Factors associated with late antiretroviral therapy initiation in Cameroon: a representative multilevel analysis.

OBJECTIVES: Many people living with HIV/AIDS in resource-limited settings begin antiretroviral therapy (ART) at low CD4 counts. Here, we investigated the simultaneous effect of individual-, facility- and regional-level factors on late ART initiation. METHODS: We conducted a survey in a nationally representative sample of 55 HIV treatment facilities in Cameroon. Medical records of 4935 patients >15 years of age who initiated ART in the month of October during the period 2007-10 were reviewed to gather individual characteristics. Late ART initiation was defined as CD4 count ≤ 100 cells/mm(3). Facility- and regional-level characteristics were also collected. Two-level regression logistic models were used to identify factors associated with late ART initiation. RESULTS: Late ART initiation was associated with being a male younger than 45 years versus female younger than 45 years [adjusted OR (AOR) = 1.5, 95% CI: 1.3-1.7] and initiating ART in the period 2007-09 versus 2010 (AOR = 1.2, 95% CI: 1.0-1.4). Late initiation was more likely in central than in district hospitals (AOR = 1.3, 95% CI: 1.1-1.6) and in hospitals without a mother-to-child transmission programme (AOR = 1.9, 95% CI: 1.3-2.8). Living in a region with a higher comprehensive knowledge of HIV/AIDS was associated with not initiating ART late (AOR = 0.8, 95% CI: 0.6-1.0). CONCLUSIONS: This study shows that risk factors associated with late ART initiation operate at multiple levels and that multilevel interventions are therefore necessary to promote earlier HIV testing and treatment.