Links to Exploration step
Le document en format XML
<record><TEI><teiHeader><fileDesc><titleStmt><title xml:lang="en">Determinants of late presentation to HIV/AIDS care in Southern Tigray Zone, Northern Ethiopia: an institution based case–control study</title><author><name sortKey="Gelaw, Yalemzewod Assefa" sort="Gelaw, Yalemzewod Assefa" uniqKey="Gelaw Y" first="Yalemzewod Assefa" last="Gelaw">Yalemzewod Assefa Gelaw</name><affiliation><nlm:aff id="Aff2">Department of Epidemiology and Biostatistics, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia</nlm:aff></affiliation></author><author><name sortKey="Senbete, Goitom Halefom" sort="Senbete, Goitom Halefom" uniqKey="Senbete G" first="Goitom Halefom" last="Senbete">Goitom Halefom Senbete</name><affiliation><nlm:aff id="Aff1">College of Medicine and Health Sciences, Wollo University, Dessie, Ethiopia</nlm:aff></affiliation></author><author><name sortKey="Adane, Akelew Awoke" sort="Adane, Akelew Awoke" uniqKey="Adane A" first="Akelew Awoke" last="Adane">Akelew Awoke Adane</name><affiliation><nlm:aff id="Aff2">Department of Epidemiology and Biostatistics, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia</nlm:aff></affiliation></author><author><name sortKey="Alene, Kefyalew Addis" sort="Alene, Kefyalew Addis" uniqKey="Alene K" first="Kefyalew Addis" last="Alene">Kefyalew Addis Alene</name><affiliation><nlm:aff id="Aff2">Department of Epidemiology and Biostatistics, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia</nlm:aff></affiliation></author></titleStmt><publicationStmt><idno type="wicri:source">PMC</idno><idno type="pmid">26633988</idno><idno type="pmc">4667535</idno><idno type="url">http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4667535</idno><idno type="RBID">PMC:4667535</idno><idno type="doi">10.1186/s12981-015-0079-2</idno><date when="2015">2015</date><idno type="wicri:Area/Pmc/Corpus">000544</idno><idno type="wicri:explorRef" wicri:stream="Pmc" wicri:step="Corpus" wicri:corpus="PMC">000544</idno></publicationStmt><sourceDesc><biblStruct><analytic><title xml:lang="en" level="a" type="main">Determinants of late presentation to HIV/AIDS care in Southern Tigray Zone, Northern Ethiopia: an institution based case–control study</title><author><name sortKey="Gelaw, Yalemzewod Assefa" sort="Gelaw, Yalemzewod Assefa" uniqKey="Gelaw Y" first="Yalemzewod Assefa" last="Gelaw">Yalemzewod Assefa Gelaw</name><affiliation><nlm:aff id="Aff2">Department of Epidemiology and Biostatistics, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia</nlm:aff></affiliation></author><author><name sortKey="Senbete, Goitom Halefom" sort="Senbete, Goitom Halefom" uniqKey="Senbete G" first="Goitom Halefom" last="Senbete">Goitom Halefom Senbete</name><affiliation><nlm:aff id="Aff1">College of Medicine and Health Sciences, Wollo University, Dessie, Ethiopia</nlm:aff></affiliation></author><author><name sortKey="Adane, Akelew Awoke" sort="Adane, Akelew Awoke" uniqKey="Adane A" first="Akelew Awoke" last="Adane">Akelew Awoke Adane</name><affiliation><nlm:aff id="Aff2">Department of Epidemiology and Biostatistics, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia</nlm:aff></affiliation></author><author><name sortKey="Alene, Kefyalew Addis" sort="Alene, Kefyalew Addis" uniqKey="Alene K" first="Kefyalew Addis" last="Alene">Kefyalew Addis Alene</name><affiliation><nlm:aff id="Aff2">Department of Epidemiology and Biostatistics, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia</nlm:aff></affiliation></author></analytic><series><title level="j">AIDS Research and Therapy</title><idno type="eISSN">1742-6405</idno><imprint><date when="2015">2015</date></imprint></series></biblStruct></sourceDesc></fileDesc><profileDesc><textClass></textClass></profileDesc></teiHeader><front><div type="abstract" xml:lang="en"><sec><title>Background</title><p>Late diagnosis and presentation to human immune deficiency virus (HIV)/acquired immune deficiency syndrome care reduce the benefits of antiretroviral therapy and increase the risk of HIV transmission.</p></sec><sec><title>Objectives</title><p>This study was conducted to identify determinants of late presentation to HIV care among people living with HIV in Southern Tigray, Northern Ethiopia.</p></sec><sec><title>Methods</title><p>An institution based un-matched case–control (1:2 ratios) supported with qualitative data was conducted in Southern Tigray Zone from March 1 to April 30, 2014. Individuals with HIV enrolled from six randomly selected health facilities were included in the study. Cases were people living with HIV who had cluster of differentiation four count <350 cells/μl or World Health Organization stages 3 or 4. A total of 442 study participants were included by systematic sampling techniques. Bivariable and multivariable binary logistic regression model was used to identify associated factors. Odds ratio with 95 % CI was computed to assess the strength of the associations.</p></sec><sec><title>Result</title><p>Age categories, 25–29 years [AOR 3, 95 % CI (1.2–8.1)] and 35–39 years [AOR 4.1, 95 % CI (1.4–12.5)], having two [AOR 6, 95 % CI (1.3–28)] and more [AOR 5.2, 95 % CI (1.1–24.8)] lifetime sexual partners, poor social support [AOR 2.3, 95 % CI (1.26–4.30)], second (next to lowest) wealth quintile [AOR 3.3, 95 % CI 91.3–8.5)], fear of stigma [AOR 4.4, 95 % CI (2.2–8.3)], fear of losing job [AOR 6.8, 95 % CI (1.8–24.5)], and reported severe illness [AOR 4.3, 95 % CI (2.26–8)] were identified to be the risk factors for late presentation.</p></sec><sec><title>Conclusion</title><p>Low socio-economic status and social support, fear of stigma were potential risk factors for late presentation. Efforts towards promoting early care seeking should target on these factors in the study area and other similar settings.</p></sec></div></front><back><div1 type="bibliography"><listBibl><biblStruct></biblStruct><biblStruct><analytic><author><name sortKey="Antinori, A" uniqKey="Antinori A">A Antinori</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Lahuerta, M" uniqKey="Lahuerta M">M Lahuerta</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Ford, N" uniqKey="Ford N">N Ford</name></author></analytic></biblStruct><biblStruct></biblStruct><biblStruct></biblStruct><biblStruct><analytic><author><name sortKey="Geng, Eh" uniqKey="Geng E">EH Geng</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Mulissa, Z" uniqKey="Mulissa Z">Z Mulissa</name></author><author><name sortKey="Jerene, D" uniqKey="Jerene D">D Jerene</name></author><author><name sortKey="Lindtjorn, B" uniqKey="Lindtjorn B">B Lindtjorn</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Lahuerta, M" uniqKey="Lahuerta M">M Lahuerta</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Nash, D" uniqKey="Nash D">D Nash</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Abaynew, Y" uniqKey="Abaynew Y">Y Abaynew</name></author><author><name sortKey="Deribew, A" uniqKey="Deribew A">A Deribew</name></author><author><name sortKey="Deribe, K" uniqKey="Deribe K">K Deribe</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Mocroft, A" uniqKey="Mocroft A">A Mocroft</name></author></analytic></biblStruct><biblStruct></biblStruct><biblStruct><analytic><author><name sortKey="Gupta, A" uniqKey="Gupta A">A Gupta</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Kigozi, Im" uniqKey="Kigozi I">IM Kigozi</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Wanyenze, Rk" uniqKey="Wanyenze R">RK Wanyenze</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Camoni, L" uniqKey="Camoni L">L Camoni</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Zoufaly, A" uniqKey="Zoufaly A">A Zoufaly</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Mojumdar, K" uniqKey="Mojumdar K">K Mojumdar</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Ndiaye, B" uniqKey="Ndiaye B">B Ndiaye</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Agaba, Pa" uniqKey="Agaba P">PA Agaba</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Alvarez Uria, G" uniqKey="Alvarez Uria G">G Alvarez-Uria</name></author></analytic></biblStruct><biblStruct></biblStruct><biblStruct><analytic><author><name sortKey="Peltzer, K" uniqKey="Peltzer K">K Peltzer</name></author><author><name sortKey="Pengpid, S" uniqKey="Pengpid S">S Pengpid</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Kelly, Jd" uniqKey="Kelly J">JD Kelly</name></author><author><name