Missed Opportunities for HIV Testing and Late-Stage Diagnosis among HIV-Infected Patients in Uganda

Rhoda K Wanyenze,Moses R Kamya,Thomas Coates,Harriet Mayanja-Kizza,Judith A Hahn,David R Bangsberg,Sharif Sawires,Robin Fatch,Steven Baveewo,Landon Myer

doi:10.1371/journal.pone.0021794

Abstract

BackgroundLate diagnosis of HIV infection is a major challenge to the scale-up of HIV prevention and treatment. In 2005 Uganda adopted provider-initiated HIV testing in the health care setting to ensure earlier HIV diagnosis and linkage to care. We provided HIV testing to patients at Mulago hospital in Uganda, and performed CD4 tests to assess disease stage at diagnosis.MethodsPatients who had never tested for HIV or tested negative over one year prior to recruitment were enrolled between May 2008 and March 2010. Participants who tested HIV positive had a blood draw for CD4. Late HIV diagnosis was defined as CD4≤250 cells/mm. Predictors of late HIV diagnosis were analyzed using multi-variable logistic regression.ResultsOf 1966 participants, 616 (31.3%) were HIV infected; 47.6% of these (291) had CD4 counts ≤250. Overall, 66.7% (408) of the HIV infected participants had never received care in a medical clinic. Receiving care in a non-medical setting (home, traditional healer and drug stores) had a threefold increase in the odds of late diagnosis (OR = 3.2; 95%CI: 2.1–4.9) compared to receiving no health care.ConclusionsLate HIV diagnosis remains prevalent five years after introducing provider-initiated HIV testing in Uganda. Many individuals diagnosed with advanced HIV did not have prior exposure to medical clinics and could not have benefitted from the expansion of provider initiated HIV testing within health facilities. In addition to provider-initiated testing, approaches that reach individuals using non-hospital based encounters should be expanded to ensure early HIV diagnosis.

Highlights

Diagnosis of HIV infection is critical for improvement of HIV treatment outcomes [1,2,3,4]
We provided HIV Counseling and Testing (HCT), determined prior HIV testing and medical history, and performed CD4 counts for patients newly diagnosed with HIV in the medical and emergency wards and the outpatient medical clinics in Mulago National Referral Hospital in Uganda and determined predictors of late HIV diagnosis
Follow-up HIV care for adult patients diagnosed with HIV during hospitalization happens through several HIV clinics within the hospital, including the Infectious Disease Clinic (IDC) and the Mulago HIV clinic

Summary

Introduction

Diagnosis of HIV infection is critical for improvement of HIV treatment outcomes [1,2,3,4]. There has been a drive to scale-up HIV Counseling and Testing (HCT) services in order to ensure early diagnosis and access to HIV services including care and treatment as well as prevention [11]. Recent reports show improvement in access to HCT, yet over 60% of infected individuals globally remain unaware of their sero-status [11]. Research studies reported late diagnosis and treatment of HIV infected individuals [14]. Late initiation of HIV treatment in sub-Saharan Africa has been associated with limited access to treatment but could be attributed to delays in diagnosis of HIV infection and to delayed linkage to care after diagnosis [14,15]. In 2005 Uganda adopted provider-initiated HIV testing in the health care setting to ensure earlier HIV diagnosis and linkage to care. We provided HIV testing to patients at Mulago hospital in Uganda, and performed CD4 tests to assess disease stage at diagnosis

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Discussion

Conclusion