P2 Audit of clinical stage at presentation and factors contributing to antiretroviral therapy delay, in HIV patients in rural Kenya

Abstract

Background The 2010 WHO guideline, “Antiretroviral Therapy for HIV Infection in Adults and Adolescents” states that those with HIV and CD4 counts ≤350 cells/mm3, should start antiretroviral therapy (ART), regardless of symptoms. Those with WHO clinical stage 3/4 should start ART irrespective of CD4 count. In a small hospital north west of Nairobi, an HIV clinic, which is fully funded, provides ART to over 4000 patients. Patients are assessed on WHO clinical stage and CD4 count for ART eligibility. Aim To audit a random sample of 100 patients attending the clinic and determine the WHO clinical stage at diagnosis, the number eligible for treatment at diagnosis and factors causing delay in ART initiation. Method Retrospective audit of 100 case notes. Recording patient gender, age, date of diagnosis, WHO stage, CD4 count, length of time from diagnosis to ART initiation and reasons for delay of treatment. “Counselling” is compulsory pre-treatment, usually over 3 weeks. “Patient default” is defined as patient non-attendance. Results 82/100 patients were eligible for treatment at diagnosis. WHO clinical stage at diagnosis: 1-26, 2-17, 3-34, 4-5. Length of time between diagnosis and treatment: <28 days: 21/82, >28 days: 61/82, range: 4-861 days, mean: 102 days. Reasons for delay in those >28 days: TB diagnosis/treatment: 21, counselling: 18, patient default: 23 (see abstract P2 table 1). (Table Presented) Conclusion 82 of 100 HIV positive patients chosen at random were eligible for treatment at presentation, as per WHO guidelines. The majority of these patients were WHO stage 3 at presentation (41%). Length of time from diagnosis to ART initiation varies greatly and this is likely multifactorial. A significant number of patients (74%) did not commence ART within 4 weeks of diagnosis. The most common reason for this was patient non-attendance. In this setting, stigma attached to HIV diagnosis, extreme poverty and lack of education contribute to both late presentation and a delay in treatment initiation.