title: Trends in the clinical characteristics of HIV-infected patients initiating antiretroviral therapy in Kenya, Uganda and Tanzania between 2002 and 2009.
abstract: BACKGROUND
  East Africa has experienced a rapid expansion in access to antiretroviral therapy (ART) for HIV-infected patients. Regionally representative socio-demographic, laboratory and clinical characteristics of patients accessing ART over time and across sites have not been well described.
  
  
  METHODS
  We conducted a cross-sectional analysis of characteristics of HIV-infected adults initiating ART between 2002 and 2009 in Kenya, Uganda and Tanzania and in the International Epidemiologic Databases to Evaluate AIDS Consortium. Characteristics associated with advanced disease (defined as either a CD4 cell count level of less than 50 cells/mm3 or a WHO Stage 4 condition) at the time of ART initiation and use of stavudine (D4T) or nevirapine (NVP) were identified using a log-link Poisson model with robust standard errors.
  
  
  RESULTS
  Among 48,658 patients (69% from Kenya, 22% from Uganda and 9% from Tanzania) accessing ART at 30 clinic sites, the median age at the time of ART initiation was 37 years (IQR: 31-43) and 65% were women. Pre-therapy CD4 counts rose from 87 cells/mm3 (IQR: 26-161) in 2002-03 to 154 cells/mm3 (IQR: 71-233) in 2008-09 (p<0.001). Accessing ART at advanced disease peaked at 35% in 2005-06 and fell to 27% in 2008-09. D4T use in the initial regimen fell from a peak of 88% in 2004-05 to 59% in 2008-09, and a greater extent of decline was observed in Uganda than in Kenya and Tanzania. Self-pay for ART peaked at 18% in 2003, but fell to less than 1% by 2005. In multivariable analyses, accessing ART at advanced immunosuppression was associated with male sex, women without a history of treatment for prevention of mother to child transmission (both as compared with women with such a history) and younger age after adjusting for year of ART initiation and country of residence. Receipt of D4T in the initial regimen was associated with female sex, earlier year of ART initiation, higher WHO stage, and lower CD4 levels at ART initiation and the absence of co-prevalent tuberculosis.
  
  
  CONCLUSIONS
  Public health ART services in east Africa have improved over time, but the fraction of patients accessing ART with advanced immunosuppression is still high, men consistently access ART with more advanced disease, and D4T continues to be common in most settings. Strategies to facilitate access to ART, overcome barriers among men and reduce D4T use are needed.
authors.affiliation: Department of Medicine, San Francisco General Hospital, University of California at San Francisco, 995 Potrero Avenue, San Francisco, CA, USA. genge@php.ucsf.edu
authors.forename: Elvin H
authors.initials: EH
authors.lastname: Geng
authors.forename: Peter W
authors.initials: PW
authors.lastname: Hunt
authors.forename: Lameck O
authors.initials: LO
authors.lastname: Diero
authors.forename: Sylvester
authors.initials: S
authors.lastname: Kimaiyo
authors.forename: Geofrey R
authors.initials: GR
authors.lastname: Somi
authors.forename: Pius
authors.initials: P
authors.lastname: Okong
authors.forename: David R
authors.initials: DR
authors.lastname: Bangsberg
authors.forename: Mwebesa B
authors.initials: MB
authors.lastname: Bwana
authors.forename: Craig R
authors.initials: CR
authors.lastname: Cohen
authors.forename: Juliana A
authors.initials: JA
authors.lastname: Otieno
authors.forename: Deo
authors.initials: D
authors.lastname: Wabwire
authors.forename: Batya
authors.initials: B
authors.lastname: Elul
authors.forename: Denis
authors.initials: D
authors.lastname: Nash
authors.forename: Philippa J
authors.initials: PJ
authors.lastname: Easterbrook
authors.forename: Paula
authors.initials: P
authors.lastname: Braitstein
authors.forename: Beverly S
authors.initials: BS
authors.lastname: Musick
authors.forename: Jeffrey N
authors.initials: JN
authors.lastname: Martin
authors.forename: Constantin T
authors.initials: CT
authors.lastname: Yiannoutsos
authors.forename: Kara
authors.initials: K
authors.lastname: Wools-Kaloustian
mesh_terms: D000328:Adult; D019380:Anti-HIV Agents / Q000008:administration & dosage*; D023241:Antiretroviral Therapy, Highly Active / Q000379:methods*; D018791:CD4 Lymphocyte Count; D003430:Cross-Sectional Studies; D004363:Drug Utilization / Q000706:statistics & numerical data; D005260:Female; D015658:HIV Infections / Q000188:drug therapy* / Q000453:epidemiology / Q000473:pathology* / Q000821:virology; D006801:Humans; D007108:Immune Tolerance; D007630:Kenya / Q000453:epidemiology; D008297:Male; D008875:Middle Aged; D019829:Nevirapine / Q000008:administration & dosage; D012737:Sex Factors; D018119:Stavudine / Q000008:administration & dosage; D013636:Tanzania / Q000453:epidemiology; D014454:Uganda / Q000453:epidemiology
chemical_list: D019380:Anti-HIV Agents; D019829:Nevirapine; D018119:Stavudine