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  • The study was based in a peri-urban township in the greater area of Cape Town, with a population of approximately 15,000 people and a measured adult HIV prevalence of 23% in 2005 [12]. The community is served by a single public-sector primary care clinic, which provides outpatient care including ART free of charge. A nearby hospital (5 km away) provides all secondary care for the population, including inpatient and antenatal services. The hospital also provides ART for some HIV-infected individuals from the community. HIV testing, CD4 count measurements and ART services: Client-initiated HIV testing services have been available to all individuals accessing either the local clinic or the hospital since 2001. Clients who tested on their own initiative are referred to as having tested through VCT services. Provider-initiated testing was routinely provided to any patient accessing TB services whose HIV status was unknown. This was extended to all pregnant females accessing the hospital or clinic in 2002 and patients accessing STI services in 2007. All testing required signed consent. All CD4 count tests were free for patients and performed by the centrally located National Health Laboratory Services (NHLS) in Cape Town. ART provision at the primary health care clinic and hospital began in 2004. Linkage to HIV and ART care: Linkage to HIV care was defined as attending for a CD4 count measurement within 6 months of HIV diagnosis. We did not ascertain if individuals actually received their CD4 counts. Linkage to ART care was defined as initiating ART within 6 months of HIV diagnosis in individuals with a CD4 count ≤200 cells/µl taken within 6 months of HIV diagnosis. Having a repeat CD4 count was defined as having had a repeated CD4 count in individuals not yet eligible for ART (CD4 count >200 cells/µl) and tested before 2009. We collected data from 3 sources. First, the primary care clinic and hospital HIV testing registers provided all data on HIV infected, adult community residents (≥18 years) diagnosed between January 2004 and March 2009. Data at the primary health care clinic were missing for the period from February 2008 to August 2008. For each test encounter recorded in the registers, we retrieved data on client identification variables (first name, surname, date of birth, and medical record number); place of residence; sex; test acceptance; test result and service. For HIV infected individuals who tested more than once, the earliest positive HIV test was considered. Second, data on CD4 counts performed at either the primary care clinic or the hospital in the period from 2004 to October 2009 were obtained from NHLS. The date of CD4 count was the date the client provided blood. Third, data from residents who initiated ART care at the primary health care clinic or hospital were obtained from electronic ART registers at the clinic and hospital. These three databases were merged on first name, surname, medical record number and date of birth. In cases where identifiers did not match completely two researchers (PG and KK) independently confirmed that records in different databases were from the same individual. Concordance between the two researchers was 97%. Cases where the two researchers disagreed were discussed until consensus was reached. For all subsequent analysis data was stripped of all personal identifiers. Written informed consent was obtained from all individuals initiated on ART and screened for ART. Individuals testing for HIV are routinely entered into the HIV testing register. Informed consent was not obtained from HIV positive individuals not linking to care, as this was a retrospective study and individuals were not actively follow-up. Data collection and analysis was approved by the University of Cape Town Ethics Committee and Partners Human Subjects Institutional Review Board and the London School of Hygiene and Tropical Medicine. A random sample (n = 885) of adults testing HIV positive through ANC, STI and VCT services between January 2004 and March 2009 was selected for this analysis. All adults testing positive through TB services were included in this analysis to ensure an adequate sample size in this group. All analyses were carried out using Stata version 11 (Stata Corp. LP, College Station, TX, United States of America). Proportions were calculated stratified by service. Total proportions were calculated taking the different sampling proportions into account. Risk ratios investigating associations between age, sex, calendar period and timely linkage to HIV care, CD4 count ≤200 cells/µl and repeated CD4 counts were estimated for each service. Risk ratios were calculated using a log binominal model [13].
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