Factors associated with late presentation for HIV/AIDS care in Harare City, Zimbabwe, 2015

CD4 count determination is important when making decisions on starting ART using the 2013 guidelines. In this study, the presentation of cases within median CD4 count of 61 cells/uL reaffirms the fact that CD4 count at presentation by patients in resource limited settings remains critically low and is an indication of late presentation [14]. Furthermore, the median delay for care after testing positive varied between cases and controls (2 days and 30 days respectively). This is consistent with what was found out in Kenya during a community testing campaign where there was a delay between testing and linkage to care [7]. The delay was attributed to lack of training on the part of service providers. The period between testing and linking to care is critical as it may result in loss to follow up of patients, therefore jeopardizing their health.

Having an HIV test due to illness was an independent risk factor associated with late presentation to HIV/AIDS care in Harare City. This factor was the most significant in this study. This finding is similar to what Abaynew et al., found out where illness at first HIV positive test was significantly associated with late presentation (OR = 2.61, 95 % CI = 1.26, 5.43) [13]. This is also supported by evidence from India where 83 % of participants classified as late presenters had an AIDS defining illness or a sexually transmitted infection [14]. This could mean that individuals are only coming to testing centers primarily when they have developed AIDS related conditions. The public health message derived from this finding is that late presentation might be a direct consequence of late diagnosis of HIV and ultimately late linkage to care and treatment.

Experiencing stigma as a result of being HIV positive was independently associated with presenting late to HIV/AIDS care (OR = 2.99, 95 % CI = 1.54, 5.79). This may be due to the fact there might be loss of material and/or emotional benefits if one’s status is known in the community, particularly in Harare City, where some occupations such as pirate taxi driving and vending are accompanied by verbal abuse thus patients who are in these occupations are stigmatized by their peers in the same trades [15]. This finding gives credence to overwhelming evidence that HIV related stigma is a hindrance to early presentation for care in Africa and beyond [16‐18].

In this study, being male was an independent risk factor for presenting late for HIV/AIDS care in Harare City. Several studies have also reported low uptake of HIV services among men as compared to women in different settings [19‐22]. This finding supports the notion that men generally do not seek testing and counseling services on a routine basis, thus leading to late diagnosis of HIV when they are already on late stage disease progression. Haskew et al., reported that men had 1.4 times higher odds of presenting to the clinic late in the course of HIV infection compared to women [9]. This finding may also be explained in the general sense, that women have more contact with the health facility on a more routine basis than men. Women attended antenatal care clinics and other maternal and child health related clinics hence are more likely to be tested as service provided in the continuum of care. The introduction of Option B+ on Harare City has also increased the likelihood of early presentation among women. Mujumdar et al., in a study of an HIV-1 infected population in rural India found out that males were twice as likely to present late more than females [14].

Patients are likely to access information about HIV through the visual and print media and crucially when they go for routine HIV testing and counseling at VCT centres situated around the city or at outpatient departments at clinics. Ndawitz et al., in Cameroon reported that living in a region with higher comprehensive knowledge of HIV/AIDS was associated with not initiating ART late (aOR = 0.8, 95 % CI = 0.6, 1.0) [21]. This suggests that information dissemination hugely increases awareness of the risks associated with HIV and this provides an opportunity for public health practitioners to craft messages for specific at risk populations in Harare City. The print and electronic media also play an active role in reaching out to communities and facilitate behavior change.

In this study, those who earned more than US$250 were less likely to present late for HIV/AIDS care. It is plausible that when income is high, this might also reciprocate into better access to health services. Louis et al., in Haiti reported that poverty i.e. earning below the poverty datum line was significantly associated with late presentation for HIV care at ART initiating clinics [22]. Furthermore, those who earn below the poverty datum line are likely to be self-employed hence do not have access to work related testing and counseling services, which are enjoyed by their formally employed counterparts. Also, those who earn less are likely to be more preoccupied with selling their wares that they may not be cognizant of the need to visit the health facility regularly [23]. In the study by Louis, it was also reported that harsh poverty was a theme of all of the respondents. With this in mind, programme managers in Harare City ought to find strategies to encourage routine testing and counseling.