• Eugene Mutimura, Diane Addison, Kathryn Anastos, Donald Hoover, Jean Claude Dusingize, Ben Karenzie, Isabelle Izimukwiye, Leo Mutesa, Sabin Nsanzimana, Denis Nash, and IeDEA Central Africa Collaboration.
• aRegional Alliance for Sustainable Development, Kigali, Rwanda bCUNY School of Public Health, New York cAlbert Einstein College of Medicine and Montefiore Medical Center, Bronx, New York dThe State University of New Jersey, New Brunswick, New Jersey, USA eRwanda Military Hospital, Kigali fMasaka District Hospital, Kigali gCollege of Medicine and Health Sciences, University of Rwanda, Kigali, Rwanda hInstitute of HIV/AIDS and Disease Prevention and Control, Rwanda Biomedical Center Kigali, Rwanda iCUNY School of Public Health and Hunter College, New York, New York, USA.
• AIDS. 2015 Jan 2;29(1):67-76.

BackgroundInitiation of antiretroviral therapy (ART) in the advanced stages of HIV infection remains a major challenge in sub-Saharan Africa. This study was conducted to better understand barriers and enablers to timely ART initiation in Rwanda where ART coverage is high and national ART eligibility guidelines first expanded in 2007-2008.MethodsUsing data on 6326 patients (≥15 years) at five Rwandan clinics, we assessed trends and correlates of CD4 cell count at ART initiation and the proportion initiating ART with advanced HIV disease (CD4 <200 cells/μl or WHO stage IV).ResultsOut of 6326 patients, 4486 enrolling in HIV care initiated ART with median CD4 cell count of 211 cells/μl [interquartile range: 131-300]. Median CD4 cell counts at ART initiation increased from 183 cells/μl in 2007 to 293 cells/μl in 2011-2012, and the proportion with advanced HIV disease decreased from 66.2 to 29.4%. Factors associated with a higher odds of advanced HIV disease at ART initiation were male sex [adjusted odds ratios (AOR) = 1.7; 95% confidence interval (CI): 1.3-2.1] and older age (AOR46-55+vs.<25 = 2.3; 95% CI: 1.2-4.3). Among those initiating ART more than 1 year after enrollment in care, those who had a gap in care of 12 or more months prior to ART initiation had higher odds of advanced HIV disease (AOR = 5.2; 95% CI: 1.2-21.1).ConclusionMarked improvements in the median CD4 cell count at ART initiation and proportion initiating ART with advanced HIV disease were observed following the expansion of ART eligibility criteria in Rwanda. However, sex disparities in late treatment initiation persisted through 2011-2012, and appeared to be driven by later diagnosis and/or delayed linkage to care among men.

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