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Risk Factors for Delayed Initiation of Combination Antiretroviral Therapy in Rural North Central Nigeria

Aliyu, Muktar H. MD, DrPH*,†; Blevins, Meridith MS; Parrish, Deidra D. MD, MPH; Megazzini, Karen M. DrPH§; Gebi, Usman I. MBBS; Muhammad, Mukhtar Y. MBBS; Ahmed, Mukhtar L. PhD; Hassan, Adiba MPH*,‖; Shepherd, Bryan E. PhD; Vermund, Sten H. MD, PhD*,†,#; Wester, C. William MD, MPH

JAIDS Journal of Acquired Immune Deficiency Syndromes: February 1st, 2014 - Volume 65 - Issue 2 - p e41–e49
doi: 10.1097/QAI.0b013e31829ceaec
Implementation and Operational Research: Epidemiology and Prevention
IOR articles

Background: Timely initiation of combination antiretroviral therapy (ART) in eligible HIV-infected patients is associated with substantial reduction in mortality and morbidity. Nigeria has the second largest number of persons living with HIV/AIDS in the world. We examined patient characteristics, time to ART initiation, retention, and mortality at 5 rural facilities in Kwara and Niger states of Nigeria.

Methods: We analyzed program-level cohort data for HIV-infected ART-naive clients (≥15 years) enrolled from June 2009 to February 2011. We modeled the probability of ART initiation among clients meeting national ART eligibility criteria using logistic regression with splines.

Results: We enrolled 1948 ART-naive adults/adolescents into care, of whom, 1174 were ART eligible (62% female). Only 74% of the eligible patients (n = 869) initiated ART within 90 days after enrollment. The median CD4+ count for eligible clients was 156 cells/μL (interquartile range: 81–257), with 67% in WHO stage III/IV disease. Adjusting for CD4+ count, WHO stage, functional status, hemoglobin, body mass index, sex, age, education, marital status, employment, clinic of attendance, and month of enrollment, we found that immunosuppression [CD4 350 vs. 200, odds ratio (OR) = 2.10, 95% confidence interval (CI): 1.31 to 3.35], functional status [bedridden vs. working, OR = 4.17 (95% CI: 1.63 to 10.67)], clinic of attendance [Kuta Hospital vs. referent: OR = 5.70 (95% CI: 2.99 to 10.89)], and date of enrollment [December 2010 vs. June 2009: OR = 2.13 (95% CI: 1.19 to 3.81)] were associated with delayed ART initiation.

Conclusions: Delayed initiation of ART was associated with higher CD4+ counts, lower functional status, clinic of attendance, and later dates of enrollment among ART-eligible clients. Our findings provide targets for quality improvement efforts that may help reduce attrition and improve ART uptake in similar settings.

Departments of *Preventive Medicine,

Medicine, and

Biostatistics, Vanderbilt Institute for Global Health, Nashville, TN;

§Westat, Rockville, MD;

Friends in Global Health, Abuja, Nigeria;

US Centers for Disease Control and Prevention, Abuja, Nigeria; and

the #Department of Pediatrics, Vanderbilt Institute for Global Health, Nashville, TN.

Correspondence to: Muktar H. Aliyu, MD, DrPH, Vanderbilt Institute for Global Health, 2525 West End Avenue, Suite 750, Nashville, TN 37203-1738 (e-mail:

The authors have no conflicts of interest to disclose.

Supported by the President's Emergency Plan for AIDS Relief (PEPFAR) through cooperative agreement No. 5U2GPS001063 from the HHS/Centers for Disease Control and Prevention (CDC), Division of Global HIV/AIDS, and the Eunice Kennedy Shriver National Institute of Child Health & Human Development of the National Institutes of Health, award number R01HD075075. Support was also received from the Fogarty Clinical Research Fellows Program at Vanderbilt, NIH award number R24TW007988.

The findings and conclusions in this article are those of the authors and do not necessarily represent the official position of the US Centers for Disease Control and Prevention or the National Institutes of Health.

Received February 05, 2013

Accepted May 21, 2013

© 2014 by Lippincott Williams & Wilkins