title: Lack of pre-antiretroviral care and competition from traditional healers, crucial risk factors for very late initiation of antiretroviral therapy for HIV--a case-control study from eastern Uganda.
abstract: BACKGROUND
  Although WHO recommends starting antiretroviral treatment at a CD4 count of 350 cells/[µ]L, many Ugandan districts still struggle with large proportions of clients initiating ART very late at CD4<50 cells/[µ]L. This study seeks to establish crucial risk factors for very late ART initiation in eastern Uganda.
  
  
  METHODS
  All adult HIV-infected clients on ART in Iganga who enrolled between 2005 and 2009 were eligible for this case-control study. Clients who started ART at CD4 cell count of <50 cells/[µ]L (very late initiators) were classified as cases and 50-200 cells/[µ]L (late initiators) as control subjects. A total of 152 cases and 202 controls were interviewed. Multivariate analyses were performed to calculate adjusted odds ratios and 95% confidence intervals.
  
  
  RESULTS
  Reported health system-related factors associated with very late ART initiation were stock-outs of antiretroviral drugs stock-outs (affecting 70% of the cases and none of the controls), competition from traditional/spiritual healers (AOR 7.8, 95 CI% 3.7-16.4), and lack of pre-ARV care (AOR 4.6, 95% CI: 2.3-9.3). Men were 60% more likely and subsistence farmers six times more likely (AOR 6.3, 95% CI: 3.1-13.0) to initiate ART very late. Lack of family support tripled the risk of initiating ART very late (AOR 3.3, 95% CI: 1.6-6.6).
  
  
  CONCLUSIONS
  Policy makers should prevent ARV stock-outs though effective ARV procurement and supply chain management. New HIV clients should seek pre-ARV care for routine monitoring and determination of ART eligibility. ART services should be more affordable, accessible and user-friendly to make them more attractive than traditional healers.
authors: District Health Office, Iganga District Administration, PO Box 358, Iganga, Uganda.
authors: Lubega
authors: L
authors: Muhamadi
authors: Nazarius Mbona
authors: NM
authors: Tumwesigye
authors: Daniel
authors: D
authors: Kadobera
authors: Gaetano
authors: G
authors: Marrone
authors: Fred
authors: F
authors: Wabwire-Mangen
authors: George
authors: G
authors: Pariyo
authors: Stefan
authors: S
authors: Peterson
authors: Anna Mia
authors: AM
authors: Ekström
mesh_terms: D000328:Adult; D019380:Anti-HIV Agents / Q000008:administration & dosage / Q000600:supply & distribution / Q000627:therapeutic use*; D018791:CD4 Lymphocyte Count; D016022:Case-Control Studies; D005260:Female; D015658:HIV Infections / Q000188:drug therapy*; D006297:Health Services Accessibility; D006801:Humans; D008297:Male; D016488:Medicine, African Traditional / Q000379:methods*; D015999:Multivariate Analysis; D012307:Risk Factors; D013997:Time Factors; D014454:Uganda
chemical_list: D019380:Anti-HIV Agents