Multi-level determinants of late ART initiation in sub-Saharan Africa

DESCRIPTION (provided by applicant): The purpose of this study, proposed by a new investigator, is to determine the multi-level factors associated with late antiretroviral therapy (ART) initiation (i.e., in the advanced stages of HIV disease) in areas of sub-Saharan Africa where ART is rapidly being scaled-up. Most patients in sub-Saharan Africa initiate ART late, resulting in substantial early mortality, more complicated and costly clinical management, and missed opportunities for prevention of HIV transmission. Without a better understanding of the determinants of late ART initiation, including the role of upstream pre-cursors (e.g., late diagnosis and late enrollment into care), efforts aimed at achieving more timely ART initiation will be severely hampered, and the full potential of ART scale-up in the region will not be achieved. The proposed study will consider factors relevant to three critical time points: diagnosis, enrollment into care, and ART initiation, and thus will be able to quantify the relative contribution of late diagnosis and late enrollment to HIV care to late ART initiation. Our ultimate goal is to inform the development of interventions to increase the likelihood of timely ART initiation. We propose a study that utilizes both quantitative and qualitative methodologies to examine the multi-level determinants of late ART initiation (defined as CD4