sortKey="Hartman, C" uniqKey="Hartman C">C Hartman</name></author><author><name sortKey="Graham, J" uniqKey="Graham J">J Graham</name></author><author><name sortKey="Kallen, Ma" uniqKey="Kallen M">MA Kallen</name></author><author><name sortKey="Giordano, Tp" uniqKey="Giordano T">TP Giordano</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Medley, Aa" uniqKey="Medley A">AA Medley</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Jenness, Sm" uniqKey="Jenness S">SM Jenness</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Getnet, Mk" uniqKey="Getnet M">MK Getnet</name></author><author><name sortKey="Damen, Hm" uniqKey="Damen H">HM Damen</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Bonjour, Ma" uniqKey="Bonjour M">MA Bonjour</name></author><author><name sortKey="Montagne, M" uniqKey="Montagne M">M Montagne</name></author><author><name sortKey="Zambrano, M" uniqKey="Zambrano M">M Zambrano</name></author><author><name sortKey="Molina, G" uniqKey="Molina G">G Molina</name></author><author><name sortKey="Lippuner, C" uniqKey="Lippuner C">C Lippuner</name></author><author><name sortKey="Wadskier, Fg" uniqKey="Wadskier F">FG Wadskier</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Sidibe, M" uniqKey="Sidibe M">M Sidibé</name></author><author><name sortKey="Goosby, Ep" uniqKey="Goosby E">EP Goosby</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Alemu, T" uniqKey="Alemu T">T Alemu</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Govindasamy, D" uniqKey="Govindasamy D">D Govindasamy</name></author><author><name sortKey="Ford, N" uniqKey="Ford N">N Ford</name></author><author><name sortKey="Kranzer, K" uniqKey="Kranzer K">K Kranzer</name></author></analytic></biblStruct><biblStruct></biblStruct><biblStruct><analytic><author><name sortKey="Waters, L" uniqKey="Waters L">L Waters</name></author><author><name sortKey="Sabin, Ca" uniqKey="Sabin C">CA Sabin</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Makasi, T" uniqKey="Makasi T">T Makasi</name></author><author><name sortKey="Modiba, L" uniqKey="Modiba L">L Modiba</name></author></analytic></biblStruct></listBibl></div1></back></TEI><pmc article-type="research-article"><pmc-dir>properties open_access</pmc-dir>
<front><journal-meta><journal-id journal-id-type="nlm-ta">AIDS Res Ther</journal-id><journal-id journal-id-type="iso-abbrev">AIDS Res Ther</journal-id><journal-title-group><journal-title>AIDS Research and Therapy</journal-title></journal-title-group><issn pub-type="epub">1742-6405</issn><publisher><publisher-name>BioMed Central</publisher-name><publisher-loc>London</publisher-loc></publisher></journal-meta><article-meta><article-id pub-id-type="pmid">26633988</article-id><article-id pub-id-type="pmc">4667535</article-id><article-id pub-id-type="publisher-id">79</article-id><article-id pub-id-type="doi">10.1186/s12981-015-0079-2</article-id><article-categories><subj-group subj-group-type="heading"><subject>Research</subject></subj-group></article-categories><title-group><article-title>Determinants of late presentation to HIV/AIDS care in Southern Tigray Zone, Northern Ethiopia: an institution based case–control study</article-title></title-group><contrib-group><contrib contrib-type="author" corresp="yes"><name><surname>Gelaw</surname><given-names>Yalemzewod Assefa</given-names></name><address><email>yalassefa@gmail.com</email><email>pipizewa@gmail.com</email></address><xref ref-type="aff" rid="Aff2"></xref></contrib><contrib contrib-type="author"><name><surname>Senbete</surname><given-names>Goitom Halefom</given-names></name><address><email>aboabuye@gmail.com</email></address><xref ref-type="aff" rid="Aff1"></xref></contrib><contrib contrib-type="author"><name><surname>Adane</surname><given-names>Akelew Awoke</given-names></name><address><email>akilew24@gmail.com</email></address><xref ref-type="aff" rid="Aff2"></xref></contrib><contrib contrib-type="author"><name><surname>Alene</surname><given-names>Kefyalew Addis</given-names></name><address><email>kefadis@gmail.com</email></address><xref ref-type="aff" rid="Aff2"></xref></contrib><aff id="Aff1"><label></label>College of Medicine and Health Sciences, Wollo University, Dessie, Ethiopia</aff><aff id="Aff2"><label></label>Department of Epidemiology and Biostatistics, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia</aff></contrib-group><pub-date pub-type="epub"><day>2</day><month>12</month><year>2015</year></pub-date><pub-date pub-type="pmc-release"><day>2</day><month>12</month><year>2015</year></pub-date><pub-date pub-type="collection"><year>2015</year></pub-date><volume>12</volume><elocation-id>40</elocation-id><history><date date-type="received"><day>26</day><month>6</month><year>2015</year></date><date date-type="accepted"><day>9</day><month>11</month><year>2015</year></date></history><permissions><copyright-statement>© Gelaw et al. 2015</copyright-statement><license license-type="OpenAccess"><license-p><bold>Open Access</bold>This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (<ext-link ext-link-type="uri" xlink:href="http://creativecommons.org/licenses/by/4.0/">http://creativecommons.org/licenses/by/4.0/</ext-link>), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (<ext-link ext-link-type="uri" xlink:href="http://creativecommons.org/publicdomain/zero/1.0/">http://creativecommons.org/publicdomain/zero/1.0/</ext-link>) applies to the data made available in this article, unless otherwise stated.</license-p></license></permissions><abstract id="Abs1"><sec><title>Background</title><p>Late diagnosis and presentation to human immune deficiency virus (HIV)/acquired immune deficiency syndrome care reduce the benefits of antiretroviral therapy and increase the risk of HIV transmission.</p></sec><sec><title>Objectives</title><p>This study was conducted to identify determinants of late presentation to HIV care among people living with HIV in Southern Tigray, Northern Ethiopia.</p></sec><sec><title>Methods</title><p>An institution based un-matched case–control (1:2 ratios) supported with qualitative data was conducted in Southern Tigray Zone from March 1 to April 30, 2014. Individuals with HIV enrolled from six randomly selected health facilities were included in the study. Cases were people living with HIV who had cluster of differentiation four count <350 cells/μl or World Health Organization stages 3 or 4. A total of 442 study participants were included by systematic sampling techniques. Bivariable and multivariable binary logistic regression model was used to identify associated factors. Odds ratio with 95 % CI was computed to assess the strength of the associations.</p></sec><sec><title>Result</title><p>Age categories, 25–29 years [AOR 3, 95 % CI (1.2–8.1)] and 35–39 years [AOR 4.1, 95 % CI (1.4–12.5)], having two [AOR 6, 95 % CI (1.3–28)] and more [AOR 5.2, 95 % CI (1.1–24.8)] lifetime sexual partners, poor social support [AOR 2.3, 95 % CI (1.26–4.30)], second (next to lowest) wealth quintile [AOR 3.3, 95 % CI 91.3–8.5)], fear of stigma [AOR 4.4, 95 % CI (2.2–8.3)], fear of losing job [AOR 6.8, 95 % CI (1.8–24.5)], and reported severe illness [AOR 4.3, 95 % CI (2.26–8)] were identified to be the risk factors for late presentation.</p></sec><sec><title>Conclusion</title><p>Low socio-economic status and social support, fear of stigma were potential risk factors for late presentation. Efforts towards promoting early care seeking should target on these factors in the study area and other similar settings.</p></sec></abstract><kwd-group xml:lang="en"><title>Keywords</title><kwd>Late presentation</kwd><kwd>HIV/AIDS</kwd><kwd>Determinants</kwd><kwd>Case–control</kwd><kwd>Ethiopia</kwd></kwd-group><custom-meta-group><custom-meta><meta-name>issue-copyright-statement</meta-name><meta-value>© The Author(s) 2015</meta-value></custom-meta></custom-meta-group></article-meta></front><body><sec id="Sec1"><title>Background</title><p>An estimated of more than 35.3 million adults were living with human immune deficiency virus (HIV) worldwide; and nearly two-third (69 %) of this were found in Sub-Saharan Africa [<xref ref-type="bibr" rid="CR1">1</xref>]. The European Late Presenter Consensus Working Group (ELPCWG), defines “late presentation” as initial presentation to HIV care with a CD4 cell count of <350 cells/μl, and defines “presentation with advanced HIV disease” as presentation for care with a CD4 count below 200 cells/μl or any acquired immune deficiency syndrome (AIDS)-defining illness or event [<xref ref-type="bibr" rid="CR2">2</xref>]. Clinically, late presentation limits opportunities to reduce further transmission [<xref ref-type="bibr" rid="CR1">1</xref>, <xref ref-type="bibr" rid="CR2">2</xref>].