Delay of Antiretroviral Therapy Initiation Is Common in East African HIV-Infected Individuals in Serodiscordant Partnerships

Mujugira, Andrew MD, MPH*,†; Celum, Connie MD, MPH*,†,‡; Thomas, Katherine K. MS*; Farquhar, Carey MD, MPH*,†,‡; Mugo, Nelly MD, MPH*,§; Katabira, Elly MD, FRCP; Bukusi, Elizabeth A. MD, PhD*,§; Tumwesigye, Elioda MD, MS; Baeten, Jared M. MD, PhD*,†,‡; for the Partners PrEP Study Team

JAIDS Journal of Acquired Immune Deficiency Syndromes:
doi: 10.1097/QAI.0000000000000192
Epidemiology and Prevention

Objective: WHO guidance recommends antiretroviral therapy (ART) initiation for all persons with a known HIV-uninfected partner, as a strategy to prevent HIV transmission. Uptake of ART among HIV-infected partners in serodiscordant partnerships is not known, which we evaluated in African HIV serodiscordant couples.

Design: Prospective cohort study.

Methods: Among HIV-infected persons from Kenya and Uganda who had a known heterosexual HIV-uninfected partner, we assessed ART initiation in those who became ART eligible under national guidelines during follow-up. Participants received quarterly clinical and semi-annual CD4 monitoring, and active referral for ART upon becoming eligible.

Results: Of 1958 HIV-infected ART-eligible partners, 58% were women, and the median age was 34 years. At the first visit when determined to be ART eligible, the median CD4 count was 273 cells per microliter (interquartile range, 221–330), 77% had WHO stage 1 or 2 HIV disease, and 96% were receiving trimethoprim-sulfamethoxazole prophylaxis. The cumulative probabilities of initiating ART at 6, 12, and 24 months after eligibility were 49.9%, 70.0%, and 87.6%, respectively. Younger age [<25 years; adjusted hazard ratio (AHR), 1.39; P = 0.001], higher CD4 count (AHR, 1.95; P < 0.001 for >350 compared with <200 cells/µL), higher education (AHR, 1.25; P < 0.001), and lack of income (AHR, 1.15; P = 0.02) were independent predictors for delay in ART initiation.

Conclusions: In the context of close CD4 monitoring, ART counseling, and active linkage to HIV care, a substantial proportion of HIV-infected persons with a known HIV-uninfected partner delayed ART initiation. Strategies to motivate ART initiation are needed, particularly for younger persons with higher CD4 counts.

Author Information

Departments of *Global Health,

Epidemiology, and

Medicine, University of Washington, Seattle, WA;

§Center for Clinical Research, Kenya Medical Research Institute, Nairobi, Kenya;

Department of Medicine, Makerere University, Kampala, Uganda; and

Kabwohe Clinical Research Centre, Kabwohe, Uganda.

Correspondence to: Andrew Mujugira, International Clinical Research Center, University of Washington, Box 359927, 325 Ninth Avenue, Seattle, WA 98104 (e-mail:

Presented in part at the 19th Conference on Retroviruses and Opportunistic Infections, March 2012, Seattle, WA (abstract #649).

Supported by research grants from the Bill & Melinda Gates Foundation (grant No. OPP47674) and the US National Institutes of Health (grant Nos. R01 MH095507 and D43 TW000007).

The authors have no conflicts of interest to disclose.

A.M., C.C., and J.M.B. designed the study. A.M. and J.M.B. wrote the first draft. A.M. performed the statistical analyses. All authors contributed to data collection, interpretation of the results, and the writing of the manuscript, and all approved the final draft.

The authors designed and executed the study, had full access to the raw data, performed all analyses, wrote the manuscript, and had final responsibility for the decision to submit for publication. The funder had no role in design, data collection, analysis, interpretation, or writing of the report.

Received November 27, 2013

Accepted February 25, 2014

© 2014 by Lippincott Williams & Wilkins