Multilevel Factors Influencing Linkage to HIV Care in a High HIV Prevalence District in South Africa: A Mixed Methods Approach.

Timely linkage to HIV care is essential for achieving South Africa's treatment goals, yet significant gaps persist in the early stages of the HIV care continuum. This study examined multilevel factors influencing linkage to care in a high HIV-prevalence rural district. A prospective convergent mixed-methods cohort study was conducted over 21 months among 1,194 adults newly diagnosed with HIV across 18 facilities in KwaZulu-Natal. Quantitative analyses (Pearson's chi-square, Mann-Whitney tests, and logistic regression) were used to identify factors associated with linkage to care within three months of diagnosis. Qualitative data from in-depth interviews with 38 purposively selected participants were analysed thematically and triangulated with quantitative findings to provide contextual insights. Overall, 83% of participants linked to care within three months. Linkage was significantly higher among those diagnosed at hospitals (OR = 4.90; 95% CI: 1.87-12.82; p = 0.003), while diagnosis at mobile clinics showed borderline significance. Among women, later sexual debut (≥ 17 years) was associated with increased likelihood of timely linkage. In contrast, condom use at last sex (OR = 0.50; 95% CI: 0.32-0.79; p = 0.03) and substance use (OR = 0.67; 95% CI: 0.47-0.96; p = 0.05) were associated with lower linkage. Qualitative findings highlighted supportive family environments and positive provider interactions as key facilitators of linkage, while stigma, fear of disclosure, confidentiality concerns, preference for traditional or spiritual healing, and health system challenges, including lost clinic files and poor counselling, emerged as significant barriers. These findings underscore the need for patient-centred, stigma-free, and responsive health systems to improve timely linkage to HIV care in high-burden settings.