One in three people with HIV start treatment late in low- and middle-income countries

16 June 2017

World Health Organization (WHO) guidelines call for all people newly diagnosed to start treatment straight away – but worrying numbers of people in high-burden countries still test and present late to care.

Women waiting outside clinic

At least one third of patients starting antiretroviral treatment (ART) in ten high-burden, low- and middle-income countries (LMICs) started treatment late in 2015, at an already advanced stage of HIV.

The results were reported by the USA Centers for Diseases Control and released this month in their Morbidity and Mortality Weekly Report.

Understanding the numbers of people with advanced HIV is critical for monitoring ART programme outcomes, informing HIV prevention strategies and predicting future linked therapies – as people who start ART late are also likely to present with other co-morbidities, most commonly tuberculosis, the leading killer of people living with HIV.

Positively, the number of people starting treatment late has dropped, and dramatically in some instances, over periods of up to 11 years, demonstrating the success of HIV testing and treatment programming in these countries.

But an unacceptably high number of people still started treatment late. If Fast-Track targets are to be met – that is, 90% of people living with HIV aware of their status, 90% of those people on treatment, and 90% of those on treatment virally suppressed – significantly more effort is needed to get more people testing and linked to care as soon as possible.

Adult records were collected of 694,138 people on antiretroviral treatment, from nearly 800 ART facilities, mostly in sub-Saharan Africa. Between 2004 and 2015, the study authors assessed prevalence of advanced disease at treatment initiation – defined as starting treatment below a CD4 count of 200 cells/mm3.

Several approaches to sampling and analysis were performed in order to account for differences in data availability, sample sizes and data collection approaches between the countries that submitted data.

As a baseline, CD4 count before treatment initiation was used, or most recent CD4 count within a year of the treatment start date. However, missing baseline data prevalence ranged from 9% in Swaziland, to 53% in Zimbabwe.

Three countries provided the most recent national medical data. The percentage of those starting treatment at an advanced disease stage declined from 73% to 37% in Mozambique (2004 – 2014); from 80% to 41% in Namibia (2004 – 2012); and from 75% to 34% in Haiti (2004 – 2015). In those same countries, very advanced disease at treatment initiation (defined as > 100 CD4 cells/mm3) declined significantly, from 39% to 18% in Mozambique; from 39% to 16% in Namibia; and from 49% to 20% in Haiti. The average CD4 count at treatment initiation across all three countries also significantly increased over the same periods.

Less recent data was analysed for the remaining seven countries. The percentage of people starting treatment late fell significantly in five countries, from 72% to 52% in Swaziland (2004 – 2010); 84% to 75% in Zimbabwe (2007-2009); 89% to 60% in Uganda (2004 – 2009); 68% to 53% in Nigeria (2004-2011), and from 91% to 80% in Vietnam (2005-2009).

There was no statistically significant decline in advanced disease prevalence at ART initiation in Zambia and Tanzania.

“Encouraging reductions in the prevalence of advanced disease at ART initiation were observed in eight of the 10 countries studied. This reflects the rapid scale-up of HIV testing and treatment services in LMIC [low- and middle-income countries] since 2004 and evolution of HIV treatment guidelines encouraging earlier ART initiation,” stated the authors.

Written by Caitlin Mahon

Content Specialist - HIV & Sexual Health