Abstract
IntroductionMost HIV-positive persons in sub-Saharan Africa initiate antiretroviral therapy (ART) with advanced infection (late ART initiation). Intervening on the drivers of late ART initiation is a critical step towards achieving the full potential of HIV treatment scale-up. This study aimed to identify modifiable factors associated with late ART initiation in Ethiopia.MethodsFrom 2012 to 2013, Ethiopian adults (n=1180) were interviewed within two weeks of ART initiation. Interview data were merged with HIV care histories to assess correlates of late ART initiation (CD4+ count <150 cells/µL or World Health Organization Stage IV).ResultsThe median CD4 count at enrolment in HIV care was 263 cells/µL (interquartile range (IQR): 140 to 390) and 212 cells/µL (IQR: 119 to 288) at ART initiation. Overall, 31.2% of participants initiated ART late, of whom 85.1% already had advanced HIV disease at enrolment. Factors associated with higher odds of late ART initiation included male sex (vs. non-pregnant females; adjusted odds ratio (aOR): 2.02; 95% CI: 1.50 to 2.73), high levels of psychological distress (vs. low/none, aOR: 1.96; 95% CI: 1.34 to 2.87), perceived communication barriers with providers (aOR: 2.42, 95% CI: 1.24 to 4.75), diagnosis via provider initiated testing (vs. voluntary counselling and testing, aOR: 1.47, 95% CI: 1.07 to 2.04), tuberculosis (TB) treatment prior to ART initiation (aOR: 2.16, 95% CI: 1.43 to 3.25) and a gap in care of six months or more prior to ART initiation (aOR: 2.02, 95% CI: 1.10 to 3.72). Testing because of partner illness/death (aOR: 0.64, 95% CI: 0.42 to 0.95) was associated with lower odds of late ART initiation.ConclusionsProgrammatic initiatives promoting earlier diagnosis, engagement in pre-ART care, and integration of TB and HIV treatments may facilitate earlier ART initiation. Men and those experiencing psychological distress may also benefit from targeted support prior to ART initiation.
Highlights
Most HIV-positive persons in sub-Saharan Africa initiate antiretroviral therapy (ART) with advanced infection
Studies of factors associated with advanced HIV infection prior to ART initiation in sub-Saharan Africa have found that sex, pregnancy, age, family composition, living arrangements, education level, employment status, competing priorities, disclosure status, emotional health and alcohol use were important correlates [8Á13]
Clinical and immunological characteristics at enrolment and ART initiation Of the 97.4% of participants with available CD4' counts and/ or World Health Organization (WHO) stage at enrolment in HIV care, 27.3% had enrolled in HIV care with advanced HIV infection (CD4 B150 cells/mL or WHO Stage IV)
Summary
Most HIV-positive persons in sub-Saharan Africa initiate antiretroviral therapy (ART) with advanced infection (late ART initiation). Conclusions: Programmatic initiatives promoting earlier diagnosis, engagement in pre-ART care, and integration of TB and HIV treatments may facilitate earlier ART initiation Men and those experiencing psychological distress may benefit from targeted support prior to ART initiation. The problem of late antiretroviral therapy (ART) initiation in sub-Saharan Africa has improved only slightly since the start of HIV scaleup in the region [6,7], making it important to identify its determinants, as well as necessary programmatic adjustments and policy changes. Studies of factors associated with advanced HIV infection prior to ART initiation (i.e. at diagnosis and/or presentation to care) in sub-Saharan Africa have found that sex, pregnancy, age, family composition, living arrangements, education level, employment status, competing priorities, disclosure status, emotional health and alcohol use were important correlates [8Á13]. Most studies have not examined factors beyond those routinely collected in HIV clinical records or the role of the pre-ART phase of care, limiting the ability to inform the development of interventions
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