Delayed entry into HIV care after diagnosis in two specialized care and treatment centres in Cameroon: the influence of CD4 count and WHO staging

The global burden of HIV is clearly unevenly distributed with sub-Saharan Africa having the greatest share of the spread and sequelae of the pandemic [1, 2]. With an estimated 24.7 million people living with HIV in sub-Saharan Africa, accounting for almost 71 % of the global HIV burden, the region continues to face enormous challenges to control the spread of the pandemic as well as to adequately and effectively managed old and newly infected people living with HIV [3]. Despite the successes registered so far in the domain of increasing access to antiretroviral medications and curbing the spread of new HIV infections, the effective tracking and monitoring of HIV infected patients still present as daunting challenges that urgently need to be addressed for the success of HIV care programmes in the sub-Saharan Africa region [4‐10].

All across Africa (sub-Saharan Africa and Cameroon in particular),the United States (US) President’s Emergency Plan For AIDS Relief (PEPFAR) through the US Centres for Disease Control and Prevention (CDC) have directed substantial amounts of funds towards addressing the challenges faced by countries towards HIV diagnosis [11]. Through local implementing partners, the efforts of PEPFAR and the CDC have resulted in improved CD4 testing that ensures the issuing of same day CD4 test results to newly diagnosed HIV positive patients [12, 13]. Despite these efforts, several studies in Africa have reported delayed entry into HIV care and loss to follow up after initial HIV diagnosis [14‐16]. Delayed entry into HIV care has been defined by the World Health Organization [17] and from several published studies as not having a CD4 measurement within 3 months of HIV diagnosis [18‐20]. A better understanding of the factors affecting delayed entry before antiretroviral therapy initiation will be necessary in guiding interventions towards ensuring timely CD4 measurement and eventual enrolment into the HIV continuum of care [21]. Despite the relevance of studies in delayed entry into HIV care, there exist limited published data on its epidemiology in Cameroon. This study was therefore designed and conducted to determine the prevalence of delayed entry into HIV care, the socio-demographic and clinical profiles of patients newly diagnosed of HIV and the factors that are associated with delayed entry into HIV care in Cameroon.

Our study reveal that the proportion of those who delayed to enter HIV care was nearly 1 out of 4 patients. This high proportion of delayed entry was driven by high CD4 count at first diagnosis and early WHO clinical stages (stages I and II).

The high percentage of those who delay to enter HIV care observed in our study is comparable to many other studies that have been carried out in other parts of the World such as the United States and Europe. Rosen and colleagues carried out a systematic review between testing and treatment initiation in sub Saharan Africa and demonstrated that the rate of delay entry between HIV diagnosis and receipt of first CD4 measurement varies between 12 % and 65 % [24]. The proportion of those who delay to enter HIV care in our study is also quite close to the 29.7 % reported by Alvarez-Uria and colleagues [25] in India and 23.2 % reported by Jennes and associates [20] in the United States. Delayed entry into care therefore cuts across both developed and developing settings of the World with its highest rate in sub Saharan Africa. This similar rates of delayed entry with non-African settings can be due to the similarity in the patterns of factors associated with delay entry such as refusal to accept HIV status in both African and non-African settings [20]. The high percentage of those who delay to enter HIV care in our setting can be linked to the fact that in the early era of rapid antiretroviral treatment (ART) scale up, much attention was directed towards initiating eligible patients on ART while those who were HIV positive and not eligible (that is those in the pre-HAART period) were not given enough attention and follow up [24]. Furthermore, the rate of delayed entry can be even higher if a single group of patients is put under investigation [26].

Several studies in Africa have attempted to investigate the factors associated with the phenomenon of delayed entry into HIV care [14, 21, 25, 27]. In our study, we investigated if factors such age, gender, educational level, alcohol consumption, travel hours from the treatment centres, sharing of results with a family member or friend,anemia,CD4 count on first diagnosis and WHO clinical staging were associated with delayed entry. From our study, high CD4 (greater than 500cells/μl) and WHO stages I and II were strongly associated with delay entry. While many studies have reported this positive relationship between high CD4 and delayed entry [15, 18, 25, 28] some other studies in Guinea-Bissau and Uganda have reported an association between low CD4 count and delayed entry [9, 29]. The relationship between high CD4 count and delay entry may be related to the observation that most of such patients feel healthy or asymptomatic (WHO stage I) [18, 29], and they may tend to think they still have some time before development of symptoms or they may live in denial, refusing to accept their HIV status. Even though our study showed that age was not significantly associated with delayed entry, there exist some evidence from other studies that young age is significantly associated with other factors which may be related to delayed entry into care such as acceptance of HIV positive status and initiation on lifelong antiretroviral therapy tend to be problematic among young HIV patients [30, 31].

Using a convenient sample and a cross sectional study design poses some limitations. Importantly, a cross sectional study design can only describe temporal relationships between factors observed and the outcome irrespective of the strength of the associations observed, and therefore only provides plausible hypotheses that can be explored using other study designs [32]. Variables such as sharing of results may change over time as participants receive appropriate post-test counselling. This could not be captured by a cross sectional study design. Using a consecutive sample in a hospital setting means our study is prone to selection bias and might not be representative of the population of HIV positive patients in Cameroon. This warrants further multicenter studies which also include individuals diagnosed in non-hospital settings such as community outreach. Using routine data captured in the files of patients led to some missing data on alcohol consumption. The quality of data collected on variables such as alcohol consumption would have been much better if face to face interviews were conducted. Due to this limitation in the quality of data collected on alcohol consumption, the association with delayed entry into HIV care should be interpreted with caution. However, in our setting where diagnosis of HIV is still associated with a substantial level of stigma, face to face interviews would have markedly resulted in a low response rate and small sample size for the study. In terms of the representativeness of our sample, since we included all HIV patients diagnosed within the period of study in the two main centres responsible for HIV care in the South West region of Cameroon, our sample could be representative of patients diagnosed within health care settings in this region of the country. With regards to data collection, despite the missing data on alcohol consumption, we encountered very little challenges on the quality of data collected on other variables because we ensured that the nurses that were in-charge of filling in and coding patient files were all trained on quality of data recording. Furthermore, it is necessary to also note that this study is the first of its kind in the subject of delayed entry in Cameroon and in an era of greater emphasis on testing, treating, tracking and follow up of HIV patients, its relevance cannot be overemphasized. Our findings provide some key information that would guide interventions to address delayed entry into HIV care after diagnosis by suggesting the group of newly diagnosed HIV patients to be suitably targeted in our setting; with the goal of reducing cascade losses at a key point in the HIV care continuum. Consequently, a larger multicenter cohort study is urgently needed to fine tune our observations made so far by establishing with a higher degree of certainty the predictors of delayed entry in our setting.

In the South West region of Cameroon, approximately 1 out of 4 patients delay to enter HIV care. This high proportion of patients who delay to enter care correlates to the findings recorded by other studies in sub Saharan Africa. Interventions tackling delay entry into HIV care might need to be favorably directed towards patients that have high CD4 counts and are at very early WHO clinical stages.

CDC, centres for disease control and prevention; HIV, human immunodeficiency virus; PEPFAR, president’s emergency plan for AIDS relief; WHO, World Health Organization.