Prevalence and factors associated with delayed ART initiation among HIV positive patients referred to Mulago ISS clinic in the test and treat era.
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Background: In 2015, the World Health Organization (WHO) recommended the test and treat strategy due to evidence that early antiretroviral therapy (ART) prevented the pathophysiological progression of HIV to AIDS, reduced HIV transmission, and improved quality of life among patients with HIV/AIDs. In 2016, Uganda adopted the WHO recommendations and updated the consolidated HIV prevention and treatment guidelines to reflect the changes. The guidelines currently recommend that HIV positive patients are started on ART within 7 days of HIV diagnosis if tested positive in a setting with ART services and within 30 days if tested positive in a setting without ART services. Although HIV testing services are widely available at health facilities and in the community, free ART services are limited to programs that operate in public and private not for profit health facilities. This necessitates referral for some patients from centers where they are tested HIV positive to centers with ART services. Unfortunately, this may result in delays to initiate ART. We assessed the prevalence and factors associated with delayed initiation of ART among patients referred for care. Methods: This was a cross-sectional study with sequential – explanatory mixed methods. The study was conducted among patients 12years and older, referred to Mulago ISS clinic for ART initiation between January 2017 – May 2021. Quantitative data including socio-demographic characteristics, circumstances of HIV testing and referral for ART, and time to ART initiation was collected using a questionnaire and analyzed using Stata version 16. The outcome of interest was status of ART initiation 30 days from HIV diagnosis. Qualitative was collected through in-depth and key informant interviews. Data was coded and analyzed by inductive thematic analysis using Atlas.ti version 9. Results: Of the 312 patients enrolled, 62.2% were female. The median (IQR) age and baseline CD4 count were 35 (28-42) years, and 315 (118.8-580.5) respectively. The prevalence of delayed ART initiation was 15.4%. The odds of delayed ART initiation were higher among patients who had their HIV diagnosis made from a private health facility versus public health facility; adjusted Odds Ratio (aOR) = 2.5 (95% confidence interval [CI] 1.1 – 5.7, p = 0.036); patients who denied their initial positive HIV test results versus those who accepted; aOR =5 (95% CI: 1.7 - 14.9, p = 0.003); and patients who did not receive a follow up phone call from the place of HIV diagnosis versus those who received; aOR=2.8 (95% CI: 1.2 - 6.8, p = 0.022). The barriers to timely ART initiation included lack of adequate counseling and support from the HIV testing facility, denial of HIV results, unclear referral from the testing facility with no referral notes given, ambiguous instructions of where to go for care, fear of discrimination, perceived pill burden, fear of drug side effects, and lack of social support from family. The facilitators of timely ART initiation included acceptance of HIV results, feeling sick after testing HIV positive but before initiating ART, counseling, privacy at the ART facility, good health worker attitudes, and availability of free ART. Conclusion: 15% of HIV positive patients referred for ART delayed to initiate ART despite testing positive five years after the test and treat guidelines were rolled out in Uganda. Most factors associated with delayed care involved health system factors especially counseling and referral practices at the HIV testing centers which can be addressed with training, support supervision and scaling up follow up phone calls in order to meet the 90-90-90 targets.