Prevalence and individual and community-level risk factors of late diagnosis among newly diagnosed people living with HIV from nine African countries

BACKGROUND: People living with HIV (PLWH) with late diagnosis (LD) (CD4 cell count <350 cells/mm³ and no prior HIV diagnosis) are at higher risk of opportunistic infections, non-AIDS defining comorbidities, and death compared to stable patients due to delayed diagnosis. We used Population'based HIV Impact Assessment (PHIA) survey data from Cameroon, Eswatini, Ethiopia, Lesotho, Malawi, Tanzania, Uganda, Zambia, and Zimbabwe to examine LD prevalence and identify individual and community-level correlates of LD.
METHODS: The PHIAs are cross-sectional, household-based surveys that use two-stage sampling to collect nationally representative data from adults aged '¥15 years. Between 2015-2017, data from interviews, home-based HIV testing, and laboratory testing were collected. Blood samples were analyzed for HIV RNA, detectable antiretrovirals, and CD4+ cell counts. Community-level variables were generated at each enumeration area-level using weighted data. Logistic regression using fixed-effects to account for cross-country variation was used to determine individual and community-level factors associated with LD in adults aged '¥15 years.
RESULTS: Of 4,408 newly diagnosed PLWH, 42.8% (95% CI: 40.9-44.8) had LD. LD prevalence ranged from 29.6% (95% CI: 25.3%-34.3%) in Uganda to 53.3% (95% CI: 49.5%-57.1%) in Zimbabwe. Newly diagnosed PLWH who resided in higher LD prevalence countries such as Ethiopia, Lesotho, Malawi, Tanzania, Zambia, and Zimbabwe, were older, of male sex, and had never tested for HIV, had higher adjusted odds of LD (Figure 1). PLWH in communities where gender norms supported a lack of health-related decision-making autonomy, had higher adjusted odds of LD.


CONCLUSIONS: Late diagnosis of HIV remains a challenge despite increases in HIV testing services. Such services should highlight the importance of early diagnosis of HIV and for individuals, particularly older men in high LD prevalence countries, to get repeatedly tested. Gender norms that inhibit health agency should be addressed by providing community-based support for promotion of health autonomy to optimize testing services.