Late enrolment in HIV care declines in sub-Saharan Africa, but majority of people still eligible for immediate ART at diagnosis

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The proportion of HIV-positive patients in sub-Saharan Africa who entered care late declined significantly between 2006 and 2011, investigators report in AIDS. However, over half of those newly enrolled in care in 2011 met World Health Organization (WHO) criteria for immediate antiretroviral therapy (ART): a CD4 count below 350 cells/mm3 or stage 3/4 disease. The study involved over 300,000 people in Kenya, Mozambique, Rwanda and Tanzania.

“Enrollment in HIV care with advanced HIV disease declined over time, concurrent with efforts to scale up HIV treatment in the same countries,” comment the authors. “Our analysis also showed that in 2011 – nearly a decade after service scale-up began in sub-Saharan Africa, more than half of all individuals enrolled in care when they already were eligible for ART by 2010 WHO guidelines.”

The research was undertaken because little is known about the proportion of people in sub-Saharan Africa who already eligible for ART when they enter care. The factors associated with late enrolment in care are also unclear.



Social attitudes that suggest that having a particular illness or being in a particular situation is something to be ashamed of. Stigma can be questioned and challenged.

advanced HIV

A modern term that is often preferred to 'AIDS'. The World Health Organization criteria for advanced HIV disease is a CD4 cell count below 200 or symptoms of stage 3 or 4 in adults and adolescents. All HIV-positive children younger than five years of age are considered to have advanced HIV disease.

Data were therefore collected from 138 HIV clinical centres about the characteristics of adult patients (15 to 85 years) who were enrolled into care between 2006 and 2011. Information from 57 centres was utilised to determine factors associated with late enrolment in 2011.

Throughout the study period, most patients were non-pregnant women (59%), in the 26 to 35 years age group (38%) and married/living with a partner (47%).

The proportion of patients enrolled late declined from 70% in 2006 to 57% in 2011. This corresponded to a 1.5% decline every six months (p < 0.001). Significant declines were observed in pregnant and non-pregnant women, men and in all four participating countries. Late enrolment in 2011 was significantly lower compared to 2006 across all sub-groups defined by age, marital status and type of centre offering care.

Median CD4 count at enrolment increased from 242 cells/mm3 in 2006 to 292 cells/mm3 in 2011 (p < 0.0001). The proportion of patients with CD4 counts of at least 350 cells/mm3 or 500 cells/mm3 increased from 19 to 25% and 11 to 15%, respectively. There was also a fall in the percentage of patients enrolled with a CD4 count below 200 cells/mm3 (23 to 21%).

Data for 46,000 people entering care in 2011 showed that late enrolment was associated with higher local HIV prevalence, HIV stigma and lower coverage of primary education. In contrast, higher population HIV testing, higher HIV knowledge and higher employment levels were all associated with a lower risk of late enrolment.

Non-pregnant women had a lower risk of late entry into care than pregnant women and men. Younger age was also associated with a lower risk of late enrolment, as was being married or living with a partner.

Compared to regions where 20% or less of the population had had an HIV test and received HIV results in the past year, regions where at least 40% of the population did so had a significantly lower risk of late enrolment (ARR = 0.70; 95% CI, 0.58-0.97).

“We observed a substantial decrease in the proportion of patients enrolled in HIV care at advanced stages of HIV disease,” conclude the authors. “Innovative approaches to increase testing uptake prior to symptom development may most rapidly reduce late enrollment in care.”


Hoffman S et al. Advanced disease at enrollment in HIV care in four sub-Saharan African countries: change from 2006 to 2011 and multilevel predictors in 2011. AIDS 28, online edition. DOI: 10.1097/QAD.0000000000000427, 2014.