</p><p>Introduction of antiretroviral therapy (ART) has substantially reduced the burden of HIV by decreasing the risk of death and improving treatment response. Late presentation for HIV care is associated with high risk of death, acquiring opportunistic infection and poor response to treatment [<xref ref-type="bibr" rid="CR3">3</xref>–<xref ref-type="bibr" rid="CR5">5</xref>]. Although people on ART have increased risk for non–AIDS illness, early initiations of ART is the option in developing countries including Ethiopia for people with HIV [<xref ref-type="bibr" rid="CR6">6</xref>].</p><p>Previous studies and reports in Sub-Saharan Africa showed that 35–65 % of HIV patients initially present with a CD4 cell counts less than 200 cells/μl or with an AIDS-defining illness [<xref ref-type="bibr" rid="CR6">6</xref>–<xref ref-type="bibr" rid="CR9">9</xref>] and 20–40 % start ART with a CD4 counts <100 cells/μl. Such late presentation is associated with lower survival, early mortality and invasive bacterial and fungal infections [<xref ref-type="bibr" rid="CR4">4</xref>]. It is also a major reason for the decreasing of retention rates in the course of ART [<xref ref-type="bibr" rid="CR3">3</xref>, <xref ref-type="bibr" rid="CR5">5</xref>, <xref ref-type="bibr" rid="CR6">6</xref>, <xref ref-type="bibr" rid="CR10">10</xref>, <xref ref-type="bibr" rid="CR11">11</xref>]. In addition to it, late presentation also poses a higher cumulative risk of HIV transmission to others [<xref ref-type="bibr" rid="CR6">6</xref>, <xref ref-type="bibr" rid="CR12">12</xref>, <xref ref-type="bibr" rid="CR13">13</xref>] as well as an economic burden to individuals particularly in the first few months of presentation [<xref ref-type="bibr" rid="CR12">12</xref>].</p><p>Although findings on late presentation are limited, the problem of late ART initiation and its poor outcomes has been reported by some researches in Ethiopia [<xref ref-type="bibr" rid="CR14">14</xref>–<xref ref-type="bibr" rid="CR16">16</xref>].</p><p>Different scholars from developed [<xref ref-type="bibr" rid="CR5">5</xref>, <xref ref-type="bibr" rid="CR6">6</xref>, <xref ref-type="bibr" rid="CR12">12</xref>] and developing countries [<xref ref-type="bibr" rid="CR3">3</xref>, <xref ref-type="bibr" rid="CR5">5</xref>, <xref ref-type="bibr" rid="CR6">6</xref>] state various definitions, reasons and determinants of late presentation to HIV care. Studies from Ethiopia are scarce at diversified contextual/structural, clinical and individual level factors. Identifying the factors associated with late presentation for HIV care seeking is important for the improvement of HIV/AIDS prevention and control programs. It also helps to early undertakes for decisions makers and program managers on the upcoming revision of country wide HIV testing and care strategies. Therefore, it is important to identify the determinants of late presentation to HIV care.</p></sec><sec id="Sec2"><title>Methods</title><sec id="Sec3"><title>Study design and study population</title><p>Un-matched case control study design supported with qualitative data was conducted from March 1 to April 20, 2014 (data collection period) in Southern Tigray Zone. The zone is located in the northern part of Ethiopia 645 km away from Addis Ababa, the capital city of Ethiopia. During the study period a total of 20 health facilities (3 general hospitals and 17 health centers) were providing voluntary counseling and testing, prevention of mother to child transmission, ART and treatment of opportunistic infection services.</p><p>The study population consisted of people over 18 years of age with HIV who were enrolled in HIV chronic care clinics and had visited the health facilities during the data collection period. Cases were people living with HIV/AIDS who had CD4 count less than 350 cell/mm<sup>3</sup> or World Health Organization (WHO) clinical stage III or IV during their first clinical visit for HIV care. Controls were PLWHA whose CD4 count was ≥350 cell/μl and WHO clinical stage I or II. Focus group discussions (FGD) were conducted with PLWHA who were a member of mother’s supporting group.</p></sec><sec id="Sec4"><title>Sampling techniques and sample size determination</title><p>The sample size was calculated using Epi Info version 7.0 by considering the following assumptions: the proportion of HIV status non-disclosure to partners among the cases was 46.2 and 29.4 % among the controls [<xref ref-type="bibr" rid="CR17">17</xref>], using 95 % CI, 90 % power and case to control ratio of 1 to 2 to detect an odds ratio of 2. Then by adding 10 % non-response rate, the final sample size was 442 (147 cases and 295 controls). Previous studies have indicated that non disclosure of HIV status to partners, alcohol use and perception of stigma increase for late presentation. Non disclosure of HIV status to partner was selected to maximize sample size.</p><p>Simple random sampling techniques were applied to select respondents. Two district hospitals and four health centers were selected randomly.</p><p>After collecting baseline CD4 count and/or WHO staging using chart reviews, people living with HIV/AIDS were classified in two groups before data collection began. Cases and controls were then selected using systematic random sampling techniques based on visits that occurred during the data collection period. We divided the sample among the six participating health institutions with a ratio of five cases to two controls. HIV-positive individual’s under 18 years of age, those with neither CD4 count data nor WHO HIV/AIDS stage recorded at first visit, and those who were overtly cognitively impaired were excluded from the study.</p></sec><sec id="Sec5"><title>Data collection and analysis</title><p>The data were collected using an interviewer administered technique by 11 trained clinical nurses working in ART clinics and supervised by two health officers. Pre-coded and structured questionnaires consisted of socio-demographic, socioeconomic, behavioral, psychosocial and social environments were used. Data collectors and supervisors were trained with respect to the objectives of the study; confidentiality of information, respondent’s rights, and interviewing technique prior to the actual data collection.</p><p>Wealth quintile information was by asking about the presence or absence of durable assets and services at the house hold level. Different indicators were used for urban and rural areas to measure wealth quintiles. The index was constructed for each household via principal components analysis. Indicators having ≥50 % rescaled communalities were used to construct wealth index and further categorized into five wealth quintiles (as lowest, second, third, fourth and highest based on the Ethiopian demographic and health survey classification [<xref ref-type="bibr" rid="CR18">18</xref>].</p><p>Data were entered to Epi Info version 7 and transferred to SPSS 20 for further statistical analysis. Descriptive and summary statistics were computed. Both bivariable and multivariable logistic regression models were used to identify associated factors. Variables having p value less than 0.2 in the bivariable analysis were remained in the multivariable model to control the effect of confounders. The Hosmer–Lemeshow goodness-of-fit statistic was used to assess the fitness of the model. Odds ratios (OR) with their 95 % confidence intervals (95 % CI) were calculated to measure the strength of association. P value less than 0.05 were considered to be significant determinants for cases and controls.</p><p>Qualitative data were collected by the principal investigator through FGD parallel to quantitative data collection. The recorded data were transcribed, translated and analyzed using thematic analysis under the sub headings of the quantitative findings and new themes for new findings.