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Open Access Research article

Evidence of improving antiretroviral therapy treatment delays: an analysis of eight years of programmatic outcomes in Blantyre, Malawi

Derek J Sloan12, Joep J van Oosterhout3, Ken Malisita3, Eddie M Phiri3, David G Lalloo4, Bernadette O’Hare3 and Peter MacPherson145*

Author Affiliations

1 Malawi-Liverpool-Wellcome Trust and Liverpool School of Tropical Medicine, Chichiri 3, PO 30096, Blantyre, Malawi

2 Centre for Global Health and Infection, University of Liverpool, Liverpool, UK

3 College of Medicine, University of Malawi, Mahatma Ghandi Road, Blantyre, Malawi

4 Faculty of Infectious and Tropical Diseases, Department of Clinical Sciences, Keppel Street, London, UK

5 Clinical Group, Liverpool School of Tropical Medicine, Pembroke Place, Liverpool L3 5QA, UK

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BMC Public Health 2013, 13:490  doi:10.1186/1471-2458-13-490

Published: 21 May 2013

Abstract

Background

Impressive achievements have been made towards achieving universal coverage of antiretroviral therapy (ART) in sub-Saharan Africa. However, the effects of rapid ART scale-up on delays between HIV diagnosis and treatment initiation have not been well described.

Methods

A retrospective cohort study covering eight years of ART initiators (2004–2011) was conducted at Queen Elizabeth Central Hospital (QECH) in Blantyre, Malawi. The time between most recent positive HIV test and ART initiation was calculated and temporal trends in delay to initiation were described. Factors associated with time to initiation were investigated using multivariate regression analysis.

Results

From 2004–2011, there were 15,949 ART initiations at QECH (56% female; 8% children [0–10 years] and 5% adolescents [10–20 years]). Male initiators were likely to have more advanced HIV infection at initiation than female initiators (70% vs. 64% in WHO stage 3 or 4). Over the eight years studied, there were declines in treatment delay, with 2011 having the shortest delay at 36.5 days. On multivariate analysis CD4 count <50 cells/μl (adjusted geometric mean ratio [aGMR]: aGMR: 0.53, bias-corrected accelerated [BCA] 95% CI: 0.42-0.68) was associated with shorter ART treatment delay. Women (aGMR: 1.12, BCA 95% CI: 1.03-1.22) and patients diagnosed with HIV at another facility outside QECH (aGMR: 1.61, BCA 95% CI: 1.47-1.77) had significantly longer treatment delay.

Conclusions

Continued improvements in treatment delays provide evidence that universal access to ART can be achieved using the public health approach adopted by Malawi However, the longer delays for women and patients diagnosed at outlying sites emphasises the need for targeted interventions to support equitable access for these groups.

Keywords:
HIV; Antiretroviral therapy; Linkage to care; HIV testing and counselling; Africa; Programmatic research