title: Risk factors for delayed initiation of combination antiretroviral therapy in rural north central Nigeria.
abstract: BACKGROUND
  Timely initiation of combination antiretroviral therapy (ART) in eligible HIV-infected patients is associated with substantial reduction in mortality and morbidity. Nigeria has the second largest number of persons living with HIV/AIDS in the world. We examined patient characteristics, time to ART initiation, retention, and mortality at 5 rural facilities in Kwara and Niger states of Nigeria.
  
  
  METHODS
  We analyzed program-level cohort data for HIV-infected ART-naive clients (≥15 years) enrolled from June 2009 to February 2011. We modeled the probability of ART initiation among clients meeting national ART eligibility criteria using logistic regression with splines.
  
  
  RESULTS
  We enrolled 1948 ART-naive adults/adolescents into care, of whom, 1174 were ART eligible (62% female). Only 74% of the eligible patients (n = 869) initiated ART within 90 days after enrollment. The median CD4 count for eligible clients was 156 cells/μL (interquartile range: 81-257), with 67% in WHO stage III/IV disease. Adjusting for CD4 count, WHO stage, functional status, hemoglobin, body mass index, sex, age, education, marital status, employment, clinic of attendance, and month of enrollment, we found that immunosuppression [CD4 350 vs. 200, odds ratio (OR) = 2.10, 95% confidence interval (CI): 1.31 to 3.35], functional status [bedridden vs. working, OR = 4.17 (95% CI: 1.63 to 10.67)], clinic of attendance [Kuta Hospital vs. referent: OR = 5.70 (95% CI: 2.99 to 10.89)], and date of enrollment [December 2010 vs. June 2009: OR = 2.13 (95% CI: 1.19 to 3.81)] were associated with delayed ART initiation.
  
  
  CONCLUSIONS
  Delayed initiation of ART was associated with higher CD4 counts, lower functional status, clinic of attendance, and later dates of enrollment among ART-eligible clients. Our findings provide targets for quality improvement efforts that may help reduce attrition and improve ART uptake in similar settings.
authors.affiliation: Departments of *Preventive Medicine, †Medicine, and ‡Biostatistics, Vanderbilt Institute for Global Health, Nashville, TN; §Westat, Rockville, MD; ‖Friends in Global Health, Abuja, Nigeria; ¶US Centers for Disease Control and Prevention, Abuja, Nigeria; and the #Department of Pediatrics, Vanderbilt Institute for Global Health, Nashville, TN.
authors.forename: Muktar H
authors.initials: MH
authors.lastname: Aliyu
authors.forename: Meridith
authors.initials: M
authors.lastname: Blevins
authors.forename: Deidra D
authors.initials: DD
authors.lastname: Parrish
authors.forename: Karen M
authors.initials: KM
authors.lastname: Megazzini
authors.forename: Usman I
authors.initials: UI
authors.lastname: Gebi
authors.forename: Mukhtar Y
authors.initials: MY
authors.lastname: Muhammad
authors.forename: Mukhtar L
authors.initials: ML
authors.lastname: Ahmed
authors.forename: Adiba
authors.initials: A
authors.lastname: Hassan
authors.forename: Bryan E
authors.initials: BE
authors.lastname: Shepherd
authors.forename: Sten H
authors.initials: SH
authors.lastname: Vermund
authors.forename: C William
authors.initials: CW
authors.lastname: Wester
mesh_terms: D000328:Adult; D044966:Anti-Retroviral Agents / Q000627:therapeutic use*; D023241:Antiretroviral Therapy, Highly Active / Q000379:methods*; D018791:CD4 Lymphocyte Count; D015331:Cohort Studies; D005260:Female; D015658:HIV Infections / Q000188:drug therapy* / Q000453:epidemiology* / Q000401:mortality / Q000473:pathology; D006302:Health Services Research; D006801:Humans; D008297:Male; D009549:Nigeria / Q000453:epidemiology; D011247:Pregnancy; D012307:Risk Factors; D012424:Rural Population; D016019:Survival Analysis; D013997:Time Factors
chemical_list: D044966:Anti-Retroviral Agents