</p></sec><sec id="Sec6"><title>Ethical consideration</title><p>This study was carried out after receiving ethical approval from the Institutional Review Committee of University of Gondar. Prior to approval, the proposal was provided to reviewers to assure the ethical issues. Permission letter was also obtained from the respective health institutions (medical director or persons in charge of institutions) to identify cases and controls through chart review by authorized ART case managers or ART nurses. Before interviewing or recording, the data collector fully explained the purpose of the study to each participant and obtained written informed consent from each participant. To ensure confidentiality, names were not mentioned in the questionnaire and result report. In addition, the collected data were locked.</p></sec></sec><sec id="Sec7"><title>Result</title><p>A total of 413 HIV positive individuals (147 cases and 266 controls) participated in this study. The median age (IQR) at time of presentation was 30 (±13) years. The median age (IQR) at time of presentation for cases and controls were 30 (±11) and 30 (±13), respectively (Table <xref rid="Tab1" ref-type="table">1</xref>).<table-wrap id="Tab1"><label>Table 1</label><caption><p>Socio-demographic characteristics at first presentation of cases and controls, Southern Tigray zone, Northern Ethiopia, 2014</p></caption><table frame="hsides" rules="groups"><thead><tr><th align="left">Variables</th><th align="left">Categories</th><th align="left">Cases, N (%)</th><th align="left">Controls, N (%)</th></tr></thead><tbody><tr><td align="left" rowspan="2">Sex</td><td align="left">Male</td><td char="(" align="char">55 (37.4)</td><td char="(" align="char">86 (32.3)</td></tr><tr><td align="left">Female</td><td char="(" align="char">92 (62.6)</td><td char="(" align="char">180 (67.7)</td></tr><tr><td align="left" rowspan="4">Marital status at first presentation</td><td align="left">Married</td><td char="(" align="char">73 (49.7)</td><td char="(" align="char">122 (45.9)</td></tr><tr><td align="left">Widowed</td><td char="(" align="char">22 (14.9)</td><td char="(" align="char">37 (13.9)</td></tr><tr><td align="left">Divorced</td><td char="(" align="char">34 (23.1)</td><td char="(" align="char">67 (25.2)</td></tr><tr><td align="left">Never married</td><td char="(" align="char">18 (12.2)</td><td char="(" align="char">40 (15)</td></tr><tr><td align="left" rowspan="2">Pregnancy (18–49)</td><td align="left">Yes</td><td char="(" align="char">11 (12.4)</td><td char="(" align="char">29 (17)</td></tr><tr><td align="left">No</td><td char="(" align="char">78 (87.6)</td><td char="(" align="char">141 (82.9)</td></tr><tr><td align="left" rowspan="3">Education at first presentation</td><td align="left">Can’t read and write</td><td char="(" align="char">87 (59.2)</td><td char="(" align="char">167 (62.8)</td></tr><tr><td align="left">Primary (1–8)</td><td char="(" align="char">40 (27.2)</td><td char="(" align="char">74 (27.8)</td></tr><tr><td align="left">Secondary and above</td><td char="(" align="char">20 (13.6)</td><td char="(" align="char">25 (9.4)</td></tr><tr><td align="left" rowspan="2">Residence</td><td align="left">Urban</td><td char="(" align="char">93 (63.3)</td><td char="(" align="char">154 (57.9)</td></tr><tr><td align="left">Rural</td><td char="(" align="char">54 (36.7)</td><td char="(" align="char">112 (42.1)</td></tr><tr><td align="left" rowspan="5">Occupation</td><td align="left">Farmer</td><td char="(" align="char">34 (23)</td><td char="(" align="char">79 (29.7)</td></tr><tr><td align="left">Professional/business occ.</td><td char="(" align="char">37 (25)</td><td char="(" align="char">49 (18.4)</td></tr><tr><td align="left">Unemployed</td><td char="(" align="char">25 (17)</td><td char="(" align="char">45 (16.9)</td></tr><tr><td align="left">House wife</td><td char="(" align="char">27 (18.4)</td><td char="(" align="char">53 (19.9)</td></tr><tr><td align="left">Daily laborer</td><td char="(" align="char">24 (16.3)</td><td char="(" align="char">40 (15)</td></tr><tr><td align="left" rowspan="6">Age category</td><td align="left">18–24</td><td char="(" align="char">19 (12.9)</td><td char="(" align="char">63 (23.7)</td></tr><tr><td align="left">25–29</td><td char="(" align="char">35 (23.8)</td><td char="(" align="char">48 (18)</td></tr><tr><td align="left">30–34</td><td char="(" align="char">36 (24.5)</td><td char="(" align="char">58 (21.8)</td></tr><tr><td align="left">35–39</td><td char="(" align="char">28 (19)</td><td char="(" align="char">32 (12)</td></tr><tr><td align="left">40–44</td><td char="(" align="char">16 (10.88)</td><td char="(" align="char">32 (12)</td></tr><tr><td align="left">45+</td><td char="(" align="char">13 (8.8)</td><td char="(" align="char">33 (12.4)</td></tr><tr><td align="left" rowspan="5">Wealth quintiles (SES)</td><td align="left">Lowest</td><td char="(" align="char">40 (27.2)</td><td char="(" align="char">42 (15.8)</td></tr><tr><td align="left">Second</td><td char="(" align="char">39 (20.4)</td><td char="(" align="char">47 (17.7)</td></tr><tr><td align="left">Third</td><td char="(" align="char">24 (16.3)</td><td char="(" align="char">57 (21.4)</td></tr><tr><td align="left">Fourth</td><td char="(" align="char">26 (17.7)</td><td char="(" align="char">59 (22.2)</td></tr><tr><td align="left">Highest</td><td char="(" align="char">18 (12.2)</td><td char="(" align="char">61 (22.9)</td></tr></tbody></table></table-wrap></p><sec id="Sec8"><title>Determinants of late presentation</title><p>Age group, having had multiple sexual partners, poor socioeconomic status, non-disclosure status to partner, presentation before 2011, low household social support, desire to protect family, severity of illness, fear of stigma and fear of losing job were all found to be independent risk factors for late presentation to HIV/AIDS care (Table <xref rid="Tab2" ref-type="table">2</xref>).<table-wrap id="Tab2"><label>Table 2</label><caption><p>Binary and multiple logistic regressions showing determinants of late presentation to HIV/AIDS care, among PLWHA receiving HIV care, Southern Tigray zone, Northern Ethiopia, 2014</p></caption><table frame="hsides" rules="groups"><thead><tr><th align="left" rowspan="2">Determinants/factors</th><th align="left" colspan="2">Presentation to HIV care</th><th align="left" rowspan="2">COR (95 % CI)</th><th align="left" rowspan="2">AOR (95 % CI)</th></tr><tr><th align="left">Cases (%)</th><th align="left">Control (%)</th></tr></thead><tbody><tr><td align="left" colspan="5">Year of presentation</td></tr><tr><td align="left"> Before 2008</td><td char="(" align="char">37 (25.2)</td><td char="(" align="char">46 (17.3)</td><td align="left">1</td><td align="left">1</td></tr><tr><td align="left"> 2009–2010</td><td char="(" align="char">62 (42.2)</td><td char="(" align="char">65 (24.4)</td><td align="left">1.2 (0.681–2.06)</td><td align="left">0.76 (0.33–1.73)</td></tr><tr><td align="left"> 2011–2012</td><td char="(" align="char">27 (18.4)</td><td char="(" align="char">65 (24.4)</td><td align="left">0.51 (0.277–0.963)</td><td align="left">0.31 (0.12–0.77)**</td></tr><tr><td align="left"> 2013–2014</td><td char="(" align="char">21 (14.3)</td><td char="(" align="char">90 (33.8)</td><td align="left">0.29 (0.153–0.552)</td><td align="left">0.14 (0.05–0.37)**</td></tr><tr><td align="left" colspan="5">Age category</td></tr><tr><td align="left"> 18–24</td><td char="(" align="char">19 (12.9)</td><td char="(" align="char">63 (23.7)</td><td align="left">1</td><td align="left">1</td></tr><tr><td align="left"> 25–29</td><td char="(" align="char">35 (23.8)</td><td char="(" align="char">48 (18)</td><td align="left">2.4 (1.23–4.73)</td><td align="left">3.0 (1.15–8.12)*</td></tr><tr><td align="left"> 30–34</td><td char="(" align="char">36 (24.5)</td><td char="(" align="char">58 (21.8)</td><td align="left">2.0 (1.06–3.98)</td><td align="left">1.4 (0.52–3.65)</td></tr><tr><td align="left"> 35–39</td><td char="(" align="char">28 (19)</td><td char="(" align="char">32 (12)</td><td align="left">2.9 (1.41–5.96)</td><td align="left">4.1 (1.35–12.46)*</td></tr><tr><td align="left"> 40–44</td><td char="(" align="char">16 (10.88)</td><td char="(" align="char">32 (12)</td><td align="left">1.7 (0.75–3.65)</td><td align="left">1.1 (0.34–3.71)</td></tr><tr><td align="left"> 45+</td><td char="(" align="char">13 (8.8)</td><td char="(" align="char">33 (12.4)</td><td align="left">1.3 (0.62–3.29)</td><td align="left">1.3 (0.37–4.23)</td></tr><tr><td align="left" colspan="5">No. of life time sexual partners</td></tr><tr><td align="left"> None</td><td char="(" align="char">4 (2.7)</td><td