Factors associated with initiation of antiretroviral therapy in the advanced stages of HIV infection in six Ethiopian HIV clinics, 2012 to 2013.
BACKGROUND
Most HIV-positive persons in sub-Saharan Africa initiate antiretroviral therapy (ART) with advanced infection (late ART initiation). Intervening on the drivers of late ART initiation is a critical step towards achieving the full potential of HIV treatment scale-up. This study aimed to identify modifiable factors associated with late ART initiation in Ethiopia.


METHODS
From 2012 to 2013, Ethiopian adults (n=1180) were interviewed within two weeks of ART initiation. Interview data were merged with HIV care histories to assess correlates of late ART initiation (CD4+ count <150 cells/µL or World Health Organization Stage IV).


RESULTS
The median CD4 count at enrollment in HIV care was 263 cells/µL (interquartile range (IQR): 140 to 390) and 212 cells/µL (IQR: 119 to 288) at ART initiation. Overall, 31.2% of participants initiated ART late, of whom 85.1% already had advanced HIV disease at enrollment. Factors associated with higher odds of late ART initiation included male sex (vs. non-pregnant females; adjusted odds ratio (aOR): 2.02; 95% CI: 1.50 to 2.73), high levels of psychological distress (vs. low/none, aOR: 1.96; 95% CI: 1.34 to 2.87), perceived communication barriers with providers (aOR: 2.42, 95% CI: 1.24 to 4.75), diagnosis via provider initiated testing (vs. voluntary counselling and testing, aOR: 1.47, 95% CI: 1.07 to 2.04), tuberculosis (TB) treatment prior to ART initiation (aOR: 2.16, 95% CI: 1.43 to 3.25) and a gap in care of six months or more prior to ART initiation (aOR: 2.02, 95% CI: 1.10 to 3.72). Testing because of partner illness/death (aOR: 0.64, 95% CI: 0.42 to 0.95) was associated with lower odds of late ART initiation.


CONCLUSIONS
Programmatic initiatives promoting earlier diagnosis, engagement in pre-ART care, and integration of TB and HIV treatments may facilitate earlier ART initiation. Men and those experiencing psychological distress may also benefit from targeted support prior to ART initiation.
Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, NY, USA.|Department of Epidemiology, City University of New York, School of Public Health, New York, NY, USA.|HIV Center for Clinical and Behavioral Studies, New York, NY, USA.
Denis
D
Nash
Department of Epidemiology, City University of New York, School of Public Health, New York, NY, USA; otymejcz@hunter.cuny.edu.
Olga
O
Tymejczyk
ICAP, Mailman School of Public Health, Columbia University, New York, NY, USA.
Tsigereda
T
Gadisa
Department of Epidemiology, City University of New York, School of Public Health, New York, NY, USA.
Sarah Gorrell
SG
Kulkarni
Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, NY, USA.|HIV Center for Clinical and Behavioral Studies, New York, NY, USA.
Susie
S
Hoffman
ICAP, Mailman School of Public Health, Columbia University, New York, NY, USA.
Muluneh
M
Yigzaw
Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, NY, USA.
Batya
B
Elul
HIV Center for Clinical and Behavioral Studies, New York, NY, USA.
Robert H
RH
Remien
Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, NY, USA.|ICAP, Mailman School of Public Health, Columbia University, New York, NY, USA.
Maria
M
Lahuerta
Oromia State Regional Bureau of Health, Addis Ababa, Ethiopia.
Shalo
S
Daba
Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, NY, USA.|ICAP, Mailman School of Public Health, Columbia University, New York, NY, USA.
Wafaa
W
El Sadr
ICAP, Mailman School of Public Health, Columbia University, New York, NY, USA.
Zenebe
Z
Melaku
D000328:Adult; D000368:Aged; D019380:Anti-HIV Agents / Q000627:therapeutic use*; D018791:CD4 Lymphocyte Count; D005002:Ethiopia; D005260:Female; D015658:HIV Infections / Q000188:drug therapy* / Q000276:immunology; D006801:Humans; D008297:Male; D008875:Middle Aged; D013997:Time Factors
D019380:Anti-HIV Agents
Ethiopia; HIV-positive adults; antiretroviral therapy guidelines; antiretroviral therapy initiation; implementation science; tuberculosis treatment