Barriers to antiretroviral initiation in HIV-1-discordant couples

Abstract

Background: In Kenya and much of sub-Saharan Africa, nearly half of all couples affected by HIV are discordant. Antiretroviral therapy (ART) slows disease progression in HIV-1-infected individuals and reduces transmission to uninfected partners. We examined time to ART initiation and factors associated with delayed initiation in HIV-1-discordant couples in Nairobi.

Methods: HIV-1-discordant couples were enrolled and followed quarterly for up to 2 years. Clinical staff administered questionnaires and conducted viral loads and CD4 counts. Participants with a CD4 count meeting ART criteria were referred to a nearby US President's Emergency Plan for AIDS Relief-funded treatment center. Barriers to ART initiation among participants with a CD4 count eligible for ART were assessed by Cox regression.

Results: Of 439 HIV-1-infected participants (63.6% females and 36.4% males), 146 met CD4 count criteria for ART during follow-up. Median time from meeting CD4 criteria until ART initiation was 8.9 months, with 42.0% of eligible participants on ART by 6 months and 63.4% on ART by 1 year. The CD4 count at the time of eligibility was inversely associated with time to ART initiation (hazard ratio = 0.49, P < 0.001). Compared with homeowners, those paying higher rents started ART 48% more slowly (P = 0.062) and those paying lower rents started 71% more slowly (P = 0.002).

Conclusions: Despite access to regular health care, referrals to treatment centers, and free access to ART, over one-third of participants with an eligible CD4 count had not started ART within 1 year. Factors of lower socioeconomic status may slow ART initiation, and targeted approaches are needed to avoid delays in treatment initiation.

Figure 1

Participants meeting CD4 count criteria to start ART were followed for ART initiation and plotted separately based on the CD4 count at the time of meeting CD4 count criteria for ART. Estimated cumulative incidence is shown for [▬] those with a CD4 count <100, [ ] those with a CD4 count 100–200, and [ ] those with a CD4 count 200–250.

Figure 2

Cumulative incidence of ART initiation following an eligible CD4 count is shown for [▬] participants that report owning their own home, [ ] those who do not own their own home and pay greater than the median rent, and [ ] those who do not own their own home and pay less than the median rent.

Figure 3

a: Cumulative incidence of ART initiation following an eligible CD4 count is shown for [—] women who did not state a desire for additional children and were not on hormonal contraceptives at enrollment, [▬] women who stated a desire for additional children and were not on hormonal contraceptives at enrollment, [ ] women who did not state a desire for additional children and were on hormonal contraceptives at enrollment, and [ ] women who stated a desire for additional children and were on hormonal contraceptives at enrollment. b: Cumulative incidence of pregnancy among women comparing [▬] the period before ART initiation to [ ] the period after ART initiation.