char="(" align="char">28 (10.5)</td><td align="left">1</td><td align="left">1</td></tr><tr><td align="left"> One</td><td char="(" align="char">49 (33.3)</td><td char="(" align="char">77 (28.9)</td><td align="left">4.4 (1.47–13.47)</td><td align="left">4.0 (0.86–18.59)</td></tr><tr><td align="left"> Two</td><td char="(" align="char">46 (31.3)</td><td char="(" align="char">98 (36.8)</td><td align="left">3.3 (1.08–9.9)</td><td align="left">6.0 (1.28–28.02)*</td></tr><tr><td align="left"> More than two</td><td char="(" align="char">48 (32.7)</td><td char="(" align="char">61 (22.9)</td><td align="left">5.5 (1.80–16.7)</td><td align="left">5.2 (1.08–24.76)*</td></tr><tr><td align="left" colspan="5">Presence of HIV infected HH member</td></tr><tr><td align="left"> Yes</td><td char="(" align="char">16 (10.9)</td><td char="(" align="char">51 (34.7)</td><td align="left">1</td><td align="left"></td></tr><tr><td align="left"> No</td><td char="(" align="char">131 (89.1)</td><td char="(" align="char">215 (65.3)</td><td align="left">1.9 (1.06–3.54)</td><td align="left"></td></tr><tr><td align="left" colspan="5">Presence of HIV care attendee</td></tr><tr><td align="left"> Yes</td><td char="(" align="char">14 (9.5)</td><td char="(" align="char">44 (16.5)</td><td char="(" align="left">1</td><td align="left"></td></tr><tr><td align="left"> No</td><td char="(" align="char">133 (90.5)</td><td char="(" align="char">222 (83.5)</td><td char="(" align="left">1.8 (1.1–3.56)</td><td align="left"></td></tr><tr><td align="left" colspan="5">Witnessed stigma</td></tr><tr><td align="left"> Low stigma</td><td char="(" align="char">91 (61.9)</td><td char="(" align="char">184 (69.2)</td><td align="left"></td><td align="left"></td></tr><tr><td align="left"> High stigma</td><td char="(" align="char">56 (38.1)</td><td char="(" align="char">82 (30.8)</td><td char="(" align="left">1.4 (0.90–2.10)</td><td align="left"></td></tr><tr><td align="left" colspan="5">Depression</td></tr><tr><td align="left"> Not depressed</td><td char="(" align="char">56 (38.1)</td><td char="(" align="char">154 (57.9)</td><td char="(" align="left">1</td><td align="left"></td></tr><tr><td align="left"> Depressed</td><td char="(" align="char">91 (61.9)</td><td char="(" align="char">112 (42.1)</td><td char="(" align="left">2.2 (1.47–3.37)</td><td align="left"></td></tr><tr><td align="left" colspan="5">Level of social support</td></tr><tr><td align="left"> Poor social support</td><td char="(" align="char">103 (70)</td><td char="(" align="char">95 (35.7)</td><td char="(" align="left">4.2 (2.73–6.49)</td><td char="(" align="left">2.3 (1.26–4.30)*</td></tr><tr><td align="left"> Good social support</td><td char="(" align="char">44 (30)</td><td char="(" align="char">171 (64.3)</td><td char="(" align="left">1</td><td char="(" align="left">1</td></tr><tr><td align="left" colspan="5">Wealth quintile (SES)</td></tr><tr><td align="left"> Lowest</td><td char="(" align="char">40 (27.2)</td><td char="(" align="char">42 (15.8)</td><td char="(" align="left">3.2 (1.63–6.37)</td><td char="(" align="left">1.05 (0.38–2.83)</td></tr><tr><td align="left"> Second</td><td char="(" align="char">39 (20.4)</td><td char="(" align="char">47 (17.7)</td><td char="(" align="left">2.8 (1.43–5.52)</td><td char="(" align="left">3.3 (1.31–8.46)*</td></tr><tr><td align="left"> Third</td><td char="(" align="char">24 (16.3)</td><td char="(" align="char">57 (21.4)</td><td char="(" align="left">1.4 (0.70–2.90)</td><td char="(" align="left">0.8 (0.27–2.31)</td></tr><tr><td align="left"> Fourth</td><td char="(" align="char">26 (17.7)</td><td char="(" align="char">59 (22.2)</td><td char="(" align="left">1.5 (0.74–3.0)</td><td char="(" align="left">1.1 (0.44–2.82)</td></tr><tr><td align="left"> Highest</td><td char="(" align="char">18 (12.2)</td><td char="(" align="char">61 (22.9)</td><td char="(" align="left">1</td><td char="(" align="left">1</td></tr><tr><td align="left" colspan="5">Disclosure to partner</td></tr><tr><td align="left"> Yes</td><td char="(" align="char">26 (35.6)</td><td char="(" align="char">72 (59)</td><td char="(" align="left">1</td><td char="(" align="left">1</td></tr><tr><td align="left"> No</td><td char="(" align="char">47 (64.4)</td><td char="(" align="char">50 (41)</td><td char="(" align="left">2.6 (1.43–4.74)</td><td char="(" align="left">2.0 (1.05–4.14)*</td></tr><tr><td align="left" colspan="5">HIV support groups in community</td></tr><tr><td align="left"> Yes</td><td char="(" align="char">70 (47.6)</td><td char="(" align="char">150 (56.4)</td><td char="(" align="left">0.70 (0.47–1.05)</td><td align="left"></td></tr><tr><td align="left"> No</td><td char="(" align="char">77 (52.4)</td><td char="(" align="char">116 (43.6)</td><td char="(" align="left">1</td><td align="left"></td></tr><tr><td align="left" colspan="5">Diet and life style change for positive result</td></tr><tr><td align="left"> Yes</td><td char="(" align="char">49 (33.3)</td><td char="(" align="char">122 (45.9)</td><td char="(" align="left">0.59 (0.39–0.89)</td><td char="(" align="left">0.45 (0.24–0.87)*</td></tr><tr><td align="left"> No</td><td char="(" align="char">98 (66.6)</td><td char="(" align="char">144 (54.1)</td><td align="left">1</td><td align="left">1</td></tr><tr><td align="left" colspan="5">Desire to protect family</td></tr><tr><td align="left"> Yes</td><td char="(" align="char">23 (15.6)</td><td char="(" align="char">126 (43.4)</td><td align="left">0.20 (0.12–0.34)</td><td align="left">0.19 (0.09–0.37)**</td></tr><tr><td align="left"> No</td><td char="(" align="char">124 (84.4)</td><td char="(" align="char">140 (52.6)</td><td align="left">1</td><td align="left">1</td></tr><tr><td align="left" colspan="5">To know CD4 count</td></tr><tr><td align="left"> Yes</td><td char="(" align="char">5 (3.4)</td><td char="(" align="char">33 (12.4)</td><td align="left">0.25 (0.095–0.65)</td><td align="left">0.37 (0.09–1.43)</td></tr><tr><td align="left"> No</td><td char="(" align="char">142 (96.6)</td><td char="(" align="char">233 (87.6)</td><td align="left">1</td><td align="left">1</td></tr><tr><td align="left" colspan="5">Severity of illness</td></tr><tr><td align="left"> Yes</td><td char="(" align="char">89 (60.5)</td><td char="(" align="char">66 (24.8)</td><td align="left">4.7 (3.01–7.16)</td><td align="left">4.3 (2.26–8.0)**</td></tr><tr><td align="left"> No</td><td char="(" align="char">58 (39.5)</td><td char="(" align="char">200 (75.2)</td><td align="left">1</td><td align="left">1</td></tr><tr><td align="left" colspan="5">Fear of stigma</td></tr><tr><td align="left"> Yes</td><td char="(" align="char">94 (63)</td><td char="(" align="char">65 (24.5)</td><td align="left">5.5 (3.5–8.5)</td><td align="left">4.4 (2.2–8.3)**</td></tr><tr><td align="left"> No</td><td char="(" align="char">53 (37)</td><td char="(" align="char">201 (75.5)</td><td align="left">1</td><td align="left">1</td></tr><tr><td align="left" colspan="5">Fear of disclosure</td></tr><tr><td align="left"> Yes</td><td char="(" align="char">60 (40.8)</td><td char="(" align="char">40 (15)</td><td align="left">3.9 (2.43–6.23)</td><td align="left">2.0 (0.99–4.32)</td></tr><tr><td align="left"> No</td><td char="(" align="char">87 (59.2)</td><td char="(" align="char">226 (84.9)</td><td align="left">1</td><td align="left">1</td></tr><tr><td align="left" colspan="5">Fear of losing job/income source</td></tr><tr><td align="left"> Yes</td><td char="(" align="char">27 (18.4)</td><td char="(" align="char">6(2.3)</td><td align="left">9.8 (3.92–24.2)</td><td align="left">6.8 (1.8–24.54)*</td></tr><tr><td align="left"> No</td><td char="(" align="char">120 (81.6)</td><td char="(" align="char">260 (97.7)</td><td align="left">1</td><td align="left">1</td></tr></tbody></table><table-wrap-foot><p>* Significant (p ≤ 0.05)</p><p>** Highly significantly (p < 0.001)</p></table-wrap-foot></table-wrap></p><p>Participants in the age group of 25–29 years [AOR 3, 95 % CI (1.15–8.12)] and those 35–39 years [AOR 4.1, 95 % CI (0.35–12.46)] were 3 and 4.1 times more likely to present late, respectively, as compared to those 18–24 years of age.</p><p>Year of presentation was associated with likelihood of late presentation. Those study participates who were visiting the HIV care before 2008 were presenting lately. The risk of late presentation to HIV care among PLWHA who presented in the years 2011–2012 [AOR 0.31, 95 % CI (0.12–0.77)] and 2013–2014 [AOR 0.14, 95 % CI (0.05–0.37)] was decreased by 69 and 86 %, respectively, as compared to those presenting before the year 2008.