Factors associated with HIV status awareness and Linkage to Care following home based testing in rural Malawi

Objective: HIV diagnosis and linkage to care are the main barriers in Africa to achieving the UNAIDS 90-90-90 targets. We assessed HIV-positive status awareness and linkage to care among survey participants in Chiradzulu District, Malawi. Method: Nested cohort study within a population-based survey of persons aged 15–59 years between February and May 2013. Participants were interviewed and tested for HIV (and CD4 if found HIV-positive) in their homes. Multivariable regression was used to determine factors associated with HIV-positive status awareness prior to the survey and subsequent linkage to care. Results: Of 8277 individuals eligible for the survey, 7270 (87.8%) participated and were tested for HIV. The overall HIV prevalence was 17.0%. Among HIV-positive participants, 77.0% knew their status and 72.8% were in care. Women (adjusted odds ratio [aOR] 6.5, 95% CI 3.2–13.1) and older participants (40–59 vs. 15–29 years, aOR 10.1, 95% CI 4.0–25.9) were more likely to be aware of their positive status. Of those newly diagnosed, 47.5% were linked to care within 3 months. Linkage to care was higher among older participants (40–59 vs. 15–29, adjusted hazard ratio [aHR] 3.39, 95% CI 1.83–6.26), women (aHR 1.73, 95% CI 1.12–2.67) and those eligible for ART (aHR 1.61, 95% CI 1.03–2.52). Conclusions: In settings with high levels of HIV awareness, home-based testing remains an efficient strategy to diagnose and link to care. Men were less likely to be diagnosed, and when diagnosed to link to care, underscoring the need for a gender focus in order to achieve the 90-90-90 targets.