Background and Objective

1. Paul K. Drain, Elena Losina, Senica Chetty, Gary Parker,Janet Giddy, Douglas Ross, Jeffrey N. Katz, Sharon Coleman, Laura M. Bogart, Kenneth A. Freedberg, Rochelle P. Walensky, Ingrid V. Bassett Risk factors for late-stage HIV disease presentation at initial HIV diagnosisin Durban, South Africa Massachusetts General Hospital, Brigham and Women’s Hospital,Harvard Medical School, Harvard School of Public Health, Boston University School of Public Health, and Boston Children’s Hospital, Boston, USA; McCord Hospital and St. Mary’s Hospital, Durban, South Africa. Supported by the National Institute of Mental Health (NIMH), National Institute of Allergy and Infectious Disease (NIAID), National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMS), Fogarty International Center (FIC), Harvard Global Health Institute, and Harvard University’s Center for AIDS Research.

2. Background and Objective • Despite expanded access to HIV testing, most South Africans newly-diagnosed with HIV present with a low CD4 count and severe immunosuppression • To determine the risk factors for presenting with late-stage HIV disease, as well as the perceived barriers to presenting earlier for care • Methods • Prospective study at 4 outpatient clinics in urban and peri-urban areas of Durban, South Africa • Surveyed 3,669 adults prior to HIV testing; report on 830 HIV-infected • Enrollment from Aug 2010 to Nov 2011 • Defined late-stage disease as a CD4 <100/mm3, threshold for many OIs • Used logistic regression models for univariate and multivariate analyses Table 1. Cohort (N=830) N (%) Demographics Age ≥40 years 249 (30)   Male 415 (50)   Did not complete H.S. 449 (54) Working outside home 469 (57) Proximity to the HIV clinic Distance to clinic ≥5 km 688 (83) Travel to clinic ≥30 min 303 (37) Health Care Usage No prior HIV testing 661 (80) Hospital stay in prior year 60 (7)

3. Results • Among 830 enrolled, 279 (34%) presented with late-stage HIV (CD4 <100/mm3) at the time of initial HIV diagnosis Table 2. Perceived barriers to earlier care (N=830) Barrier Univariate Odds Ratio (95% CI) Felt too sick 3.0 (2.0 – 4.4) Could not afford transport 1.8 (1.3 – 2.5) Could not afford medications 1.8 (1.3 – 2.5) Not arrange transport to clinic 1.7 (1.2 – 2.4) Wait too long to see doctor 1.5 (1.1 – 2.1) Could not go during open hours 1.5 (1.0 – 2.1) Had to take care of someone 1.5 (0.9 – 2.2) Were not treated with respect 1.4 (0.8 – 2.3) They do not speak my language 1.2 (0.7 – 1.9) Could not get time off work 1.2 (0.8 – 1.7) Didn’t feel sick enough 1.0 (0.7 – 1.4) Didn’t know where to find care 0.9 (0.6 – 1.3)

4. Table 3. Multivariate model for risk of late-stage HIV disease (N=830)  Adjusted Odds Ratio (95% CI) for late-stage HIV Distance to clinic ≥5 kilometers 2.8 (1.7 – 4.7) Gone without healthcare because needed money for food, clothing, or housing 1.7 (1.2 – 2.4) Male 1.7 (1.2 – 2.3) Any overnight hospital stay in last year 1.6 (0.9 – 2.9) Currently working outside home 1.5 (1.1 – 2.1) Service delivery barriers 1.5 (1.1 – 2.1) Poor Emotional Health (< median value) 1.4 (1.0 – 1.9) Poor Social Support (< median value) 1.3 (0.9 – 1.9) Age ≥40 years 1.1 (0.8 – 1.5) • Conclusions • In Durban, the strongest independent risk factors for presentation with late- stage HIV disease were living further from the clinic, having competing needs to healthcare, and being male. • Self-reported barriers related to personal illness, cost of care, transportation difficulties, and poor service delivery were associated with late-stage disease. • Interventions to overcome these barriers and promote early HIV diagnosis are urgently needed to decrease late-stage HIV disease in resource-poor settings.