</p><p>Presence of more than one lifetime sexual partner was also associated with late presentation to HIV care. HIV-positive individuals with two lifetime sexual partners were six times [AOR 6, 95 % CI (1.28–28.02)] more likely to present late as compared with participants with none. Those with more than two life time sexual partners were also 5.2 times [AOR 5.2, 95 % CI (1.08–24.76)] more likely to present late compared to those with none.</p><p>The second (next to lowest) wealth quintile of HIV-positive individuals was 3.3 times [AOR 3.3, 95 % CI (1.31–8.46)] more likely to present late as compared to the highest wealth quintile group.</p><p>Partner or spousal HIV status disclosure was found to deter presentation. Married participants who did not disclose their HIV status to their partner were two times more likely to present late [AOR 2, 95 % CI (1.05–4.14)] compared to those who did.</p><p>HIV positive individuals who had poor house hold social support were 2.3 times more likely to present late as compared to those who had good social support at home [AOR 2.3, 95 % CI (1.26–4.30)].</p><p>Barriers perceived by PLWHA were also associated with late presentation. Participants who reported fear of stigma were 4.4 times more likely to present late as compared to those who did not [AOR 4.4, 95 % CI (2.23–8.27)]. Participants who reported fear of losing their source of income were 6.8 more likely to present late as compared to those who did not [AOR 6.8, 95 % CI (1.8–24.54)].</p><p>The way participants perceived the benefits of HIV care also contributed to discrepancy in stage at presentation. Participants who responded that “protecting family” was their reason for initiating care were 81 % less likely to present late, as compared to those who did not [AOR 0.19, 95 % CI (0.09–0.37)]. By contrast, participants who responded that “severe illness” was a reason for initiating care were 4.3 times more likely to present late as compared to those who did not [AOR 4.3, 95 % CI (2.26–8.0)].</p><p>The qualitative results revealed that fear of stigma, fear of losing income source/former job, use of alternative therapies, lack of familial pressure to initiate care, inadequacy of social support (spouse, friends and religious leaders) and inadequate knowledge about delay to care were the barriers reported by people living with HIV/AIDS in the study area (Table <xref rid="Tab3" ref-type="table">3</xref>).<table-wrap id="Tab3"><label>Table 3</label><caption><p>FGD results extracted from HIV positive individuals works on mothers supporting groups concerning barriers to early HIV/AIDS care, Southern Tigray Zone, April 2014</p></caption><table frame="hsides" rules="groups"><thead><tr><th align="left">Barriers to HIV/AIDS care</th><th char="c" align="left">HIV/AIDS positive individuals working on Mother Supporting Group</th></tr></thead><tbody><tr><td char="c" align="char">Fear of stigma</td><td char="c" align="char">“… I was worried that people will talk about me if they hear I tested positive”… Male-32 “When I became aware of my HIV status my challenge was fear of health professionals and seeing other individuals I know while attending the ART clinic”, Female-27.</td></tr><tr><td char="c" align="char">Fear of losing income source/former job</td><td char="c" align="char">“People seem supportive towards HIV positives at first, but the pain is that they gradually change their feeling and treat you as ‘too weak’ to accomplish your duty …HIV positives will be shifted to lower status/position”, Male-55<break></break>“Although they are HIV positive, numerous commercial sex workers in the town continue their commercial sex work”, Female-27</td></tr><tr><td char="c" align="char">Use of non-medical treatment</td><td char="c" align="char">“…then she ate a dried Wild boar’s meat and Wild boar’s bile”, Female-30<break></break>“…he told me a very bitter plant called ‘Oure’ or ‘Eret’ is medicine for HIV and he had been drinking it until he ended up dying”, Female-30<break></break>“I went to a local traditional healer called ‘TonqualIi’ or magician and spent around 3000 Ethiopian Birr then he told to my wife wash my body using sheep’s blood and dung added together ….”, Male-38<break></break>“There was one HIV-positive neighbor with symptoms of diarrhea, she bought drugs from the pharmacy, was relieved of her symptoms for some time and then went to other pharmacy a few days later….”, Female-30<break></break>“My husband and were severely diseased and confined to bed for around 6 months. He had been telling that his illness was due to other diseases like malaria, and he has been getting medicines from drug stores”, Female-34</td></tr><tr><td char="c" align="char">Low families driving force for initiation care</td><td char="c" align="char">“We should let peoples think for the next generation…If my children are healthy…..”, Male -32 … “My child is negative”, Female-27, “My wife and children are negative”, Males-32, 55</td></tr><tr><td char="c" align="char">Inadequacy of social support (spouse, friends and religious leaders)</td><td char="c" align="char">“… I show him my ART drugs that I am taking and he became persuaded to take his treatment too”, Female-55<break></break>“I become angry and decided not to take any treatment for 1 year. Later on my friends were taking HIV treatment and they encouraged me to take treatment.” Male-28<break></break>“Males say that we are healthy even though we have the HIV and nothing bad is going on us, but, females become ill and suffer from headache and they come to ART clinics saying I tested positive for HIV …”, Female-27<break></break>“….later on my wife went to the health center and tested positive after that she encouraged me to be tested …”, Male-38<break></break>“…..I then persuaded my husband to be tested for HIV and avoided taking other drugs from outside the treatment center’’, Female-34<break></break>“My brother shouts at me, you should be tested and know the cause for your illness today; I will help every expense that follows …..”, Female-35<break></break>“…she was severely ill and her family said that they didn’t want to take care of the dead”, Female-27</td></tr><tr><td char="c" align="char">Inadequate knowledge</td><td char="c" align="char">“The HIV testing sites that are conducted in the shade in town are always crowded with people being tested, especially males. But they don’t come to care once they have tested positive [F-55] and they can only be accessed after they become diseased, arriving on a stretcher or by ambulance, or when found during house-to-house tracing by volunteer HIV support groups. …”, Female-34</td></tr></tbody></table></table-wrap></p></sec></sec><sec id="Sec9"><title>Discussion</title><p>This study identified determinants of late presentation to HIV/AIDS care in ART services are accessible at primary health care units. Although different studies reported various risk factors for late presentation, the present study assessed people’s perceived need for care, perceived barriers to HIV care, socioeconomic status, and the role of social support.</p><p>Consistent with previous studies in Europe and Africa [<xref ref-type="bibr" rid="CR11">11</xref>, <xref ref-type="bibr" rid="CR19">19</xref>–<xref ref-type="bibr" rid="CR22">22</xref>, <xref ref-type="bibr" rid="CR29">29</xref>] HIV-positive participants were present late for care when their age gets old. It has been posited that when age increase adults are more likely to have a moral or ethical reason for presenting earlier to care. However, a study in India reported young adults present late [<xref ref-type="bibr" rid="CR23">23</xref>]. This could be explained by differences in method and project design, as well as varying social and cultural issues. In countries like Ethiopia, old peoples considered as immaculate. In the context of the study setting elder individuals are a pronounced in the milieu.