title: Advanced HIV disease at presentation to care in Nairobi, Kenya: late diagnosis or delayed linkage to care?--a cross-sectional study.
abstract: BACKGROUND
  Presenting to care with advanced HIV is common in sub-Saharan Africa and increases the risk of severe disease and death; however, it remains unclear whether this is a consequence of late diagnosis or a delay in seeking care after diagnosis. The objectives of this cross-sectional study were to determine factors associated with advanced HIV at presentation to care and whether this was due to late diagnosis or delays in accessing care.
  
  
  METHODS
  Between 2013 and 2015, adults presenting to care were recruited at two clinics in low-income areas of Nairobi, Kenya. Participants were considered to have advanced HIV if their CD4 count was below 200 cells/μL, or they were in WHO stage 4. Information on previous HIV diagnoses was collected using interviewer-administered questionnaires. Logistic regression was used to determine the association between clinical and socio-demographic factors and advanced HIV.
  
  
  RESULTS
  Of 753 participants presenting to HIV care, 248 (33 %) had advanced HIV. Almost 60 % (146/248) of those presenting with advanced HIV had been previously diagnosed, most of whom (102/145; 70 %) presented to care within three months of their initial diagnosis. The median time to presentation to HIV care after an initial diagnosis was 22 days (IQR 6-147) for those with advanced HIV, compared to 19 days (IQR 4-119) for those with non-advanced HIV (p = 0.716). Clinic (adjusted odds ratio [AOR] 1.55, 95 % CI 1.09-2.20) and age (AOR 1.72 per unit increase in age category, 95 % CI 1.45-2.03) were associated with presenting with advanced HIV.
  
  
  CONCLUSIONS
  Presentation to care with advanced HIV was primarily due to delayed diagnosis, rather than delayed linkage to care after diagnosis. Variation by clinic suggests that outreach and other community-based efforts may drive earlier testing and linkage to care. Our findings highlight the ongoing importance of implementing strategies to encourage earlier HIV diagnosis, particularly among adults 30 years and older.
authors.affiliation: Department of Public Health Sciences/Global Health (IHCAR), Karolinska Institutet, Widerströmska Huset, Tomtebodavägen 18A, Stockholm, 171-77, Sweden. miavanderkop@gmail.com.|Department of Medicine, University of British Columbia, 828 West 10th Avenue, Vancouver, BC, V5Z 1M9, Canada. miavanderkop@gmail.com.
authors.forename: Mia Liisa
authors.initials: ML
authors.lastname: van der Kop
authors.affiliation: Department of Clinical Epidemiology and Biostatistics, McMaster University, 50 Charlton Avenue East, Hamilton, ON, L8N 4A6, Canada.
authors.forename: Lehana
authors.initials: L
authors.lastname: Thabane
authors.affiliation: Department of Public Health Sciences/Global Health (IHCAR), Karolinska Institutet, Widerströmska Huset, Tomtebodavägen 18A, Stockholm, 171-77, Sweden.
authors.forename: Patricia Opondo
authors.initials: PO
authors.lastname: Awiti
authors.affiliation: Amref Health Africa, Langata Road, Nairobi, Kenya.
authors.forename: Samuel
authors.initials: S
authors.lastname: Muhula
authors.affiliation: Amref Health Africa, Langata Road, Nairobi, Kenya.
authors.forename: Lennie Bazira
authors.initials: LB
authors.lastname: Kyomuhangi
authors.affiliation: Department of Medicine, University of British Columbia, 828 West 10th Avenue, Vancouver, BC, V5Z 1M9, Canada.
authors.forename: Richard Todd
authors.initials: RT
authors.lastname: Lester
authors.affiliation: Department of Public Health Sciences/Global Health (IHCAR), Karolinska Institutet, Widerströmska Huset, Tomtebodavägen 18A, Stockholm, 171-77, Sweden.|Department of Infectious Diseases, I73, Karolinska University Hospital, 141 86, Stockholm, Sweden.
authors.forename: Anna Mia
authors.initials: AM
authors.lastname: Ekström
mesh_terms: D000328:Adult; D000554:Ambulatory Care Facilities; D019380:Anti-HIV Agents / Q000627:therapeutic use; D018791:CD4 Lymphocyte Count; D003430:Cross-Sectional Studies; D057210:Delayed Diagnosis; D005260:Female; D015658:HIV Infections / Q000175:diagnosis* / Q000188:drug therapy / Q000473:pathology; D006801:Humans; D007630:Kenya; D016015:Logistic Models; D008297:Male; D008875:Middle Aged; D016017:Odds Ratio; D012720:Severity of Illness Index; D011795:Surveys and Questionnaires
chemical_list: D019380:Anti-HIV Agents
keywords: Advanced HIV; HIV/AIDS; Informal settlements; Kenya; Presentation to HIV care; Sub-Saharan Africa