Linkage to Care Following an HIV Diagnosis in Three Public Sector Clinics in eThekwini (Durban), South Africa: Findings from a Prospective Cohort Study

  • Susie HoffmanEmail author
  • Cheng-Shiun Leu
  • Gita Ramjee
  • Kelly Blanchard
  • Anisha D. Gandhi
  • Lucia O’Sullivan
  • Elizabeth A. Kelvin
  • Theresa M. Exner
  • Joanne E. Mantell
  • Naomi Lince-Deroche
Original Paper


Linkage to care following an HIV diagnosis remains an important HIV care continuum milestone, even in the era of universal ART eligibility. In an 8-month prospective cohort study among 459 (309 women, 150 men) newly-diagnosed HIV-positive individuals in three public-sector clinics in Durban metropolitan region, South Africa, from 2010 to 2013, median time to return to clinic for CD4+ results (linkage) was 10.71 weeks (95% CI 8.52–12.91), with 54.1% 3-month cumulative incidence of linkage. At study completion (9.23 months median follow-up), 26.2% had not linked. Holding more positive outcome-beliefs about enrolling in care was associated with more rapid linkage [adjusted hazard ratio (AHR)each additional belief 1.31; 95% CI 1.05–1.64] and lower odds of never linking [adjusted odds ratio (AOR) 0.50; 95% CI 0.33–0.75]. Holding positive ARV beliefs was strongly protective against never linking to care. Age over 30 years (AHR 1.59; 95% CI 1.29–1.97) and disclosing one’s HIV-positive status within 30 days of diagnosis (AHR 1.52; 95% CI 1.10–2.10) were associated with higher linkage rates and lower odds of never linking. Gender was not associated with linkage and did not alter the effect of other predictors. Although expanded access to ART has reduced some linkage barriers, these findings demonstrate that people’s beliefs and social relations also matter. In addition to structural interventions, consistent ART education and disclosure support, and targeting younger individuals for linkage are high priorities.


Linkage to care Enrollment in care Delayed linkage Delayed enrollment Delayed presentation HIV care continuum Time from diagnosis to linkage Newly-diagnosed HIV-positive 



We gratefully acknowledge the study participants who shared their experiences with study team members, the Medical Research Council HIV Prevention Research Unit (HPRU), interviewers, data managers, and transcribers who worked on the Pathways Study, the volunteers and staff at Ibis Reproductive Health and the students at Columbia University Mailman School of Public Health who assisted with data management and coding. Special thanks to Suraya Dawad for directing data collection activities, to Neetha Morar for overall study support, and to Bridgit Burns for data management supervision. This manuscript is dedicated to the memory of Drs. Alan Berkman and Urvashi Vasant, both of whom contributed to the conception of this study but tragically died before it was completed.


This research was supported by the National Institute of Mental Health, (R01 MH83561 and R01 MH083561-03S1; Principal Investigator: Susie Hoffman, DrPH; by a center grant from the National Institute of Mental Health to the HIV Center for Clinical and Behavioral Studies at NY State Psychiatric Institute and Columbia University [P30-MH43520; Principal Investigators: Anke A. Ehrhardt (1987-2013)/Robert H. Remien, Ph.D. (2013-2018)]. Dr. Gandhi was supported by a training grant from the National Institute of Mental Health (T32 MH19139, Behavioral Sciences Research in HIV Infection; Principal Investigator: Theo Sandfort, Ph.D.). Additional support was provided by the South African Medical Research Council HIV Prevention Research Unit (MRC HPRU). The content is solely the responsibility of the authors and does not necessarily represent the official views of NIMH or the MRC HPRU.

Compliance with Ethical Standards

Conflict of interest

The authors declare no conflicts of interest.

Supplementary material

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Supplementary material 1 (DOCX 68 kb)


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Copyright information

© Springer Science+Business Media, LLC, part of Springer Nature 2019

Authors and Affiliations

  • Susie Hoffman
    • 1
    • 2
    Email author
  • Cheng-Shiun Leu
    • 1
    • 3
  • Gita Ramjee
    • 4
  • Kelly Blanchard
    • 5
    • 8
  • Anisha D. Gandhi
    • 1
  • Lucia O’Sullivan
    • 6
  • Elizabeth A. Kelvin
    • 7
  • Theresa M. Exner
    • 1
  • Joanne E. Mantell
    • 1
  • Naomi Lince-Deroche
    • 5
    • 8
  1. 1.HIV Center for Clinical and Behavioral Studies, Division of Gender, Sexuality, and HealthNew York State Psychiatric Institute and Columbia UniversityNew YorkUSA
  2. 2.Department of Epidemiology, Mailman School of Public HealthColumbia UniversityNew YorkUSA
  3. 3.Department of Biostatistics, Mailman School of Public HealthColumbia UniversityNew YorkUSA
  4. 4.HIV Prevention Research UnitSouth African Medical Research CouncilDurbanSouth Africa
  5. 5.Ibis Reproductive HealthCambridgeUSA
  6. 6.Department of PsychologyUniversity of New BrunswickFrederictonCanada
  7. 7.Epidemiology & Biostatistics Program, CUNY Graduate School of Public Health and Health PolicyCity University of New YorkNew YorkUSA
  8. 8.Ibis Reproductive HealthJohannesburgSouth Africa

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