Late presentation for diagnosis of HIV infection among HIV positive patients in South Tigray Zone, Ethiopia

Several previous studies have found high prevalence of late presentation depending on the various definition of late presentation. In this study, late presenter was defined as patients that had been placed on Anti-retroviral therapy in less than 3 months of their first positive HIV test. Accordingly, it was found that late HIV diagnosis occurred in about two third of the study participants (68.82 %). Reports from different Sub-Saharan Africa also found high prevalence of late testers; however, the use of different definitions makes comparisons difficult. For instance, in a study conducted in Nigeria, 50 % of HIV-infected individuals were late diagnosed based on the criteria of CD4 < 200 cells/μL at HIV diagnosis. Similarly, in a peri-urban community near Cape Town, South Africa, 36 % of HIV-infected individuals were late presenter for diagnosis [14].

The main reason for being late in this study was feeling healthy. People often do not attribute their risk behaviors for acquisition of HIV as far as they feel healthy. This has been the case for several previous studies where low perception of individual risk was significantly associated with failure to utilize HIV testing services [9, 15–17]. Although it was not significant, late diagnosis was higher among those that had not felt at risk of HIV-infection than those who did in this study. For many of the study participants, perception of HIV as a highly stigmatizing disease served as a powerful barrier for testing. Other studies from Ethiopia and Sub-Saharan Africa countries also indicated that a perception of HIV as a highly stigmatizing disease was common among people who presented with late-stage disease [9, 18]. It was also found that for some participants in the current study using traditional treatments was the deterrent for having early HIV test. This finding is supported by the study conducted in Uganda that reported those who had received care from non-medical providers were more likely to be diagnosed late [8]. Several factors, in fact, may contribute for the patients to rely on tradition treatments in developing countries such as less coverage of modern health care, perception of the healers as being accessible, nearer, less expensive, and more holistic [19].

Late diagnosis of HIV has important individual, public health and economic consequences. A substantial proportion of people who died from AIDS are late presenters [10]. This study also investigated factors associated with late HIV diagnosis in Southern Tigray, Ethiopia. It was found that use of Khat, ambulatory functional status and bed ridden functional status, being Muslim were found to be the factors that were significantly associated with being late for HIV diagnosis.

Use of khat had an increased odd of being late for diagnosis compared to those who did not chewing khat. Previous studies revealed that substance use such as alcohol and injection drug use implicated with high risk of late diagnosis and care [3, 18, 20]. Khat may produce euphoria, increased confidence, and enhanced alertness [21–23]. This feeling of well being may affect their health seeking behavior and to come late for diagnosis. Moreover, Khat chewers believe that Khat use for relieving stress and pain [24]. A study by Glenice and Ramps showed that khat chewers in Yemen believed Khat was beneficial for mild ailments like headache, fevers and depression [25]. This Use of Khat for relieving pain might have made the participants to disregard HIV related symptoms and pain until they were late in the course of HIV progression.

Bedridden functional status was associated more likely for being late than those in working status in this study. This could indicate the presentation of patients at the health facilities during the advanced stage of disease progression. This trend of testing after the immune system is destroyed and opportunistic diseases are emerged has been the case in several studies elsewhere [6, 18, 26]. Interventions such as encouragement from family, friends, and health care providers for these patients to be tested are needed to circumvent the fear of diagnosis and denial of the likelihood of being infected [2].

Another interesting result of the present study was the association of ambulatory functional status with being late for diagnosis. The possible explanations for this could be not feeling being at risk by the participants and misdiagnosis of HIV infection by the health professionals. The latter reason is well-supported by different studies done elsewhere [2, 26, 27] which also that reported the admission of HIV-infected persons in a variety of health care settings in the years prior to diagnosis. To overcome this matter/issue, health professionals should play important role in recommending HIV test not only in presence of AIDS defining diseases but also for specific HIV indicator conditions [28].

In this study Muslim religion showed a significant association with late HIV diagnosis. This might be explained by fear of stigmatization if they found positive for HIV. A study conducted on religion and HIV diagnosis showed that people who disclosed their HIV status were at risk of isolation from mosques/church as those who are HIV positive may be seen as being punished for sins such as promiscuity, and HIV is considered a ‘curse from God’ [29].

The main limitation of this study could be the design employed which was cross sectional. A cross sectional, in general, might suffer from temporal relationship establishment with some variables and could not provide much more substantial evidence of causality, unlike a longitudinal design.