Linkage to HIV care following diagnosis in the WHO European Region: A systematic review and meta-analysis, 2006-2017

Background: Timely linkage to care after HIV diagnosis is crucial as delayed access can result in poor patient outcomes. The aim of this systematic review was to synthesise the evidence to achieve a better understanding of what proportion of patients are linked to care and what factors impact linkage. Methods: Systematic searches were run in six databases up to the end of February 2017. The grey literature was also reviewed. Inclusion criteria were: sample size ≥50 people (aged ≥15), from the WHO European Region, published 2006–2017 and in English. Linkage to care was defined as a patient seen for HIV care after diagnosis. Study selection, data extraction and quality assurance were performed by two independent reviewers. Random-effects meta-analysis was carried out to summarise linkage to care within three months of diagnosis. Results: Twenty-four studies were included; 22 presented linkage to care data and seven examined factors for linkage. Linkage among 89,006 people in 19 countries was captured. Meta-analysis, restricted to 12 studies and measuring prompt linkage within three months, gave a pooled estimate of 85% (95% CI: 75%-93%). Prompt linkage was higher in studies including only people in care (94%; 95% CI: 91%-97%) than in those of all new diagnoses (71%; 95% CI: 50%-87%). Heterogeneity was high across and within strata (>99%). Factors associated with delaying or not linking to care included: acquiring HIV through heterosexual contact/injecting drug use, younger age at diagnosis, lower levels of education, feeling well at diagnosis and diagnosis outside an STI clinic. Conclusion: Overall, linkage to care was high, though estimates were lower in studies with a high proportion of people who inject drugs. The high heterogeneity between studies made it challenging to synthesise findings. Studies should adopt a standardised definition with a three month cut-off to measure prompt linkage to care to ensure comparability.