A study of almost 80,000 health care clients in South Africa, Tanzania, and Uganda has found that clients are most likely to agree to HIV testing and counseling when a nurse or lay counselor offers the service before clinical consultation, rather than during or after.

Study authors examined three models of HIV testing and counseling to see if one might help health workers more effectively link newly diagnosed clients to antiretroviral medicines and other ongoing care. The models included the following scenarios:

A) Health workers referred eligible clients (aged 18-49 who had not been tested in the past year and were not known to be HIV-positive) to on-site voluntary counseling and testing with counselors after clinical consultation.

B) Health workers offered and provided testing and counseling to eligible clients during clinical consultation.

C) Nurses or lay counselors offered and provided testing and counseling to eligible clients before clinical consultation.

Both diagnosis and linkage to continuing care are critical steps in addressing the HIV epidemic and in achieving an AIDS-free generation, as UNAIDS and the global community have pledged to do by 2030.

Of the 16,099 age-eligible clients who were tested during the three-month study, 10% tested HIV-positive. Model C resulted in the highest proportion of clients tested (54.1%), followed by Model A (41.7%) and Model B (33.9%).

But in terms of linking clients to continuing care, there was no significant difference across models. While 94% of clients who tested HIV-positive were referred to care, only 58% entered care. This is a problem health sectors have long struggled to remedy.

“While the percentage of people ever tested for HIV in sub-Saharan Africa has increased over the past several years, linkage to care for patients with newly diagnosed HIV has remained low,” study authors write, “compromising the success of care, treatment, and prevention efforts.”

Understanding the characteristics of clients who have just been diagnosed with HIV and immediately enter care can help health workers develop solutions to link even more newly diagnosed clients with the care they need. That would mean fewer clients fall out of the HIV care continuum.

“In Tanzania, we have a health worker shortage that makes it difficult to offer universal HIV testing, which is a crucial part of making sure the one million Tanzanian adults living with HIV can get the care they need,” says Lucy Mphuru, one of the study authors and project director at IntraHealth International in Tanzania. “These study results give us some powerful evidence that will help us make sure more people know their HIV statuses. But we’re also finding that we have a lot of work to do in guiding clients to care after their initial diagnoses.”

“Implementation and Operational Research: Strengthening HIV Test Access and Treatment Uptake Study (Project STATUS): A Randomized Trial of HIV Testing and Counseling Interventions” was published in the August 15 issue of the Journal of Acquired Immune Deficiency Syndromes.

IntraHealth’s work in Tanzania is funded by the US Centers for Disease Control and Prevention.