1. Risk factors for late-stage HIV disease presentation at initial HIV diagnosis in Durban, South Africa Paul K. Drain, Elena Losina, Senica Chetty, Gary Parker, Janet Giddy, Douglas Ross, Jeffrey N. Katz, Sharon Coleman, Laura M. Bogart, Kenneth A. Freedberg, Rochelle P. Walensky, Ingrid V. Bassett Supported by the National Institute of Mental Health (NIMH), National Institute of Allergy and Infectious Disease (NIAID), National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMS), Fogarty International Center (FIC), Harvard Global Health Institute, and Harvard University’s Center for AIDS Research. Massachusetts General Hospital, Brigham and Women’s Hospital, Harvard Medical School, Harvard School of Public Health, Boston University School of Public Health, and Boston Children’s Hospital, Boston, USA; McCord Hospital and St. Mary’s Hospital, Durban, South Africa.

2. Background and Objective Despite expanded access to HIV testing, most South Africans newly-diagnosed with HIV present with a low CD4 count and severe immunosuppression To determine the risk factors for presenting with late-stage HIV disease, as well as the perceived barriers to presenting earlier for care Methods Prospective study at 4 outpatient clinics in urban and peri-urban areas of Durban, South Africa Surveyed 3,669 adults prior to HIV testing; report on 830 HIV-infected Enrollment from Aug 2010 to Nov 2011 Defined late-stage disease as a CD4 <100/mm 3, threshold for many OIs Used logistic regression models for univariate and multivariate analyses Table 1. Cohort (N=830) N (%) Demographics Age ≥40 years249 (30) Male415 (50) Did not complete H.S.449 (54) Working outside home469 (57) Proximity to the HIV clinic Distance to clinic ≥5 km688 (83) Travel to clinic ≥30 min303 (37) Health Care Usage No prior HIV testing661 (80) Hospital stay in prior year 60 (7)

3. Results Among 830 enrolled, 279 (34%) presented with late-stage HIV (CD4 <100/mm 3 ) at the time of initial HIV diagnosis Table 2. Perceived barriers to earlier care (N=830) Barrier Univariate Odds Ratio (95% CI) Felt too sick3.0 (2.0 – 4.4) Could not afford transport1.8 (1.3 – 2.5) Could not afford medications1.8 (1.3 – 2.5) Not arrange transport to clinic1.7 (1.2 – 2.4) Wait too long to see doctor1.5 (1.1 – 2.1) Could not go during open hours 1.5 (1.0 – 2.1) Had to take care of someone 1.5 (0.9 – 2.2) Were not treated with respect 1.4 (0.8 – 2.3) They do not speak my language1.2 (0.7 – 1.9) Could not get time off work1.2 (0.8 – 1.7) Didn’t feel sick enough1.0 (0.7 – 1.4) Didn’t know where to find care0.9 (0.6 – 1.3)

4. Conclusions In Durban, the strongest independent risk factors for presentation with late- stage HIV disease were living further from the clinic, having competing needs to healthcare, and being male. Self-reported barriers related to personal illness, cost of care, transportation difficulties, and poor service delivery were associated with late-stage disease. Interventions to overcome these barriers and promote early HIV diagnosis are urgently needed to decrease late-stage HIV disease in resource-poor settings. Table 3. Multivariate model for risk of late-stage HIV disease (N=830) Adjusted Odds Ratio (95% CI) for late-stage HIV Distance to clinic ≥5 kilometers2.8 (1.7 – 4.7) Gone without healthcare because needed money for food, clothing, or housing1.7 (1.2 – 2.4) Male1.7 (1.2 – 2.3) Any overnight hospital stay in last year1.6 (0.9 – 2.9) Currently working outside home1.5 (1.1 – 2.1) Service delivery barriers1.5 (1.1 – 2.1) Poor Emotional Health (< median value)1.4 (1.0 – 1.9) Poor Social Support (< median value)1.3 (0.9 – 1.9) Age ≥40 years1.1 (0.8 – 1.5)