title: Advanced disease at enrollment in HIV care in four sub-Saharan African countries: change from 2006 to 2011 and multilevel predictors in 2011.
abstract: OBJECTIVE
  To examine changes between 2006 and 2011 in the proportion of HIV-positive patients newly enrolled in HIV care with advanced disease and the median CD4 cell count at enrollment; and identify patient, facility, and contextual-level factors associated with late enrollment in care in 2011.
  
  
  METHODS
  Cross-sectional over time.
  
  
  METHODS
  For time-trends analyses, routinely collected patient-level data (307 110 adults newly enrolled in 138 HIV clinical care facilities) in Kenya, Mozambique, Rwanda and Tanzania; and for analyses of correlates, patient-level data (46 201 in 195 facilities), and facility and population-level survey data were used. Late enrollment was defined as CD4 cell count 350 cells/μl or less and/or WHO clinical stage 3/4.
  
  
  RESULTS
  Late enrollment declined from 69.9 to 57.2% (P < 0.0001); median CD4 cell count increased from 242 to 292 cells/μl (Ptrend < 0.0001). In 2011, risk of late enrollment was significantly higher for men and nonpregnant women vs. pregnant women; patients aged above 25 vs. 15-25 years; nonmarried vs. married; and those entering from sites other than prevention of mother-to-child transmission. More extensive HIV testing coverage in the region of a facility was significantly associated with lower risk of late enrollment.
  
  
  CONCLUSIONS
  Despite improvement, in 2011, 57% of patients entered HIV care who were already antiretroviral therapy-eligible. The lower risk of late enrollment among those referred from prevention of mother-to-child transmission and in regions where HIV testing coverage was higher suggests that innovative approaches to rapidly increase testing uptake among people living with HIV prior to the development of symptoms have the potential to reduce late enrollment in care.
authors.affiliation: aHIV Center for Clinical and Behavioral Studies at the NYS Psychiatric Institute and Columbia University bDepartment of Epidemiology, Mailman School of Public Health, Columbia University cICAP-Columbia University, Mailman School of Public Health dEpidemiology and Biostatistics Program, CUNY School of Public Health, New York, USA eMinistry of Health, Maputo, Mozambique.
authors.forename: Susie
authors.initials: S
authors.lastname: Hoffman
authors.forename: Yingfeng
authors.initials: Y
authors.lastname: Wu
authors.forename: Maria
authors.initials: M
authors.lastname: Lahuerta
authors.forename: Sarah Gorrell
authors.initials: SG
authors.lastname: Kulkarni
authors.forename: Harriet
authors.initials: H
authors.lastname: Nuwagaba-Biribonwoha
authors.forename: Wafaa El
authors.initials: WE
authors.lastname: Sadr
authors.forename: Robert H
authors.initials: RH
authors.lastname: Remien
authors.forename: Veronicah
authors.initials: V
authors.lastname: Mugisha
authors.forename: Mark
authors.initials: M
authors.lastname: Hawken
authors.forename: Ema
authors.initials: E
authors.lastname: Chuva
authors.forename: Denis
authors.initials: D
authors.lastname: Nash
authors.forename: Batya
authors.initials: B
authors.lastname: Elul
mesh_terms: D000293:Adolescent; D000328:Adult; D017954:Africa South of the Sahara; D000368:Aged; D000369:Aged, 80 and over; D044966:Anti-Retroviral Agents / Q000008:administration & dosage*; D018791:CD4 Lymphocyte Count; D003430:Cross-Sectional Studies; D057210:Delayed Diagnosis; D005260:Female; D015658:HIV Infections / Q000175:diagnosis* / Q000188:drug therapy / Q000276:immunology / Q000473:pathology*; D006801:Humans; D008297:Male; D008875:Middle Aged; D011247:Pregnancy; D055815:Young Adult
chemical_list: D044966:Anti-Retroviral Agents