</p><p>Participants with a history of multiple sexual partners were more likely to present late to care. This was also reported in previous study in Ethiopia [<xref ref-type="bibr" rid="CR17">17</xref>]. However, in Uganda [<xref ref-type="bibr" rid="CR11">11</xref>] and Venezuela [<xref ref-type="bibr" rid="CR24">24</xref>] HIV-positive individuals with more than one sexual partner presented early. One factor for this different finding might be the emphasis of taboo on sexually active behaviors in Ethiopian society, and an increased propensity to feel embarrassment regarding this behavior [<xref ref-type="bibr" rid="CR25">25</xref>]. Although having legal multiple sexual partners are practiced in Islamic religions of Ethiopia, seeking treatment related to sexual transmitted disease is still lack.</p><p>Socioeconomic positions of the study participants were also the determinant factors to present late for HIV care. Participants in the second (next to the lowest) wealth quintile were statistically associated with late presentation. This was also consistent with previous systematic review of three indicators of socio economic status (education, income and occupation) [<xref ref-type="bibr" rid="CR26">26</xref>]. Despite the difference in measurement of socioeconomic positions of HIV positive individuals, some studies also describe income as a determinant factor for late presentation [<xref ref-type="bibr" rid="CR6">6</xref>, <xref ref-type="bibr" rid="CR14">14</xref>, <xref ref-type="bibr" rid="CR17">17</xref>]. In the context of Ethiopian health care delivery system voluntary counseling and testing, diagnosis and ART services are exempted.</p><p>In Ethiopia peoples are most of the time living together; shares the same dish and chalice in different occasions. Participants with poor social support were more likely present late, consistent with studies done in Durban, South Africa [<xref ref-type="bibr" rid="CR14">14</xref>] and Houston, Texas [<xref ref-type="bibr" rid="CR27">27</xref>]. Here we believe that social stigma and lack of social support can contribute towards people feeling inhibited in seeking HIV/AIDS care. The qualitative data also support this finding. Behavioral change and communication concerned with social stigma and poor social support needs to be done using key informants, religious person and mother supporting groups.</p><p>Poor partner’s communication on reproductive health matters has an impact for health status of the family. Partners who did not disclose their status to their partner were more likely to present late. Similarly, studies done in Uganda [<xref ref-type="bibr" rid="CR6">6</xref>], Kenya [<xref ref-type="bibr" rid="CR28">28</xref>] and Ethiopia [<xref ref-type="bibr" rid="CR17">17</xref>], revealed that disclosure to partners can initiate timely HIV/AIDS care. HIV/AIDS related stigma and discrimination has declined dramatically in Ethiopia and support following disclosure has improved.</p><p>The current study reported that participants who had been visiting health facilities in recent years were more likely to present early as compared to those visited health facilities before 2008. This finding is consistent with studies done in Nigeria [<xref ref-type="bibr" rid="CR29">29</xref>], Belgium and France [<xref ref-type="bibr" rid="CR22">22</xref>], New York City [<xref ref-type="bibr" rid="CR30">30</xref>] and India [<xref ref-type="bibr" rid="CR23">23</xref>]. This could be due to the increased access to care, overall awareness of HIV, media accessibility and a reduction in stigma over time [<xref ref-type="bibr" rid="CR31">31</xref>–<xref ref-type="bibr" rid="CR33">33</xref>].</p><p>Fear of stigma and losing one’s job were determinant factors for late presentation consistent with previous studies in Sub-Saharan Africa [<xref ref-type="bibr" rid="CR34">34</xref>] and Zimbabwe [<xref ref-type="bibr" rid="CR35">35</xref>]. This is also supported by the qualitative FGD report that showed fear of stigma and losing job/customers were barriers. This is could be common problem of female participant’s sex worker.</p><p>Our study also showed that participants who perceived HIV as a sever disease were more likely to seek care early. This is demonstrated in the qualitative data in which protecting family members was a driver to initiate HIV care early.</p><p>In this study the use of traditional medicine and a holy water as a treatment and sex of respondents were not statistically significant with late presentation to HIV/AIDS care. However, data from the FGD indicates that male’s patients who had visited traditional medicine and/or holy water sites were more likely to present late for HIV/AIDS care. This discrepancy could be due to that HIV positive individuals might fear to disclose the utilization of these services. It could be also due to the rareness of such traditional treatments.</p><p>The potential limitations of this study were that the study may have been prone to recall biases and that there may have been misclassification of presentation or diseases do to social pressure.</p></sec><sec id="Sec10"><title>Conclusion</title><p>Age older than 25, having multiple sexual partners, poor socioeconomic status, non-disclosure to partner, presentation before 2011 for care, low house hold social support, desire to protect family, severity of illness, fear of stigma and fear of losing job were all found to be independent risk factors for late presentation to HIV/AIDS care.</p></sec></body><back><ack><title>Authors’ contributions</title><p>GHS designed the study, performed the statistical analysis, and drafted the paper. YAG and AAA participated in the paper writing. YAG, AAA and KAA participated in manuscript drafting and editing. All authors contributed to the data analysis. All authors read and approved the final manuscript.</p><sec id="FPar1"><title>Acknowledgements</title><p>The Southern Tigre zonal Health Department, hospitals’ and Health centers’ staff, study participants, and data collectors deserve appreciation for their cooperation and assistance.</p></sec><sec id="FPar2"><title>Competing interests</title><p>The authors declare that they have no competing interests.</p></sec></ack><ref-list id="Bib1"><title>References</title><ref id="CR1"><label>1.</label><mixed-citation publication-type="other">World Health Organization. HIV and adolescents: guidance for HIV testing and counselling and care for adolescents living with HIV: recommendations for a public health approach and considerations for policy-makers and managers. 2013.<ext-link ext-link-type="uri" xlink:href="http://www.who.int/iris/bitstream/10665/94334/1/9789241506168_eng.pdf">http://www.who.int/iris/bitstream/10665/94334/1/9789241506168_eng.pdf</ext-link>.</mixed-citation></ref><ref id="CR2"><label>2.</label><element-citation publication-type="journal"><person-group person-group-type="author"><name><surname>Antinori</surname><given-names>A</given-names></name><etal></etal></person-group><article-title>Late presentation of HIV infection: a consensus definition</article-title><source>HIV Med</source><year>2011</year><volume>12</volume><issue>1</issue><fpage>61</fpage><lpage>64</lpage><pub-id pub-id-type="doi">10.1111/j.1468-1293.2010.00857.x</pub-id><pub-id pub-id-type="pmid">20561080</pub-id></element-citation></ref><ref id="CR3"><label>3.</label><element-citation publication-type="journal"><person-group person-group-type="author"><name><surname>Lahuerta</surname><given-names>M</given-names></name><etal></etal></person-group><article-title>The problem of late ART initiation in Sub-Saharan Africa: a transient aspect of scale-up or a long-term phenomenon?</article-title><source>J Health Care Poor Underserved</source><year>2013</year><volume>24</volume><issue>1</issue><fpage>359</fpage><lpage>383</lpage><pub-id pub-id-type="doi">10.1353/hpu.2013.0014</pub-id><pub-id pub-id-type="pmid">23377739</pub-id></element-citation></ref><ref id="CR4"><label>4.</label><element-citation publication-type="journal"><person-group person-group-type="author"><name><surname>Ford</surname><given-names>N</given-names></name><etal></etal></person-group><article-title>Getting to zero HIV deaths: progress, challenges and ways forward</article-title><source>J Int AIDS Soc</source><year>2013</year><volume>16</volume><issue>1</issue><fpage>18927</fpage><pub-id pub-id-type="doi">10.7448/IAS.16.1.18927</pub-id><pub-id pub-id-type="pmid">24314398</pub-id></element-citation></ref><ref id="CR5"><label>5.</label><mixed-citation publication-type="other">World Health Organization. Global update on HIV treatment: results, impact and opportunities. 2013. Available: <ext-link ext-link-type="uri" xlink:href="http://www.who.int/hiv/pub/progressreports/update2013/en/">http://www.who.int/hiv/pub/progressreports/update2013/en/</ext-link>.