title: Barriers to antiretroviral initiation in HIV-1-discordant couples.
abstract: BACKGROUND
  In Kenya and much of sub-Saharan Africa, nearly half of all couples affected by HIV are discordant. Antiretroviral therapy (ART) slows disease progression in HIV-1-infected individuals and reduces transmission to uninfected partners. We examined time to ART initiation and factors associated with delayed initiation in HIV-1-discordant couples in Nairobi.
  
  
  METHODS
  HIV-1-discordant couples were enrolled and followed quarterly for up to 2 years. Clinical staff administered questionnaires and conducted viral loads and CD4 counts. Participants with a CD4 count meeting ART criteria were referred to a nearby US President's Emergency Plan for AIDS Relief-funded treatment center. Barriers to ART initiation among participants with a CD4 count eligible for ART were assessed by Cox regression.
  
  
  RESULTS
  Of 439 HIV-1-infected participants (63.6% females and 36.4% males), 146 met CD4 count criteria for ART during follow-up. Median time from meeting CD4 criteria until ART initiation was 8.9 months, with 42.0% of eligible participants on ART by 6 months and 63.4% on ART by 1 year. The CD4 count at the time of eligibility was inversely associated with time to ART initiation (hazard ratio = 0.49, P < 0.001). Compared with homeowners, those paying higher rents started ART 48% more slowly (P = 0.062) and those paying lower rents started 71% more slowly (P = 0.002).
  
  
  CONCLUSIONS
  Despite access to regular health care, referrals to treatment centers, and free access to ART, over one-third of participants with an eligible CD4 count had not started ART within 1 year. Factors of lower socioeconomic status may slow ART initiation, and targeted approaches are needed to avoid delays in treatment initiation.
authors.affiliation: Department of Epidemiology, University of Washington, Seattle, WA 98104-2499, USA. brguth@u.washington.edu
authors.forename: Brandon L
authors.initials: BL
authors.lastname: Guthrie
authors.forename: Robert Y
authors.initials: RY
authors.lastname: Choi
authors.forename: Amy Y
authors.initials: AY
authors.lastname: Liu
authors.forename: Romel D
authors.initials: RD
authors.lastname: Mackelprang
authors.forename: Anne F
authors.initials: AF
authors.lastname: Rositch
authors.forename: Rose
authors.initials: R
authors.lastname: Bosire
authors.forename: Lucy
authors.initials: L
authors.lastname: Manyara
authors.forename: Ann
authors.initials: A
authors.lastname: Gatuguta
authors.forename: James N
authors.initials: JN
authors.lastname: Kiarie
authors.forename: Carey
authors.initials: C
authors.lastname: Farquhar
mesh_terms: D000328:Adult; D019380:Anti-HIV Agents / Q000008:administration & dosage*; D023241:Antiretroviral Therapy, Highly Active; D018791:CD4 Lymphocyte Count; D005191:Family Characteristics; D005260:Female; D015658:HIV Infections / Q000188:drug therapy* / Q000276:immunology / Q000821:virology*; D015497:HIV-1 / Q000302:isolation & purification*; D006801:Humans; D007630:Kenya; D008297:Male; D010342:Patient Acceptance of Health Care / Q000706:statistics & numerical data*; D012959:Socioeconomic Factors; D011795:Surveys and Questionnaires; D013997:Time Factors; D019562:Viral Load
chemical_list: D019380:Anti-HIV Agents