title: Program-level and contextual-level determinants of low-median CD4+ cell count in cohorts of persons initiating ART in eight sub-Saharan African countries.
abstract: OBJECTIVE
  In sub-Saharan Africa, many patients initiate antiretroviral therapy (ART) at CD4 cell counts much lower than those recommended in national guidelines. We examined program-level and contextual-level factors associated with low median CD4 cell count at ART initiation in populations initiating ART.
  
  
  METHODS
  Multilevel analysis of aggregate and program-level service delivery data.
  
  
  METHODS
  We examined data on 1690 cohorts of patients initiating ART during 2004-2008 in eight sub-Saharan African countries. Cohorts with median CD4 less than 111 cells/μl (the lowest quartile) were classified as having low median CD4 cell count at ART initiation. Cohort information was combined with time-updated program-level data and subnational contextual-level data, and analyzed using multilevel models.
  
  
  RESULTS
  The 1690 cohorts had median CD4 cell count of 136 cells/μl and included 121,504 patients initiating ART at 267 clinics. Program-level factors associated with low cohort median CD4 cell count included urban setting [adjusted odds ratio (AOR) 2.1; 95% confidence interval (CI) 1.3-3.3], lower provider-to-patient ratio (AOR 2.2; 95% CI 1.3-4.0), no PMTCT program (AOR 3.6; 95% CI 1.0-12.8), outreach services for ART patients only vs. both pre-ART and ART patients (AOR 2.4; 95% CI 1.5-3.9), fewer vs. more adherence support services (AOR 1.6; 95% CI 1.0-2.5), and smaller cohort size (AOR 2.5; 95% CI 1.4-4.5). Contextual-level factors associated with low cohort median CD4 cell count included initiating ART in areas where a lower proportion of the population heard of AIDS, tested for HIV recently, and a higher proportion believed 'limiting themselves to one HIV-uninfected sexual partner reduces HIV risk'.
  
  
  CONCLUSIONS
  Determinants of CD4 cell count at ART initiation in populations initiating ART operate at multiple levels. Structural interventions targeting points upstream from ART initiation along the continuum from infection to diagnosis to care engagement are needed.
authors.affiliation: International Center for AIDS Care and Treatment Programs, Columbia University Mailman School of Public Health, New York, New York, USA. dnash@hunter.cuny.edu
authors.forename: Denis
authors.initials: D
authors.lastname: Nash
authors.forename: Yingfeng
authors.initials: Y
authors.lastname: Wu
authors.forename: Batya
authors.initials: B
authors.lastname: Elul
authors.forename: David
authors.initials: D
authors.lastname: Hoos
authors.forename: Wafaa
authors.initials: W
authors.lastname: El Sadr
mesh_terms: D000293:Adolescent; D000328:Adult; D017954:Africa South of the Sahara / Q000453:epidemiology; D044966:Anti-Retroviral Agents / Q000627:therapeutic use*; D044383:Black People; D018791:CD4 Lymphocyte Count / Q000379:methods; D002648:Child; D015331:Cohort Studies; D004334:Drug Administration Schedule; D005260:Female; D015658:HIV Infections / Q000188:drug therapy* / Q000453:epidemiology / Q000276:immunology; D006801:Humans; D008297:Male; D008875:Middle Aged; D016017:Odds Ratio; D012307:Risk Factors; D012423:Rural Health; D014504:Urban Health; D019562:Viral Load; D055815:Young Adult
chemical_list: D044966:Anti-Retroviral Agents