Factors affecting linkage to HIV care and ART initiation following referral for ART by a mobile health clinic in South Africa: evidence from a multimethod study

  • Brendan Maughan-BrownEmail author
  • Abigail Harrison
  • Omar Galárraga
  • Caroline Kuo
  • Philip Smith
  • Linda-Gail Bekker
  • Mark N. Lurie


Linkage to care from mobile clinics is often poor and inadequately understood. This multimethod study assessed linkage to care and antiretroviral therapy (ART) uptake following ART-referral by a mobile clinic in Cape Town (2015/2016). Clinic record data (N = 86) indicated that 67% linked to care (i.e., attended a clinic) and 42% initiated ART within 3 months. Linkage to care was positively associated with HIV-status disclosure intentions (aOR: 2.99, 95% CI 1.13–7.91), and treatment readiness (aOR: 2.97, 95% CI 1.05–8.34); and negatively with good health (aOR: 0.35, 95% CI 0.13–0.99), weekly alcohol consumption (aOR: 0.35, 95% CI 0.12–0.98), and internalised stigma (aOR: 0.32, 95% CI 0.11–0.91). Following linkage, perceived stigma negatively affected ART-initiation. In-depth interviews (N = 41) elucidated fears about ART side-effects, HIV-status denial, and food insecurity as barriers to ART initiation; while awareness of positive ART-effects, follow-up telephone counselling, familial responsibilities, and maintaining health to avoid involuntary disclosure were motivating factors. Results indicate that an array of interventions are required to encourage rapid ART-initiation following mobile clinic HIV-testing services.


Linkage to care HIV/AIDS Barriers to ART initiation Community-based HIV testing services Mobile clinic HIV care continuum Qualitative HIV treatment cascade 



The authors gratefully acknowledge the staff of the Tutu Tester Mobile Clinic for their valuable assistance with developing the study materials and with data collection. We are also grateful for data access from the Western Cape Government Department of Health and assistance in linking study participants to electronic clinic records from Andrew Boulle, Jonathan Euvrard and Meg Osler (Centre for Infectious Disease Epidemiology and Research) and Nicki Tiffin (Provincial Health Data Centre, Western Cape Government).


This study was partially funded by the National Research Foundation, South Africa, through the Research Career Advancement Fellowship. Data collection for this study was partially funded by the Eunice Kennedy Shriver National Institute of Child Health and Human Development of the National Institutes of Health (Award No. R24HD077976, SASH). Support was provided by the National Institutes of Health through the Brown University Population Studies and Training Center (PSTC) (P2CHD041020-16). CK and ML derived support for analysis, interpretation and writing from the National Institute of Mental Health (Grants K01MH 096646; and R01 MH106600, i-ALARM). The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health, the National Research Foundation, or anyone else. The funders had no role in study design, data collection and analysis, manuscript preparation, or decision to publish.

Compliance with ethical standards

Conflict of interest

Brendan Maughan-Brown, Abigail Harrison, Omar Galárraga, Caroline Kuo, Philip Smith, Linda-Gail Bekker and Mark N. Lurie declare that they have no conflict of interest.

Human and animal rights and Informed consent

The Human Research Ethics Committee, Faculty of Health Sciences, University of Cape Town provided study approval (Ref: 849/2014). The Western Cape Government Department of Health approved access to provincial health data (Ref: WC_2015RP1_270). Written informed consent was obtained from all study participants.

Supplementary material

10865_2018_5_MOESM1_ESM.docx (36 kb)
Supplementary material 1 (DOCX 36 kb)


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Copyright information

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

Authors and Affiliations

  1. 1.Southern Africa Labour and Development Research Unit (SALDRU)University of Cape TownRondebosch, Cape TownSouth Africa
  2. 2.Department of Behavioral and Social SciencesBrown University School of Public HealthProvidenceUSA
  3. 3.Department of Health Services, Policy and Practice (HSPP)Brown University School of Public HealthProvidenceUSA
  4. 4.Department of Psychiatry and Mental HealthUniversity of Cape TownCape TownSouth Africa
  5. 5.The Desmond Tutu HIV CentreUniversity of Cape TownCape TownSouth Africa
  6. 6.Department of EpidemiologyBrown University School of Public HealthProvidenceUSA

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