies addressed factors associated with not linking to care or delayed linkage.




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