Forty percent of patients with HIV in Uganda only have their infection diagnosed when they are already ill because of HIV, or have developed AIDS, investigators report in a study published in the online edition of the Journal of Acquired Immune Deficiency Syndromes. The authors believe that this figure is likely to represent the lower bound for number of patients diagnosed late.
Access to antiretroviral therapy in sub-Saharan Africa and other resource-limited settings is expanding. Access to HIV treatment in Uganda is free and widespread for patients who are WHO stage 3 or 4 HIV disease (AIDS), or who have a CD4 cell count below 200 cells/mm3.
Individuals who initiate antiretroviral treatment when they have a very low CD4 cell count or are severely unwell because of HIV often have a poor outcome. Research to date suggests that between 15 and 43% of individuals in resource-limited settings are in this situation when they start HIV treatment.
Knowing how many patients are diagnosed late and the factors associated with this can assist in the development of programmes to overcome late entry into HIV care. Therefore investigators at the Mbarara University Teaching Hospital in Uganda conducted a cross-sectional study starting in February 2007, and lasting one year, to identify the proportion of patients diagnosed late and the factors accompanying late presentation.
A total of 2311 individuals were included in the investigators’ analyses. HIV was diagnosed late in 40% of these patients.
Men were more likely to be diagnosed late than women (50% vs 36%), as were non-pregnant women compared to pregnant women (36% vs 15%).
Late diagnosis was more prevalent amongst older individuals, with over 50% of those aged between 46 and 50 being severely ill at the time their HIV was detected compared to 35% of 16 to 25 year-olds. The investigators suggest that this could be a legacy of the period from antiretroviral therapy was unavailable and there were few perceived advantages for knowledge of HIV status.
A lower level of education was also associated with late diagnosis, and 43% of individuals who reported being unemployed had progressed to advanced HIV disease at their time of diagnosis compared to 33% of those in business occupations.
Patients with a long journey to a health facility were also more likely to be diagnosed late, with 44% of those having a journey time of two or more hours falling into this category, compared to 35% of individuals with a journey time of less than 30 minutes to their local clinic.
Proximity to HIV was also an important factor. Almost two-thirds (62%) of individuals with no HIV-positive household members were already severely ill because of HIV compared to 39% of those with one or more member with the infection.
There was also a higher rate of late diagnosis amongst unmarried (43%) and divorced (49%) individuals than married patients (35%).
Surprisingly, a higher proportion of patients who reported no alcohol consumption in the previous year (42%) were diagnosed late than those who reported heavy drinking (32%). The investigators suggest that this could be because heavy drinkers had a better perception of risk, but identify this an area that needs further research.
Statistical analysis that controlled for possible confounding factors found the following factors associated with late diagnosis:
- Male sex (p
- Older age (p
- No secondary education (p
- Unemployment (p
- Marital status (single, p
When the investigators restricted their analysis to women, they found that having no children under five years of age (p
Similar risk factors for late diagnosis were also present amongst men, as was Munyankole tribal identity.
“In an era when highly active antiretroviral therapy is not only free but also widely available in Uganda, we found that 40% of patients in a large HIV clinic had late-stage HIV disease at their initial clinic visit,” comment the investigators.
They conclude that the low CD4 cell counts and advanced HIV disease that are often present in patients starting HIV therapy in Africa is because of late diagnosis, rather than the “selective treatment of patients with late-stage disease”.
Kigozi IM et al. Late-disease stage at presentation to an HIV clinic in the era of free antiretroviral therapy in sub-Saharan Africa. J Acquir Immune Defic Syndr (online edition), 2009.