</mixed-citation></ref><ref id="CR6"><label>6.</label><mixed-citation publication-type="other">David HS. CROI: cardiovascular disease and co-morbidities in HIV. 20th conference on retroviruses and opportunistic infections. March 3–6. Atlanta, GA. 2013.</mixed-citation></ref><ref id="CR7"><label>7.</label><element-citation publication-type="journal"><person-group person-group-type="author"><name><surname>Geng</surname><given-names>EH</given-names></name><etal></etal></person-group><article-title>Trends in the clinical characteristics of HIV-infected patients initiating antiretroviral therapy in Kenya, Uganda and Tanzania between 2002 and 2009</article-title><source>J Int AIDS Soc</source><year>2011</year><volume>14</volume><fpage>46</fpage><pub-id pub-id-type="doi">10.1186/1758-2652-14-46</pub-id><pub-id pub-id-type="pmid">21955541</pub-id></element-citation></ref><ref id="CR8"><label>8.</label><element-citation publication-type="journal"><person-group person-group-type="author"><name><surname>Mulissa</surname><given-names>Z</given-names></name><name><surname>Jerene</surname><given-names>D</given-names></name><name><surname>Lindtjorn</surname><given-names>B</given-names></name></person-group><article-title>Patients present earlier and survival has improved, but pre-ART attrition is high in a six-year HIV cohort data from Ethiopia</article-title><source>PLoS One</source><year>2010</year><volume>5</volume><issue>10</issue><fpage>e13268</fpage><pub-id pub-id-type="doi">10.1371/journal.pone.0013268</pub-id><pub-id pub-id-type="pmid">20949010</pub-id></element-citation></ref><ref id="CR9"><label>9.</label><element-citation publication-type="journal"><person-group person-group-type="author"><name><surname>Lahuerta</surname><given-names>M</given-names></name><etal></etal></person-group><article-title>Factors associated with late antiretroviral therapy initiation among adults in Mozambique</article-title><source>PLoS One</source><year>2012</year><volume>7</volume><issue>5</issue><fpage>e37125</fpage><pub-id pub-id-type="doi">10.1371/journal.pone.0037125</pub-id><pub-id pub-id-type="pmid">22615917</pub-id></element-citation></ref><ref id="CR10"><label>10.</label><element-citation publication-type="journal"><person-group person-group-type="author"><name><surname>Nash</surname><given-names>D</given-names></name><etal></etal></person-group><article-title>Program-level and contextual-level determinants of low-median CD4+ cell count in cohorts of persons initiating ART in eight Sub-Saharan African countries</article-title><source>AIDS</source><year>2011</year><volume>25</volume><issue>12</issue><fpage>1523</fpage><lpage>1533</lpage><pub-id pub-id-type="doi">10.1097/QAD.0b013e32834811b2</pub-id><pub-id pub-id-type="pmid">21750418</pub-id></element-citation></ref><ref id="CR11"><label>11.</label><element-citation publication-type="journal"><person-group person-group-type="author"><name><surname>Abaynew</surname><given-names>Y</given-names></name><name><surname>Deribew</surname><given-names>A</given-names></name><name><surname>Deribe</surname><given-names>K</given-names></name></person-group><article-title>Factors associated with late presentation to HIV/AIDS care in South Wollo ZoneEthiopia: a case–control study</article-title><source>AIDS Res Ther</source><year>2011</year><volume>8</volume><issue>8</issue><fpage>8</fpage><pub-id pub-id-type="doi">10.1186/1742-6405-8-8</pub-id><pub-id pub-id-type="pmid">21356115</pub-id></element-citation></ref><ref id="CR12"><label>12.</label><element-citation publication-type="journal"><person-group person-group-type="author"><name><surname>Mocroft</surname><given-names>A</given-names></name><etal></etal></person-group><article-title>Risk factors and outcomes for late presentation for HIV-positive persons in Europe: results from the collaboration of observational HIV epidemiological research Europe study (COHERE)</article-title><source>PLoS Med</source><year>2013</year><volume>10</volume><issue>9</issue><fpage>e1001510</fpage><pub-id pub-id-type="doi">10.1371/journal.pmed.1001510</pub-id><pub-id pub-id-type="pmid">24137103</pub-id></element-citation></ref><ref id="CR13"><label>13.</label><mixed-citation publication-type="other">CSA. Ethiopia Demographic and Health Survey 2011. Addis Ababa. Central Statistical Agency [Ethiopia] and ICF International; 2012.</mixed-citation></ref><ref id="CR14"><label>14.</label><element-citation publication-type="journal"><person-group person-group-type="author"><name><surname>Gupta</surname><given-names>A</given-names></name><etal></etal></person-group><article-title>Early mortality in adults initiating antiretroviral therapy (ART) in low- and middle-income countries (LMIC): a systematic review and meta-analysis</article-title><source>PLoS One</source><year>2011</year><volume>6</volume><issue>12</issue><fpage>e28691</fpage><pub-id pub-id-type="doi">10.1371/journal.pone.0028691</pub-id><pub-id pub-id-type="pmid">22220193</pub-id></element-citation></ref><ref id="CR15"><label>15.</label><element-citation publication-type="journal"><person-group person-group-type="author"><name><surname>Kigozi</surname><given-names>IM</given-names></name><etal></etal></person-group><article-title>Late-disease stage at presentation to an HIV clinic in the era of free antiretroviral therapy in Sub-Saharan Africa</article-title><source>J Acquir Immune Defic Syndr</source><year>2009</year><volume>52</volume><issue>2</issue><fpage>280</fpage><lpage>289</lpage><pub-id pub-id-type="doi">10.1097/QAI.0b013e3181ab6eab</pub-id><pub-id pub-id-type="pmid">19521248</pub-id></element-citation></ref><ref id="CR16"><label>16.</label><element-citation publication-type="journal"><person-group person-group-type="author"><name><surname>Wanyenze</surname><given-names>RK</given-names></name><etal></etal></person-group><article-title>Missed opportunities for HIV testing and late-stage diagnosis among HIV-infected patients in Uganda</article-title><source>PLoS One</source><year>2011</year><volume>6</volume><issue>7</issue><fpage>e21794</fpage><pub-id pub-id-type="doi">10.1371/journal.pone.0021794</pub-id><pub-id pub-id-type="pmid">21750732</pub-id></element-citation></ref><ref id="CR17"><label>17.</label><element-citation publication-type="journal"><person-group person-group-type="author"><name><surname>Camoni</surname><given-names>L</given-names></name><etal></etal></person-group><article-title>Late presenters among persons with a new HIV diagnosis in Italy, 2010–2011</article-title><source>BMC Public Health</source><year>2013</year><volume>13</volume><issue>1</issue><fpage>281</fpage><pub-id pub-id-type="doi">10.1186/1471-2458-13-281</pub-id><pub-id pub-id-type="pmid">23537210</pub-id></element-citation></ref><ref id="CR18"><label>18.</label><element-citation publication-type="journal"><person-group person-group-type="author"><name><surname>Zoufaly</surname><given-names>A</given-names></name><etal></etal></person-group><article-title>Late presentation for HIV diagnosis and care in Germany</article-title><source>HIV Med</source><year>2012</year><volume>13</volume><issue>3</issue><fpage>172</fpage><lpage>181</lpage><pub-id pub-id-type="doi">10.1111/j.1468-1293.2011.00958.x</pub-id><pub-id pub-id-type="pmid">22093171</pub-id></element-citation></ref><ref id="CR19"><label>19.</label><element-citation publication-type="journal"><person-group person-group-type="author"><name><surname>Mojumdar</surname><given-names>K</given-names></name><etal></etal></person-group><article-title>Late presenters to HIV care and treatment, identification of associated risk factors in HIV-1 infected Indian population</article-title><source>BMC Public Health</source><year>2010</year><volume>10</volume><fpage>416</fpage><pub-id pub-id-type="doi">10.1186/1471-2458-10-416</pub-id><pub-id pub-id-type="pmid">20626905</pub-id></element-citation></ref><ref id="CR20"><label>20.</label><element-citation publication-type="journal"><person-group person-group-type="author"><name><surname>Ndiaye</surname><given-names>B</given-names></name><etal></etal></person-group><article-title>Factors associated with presentation to care with advanced HIV disease in Brussels and Northern France: 1997–2007</article-title><source>BMC Infect Dis</source><year>2011</year><volume>11</volume><fpage>11</fpage><pub-id pub-id-type="doi">10.1186/1471-2334-11-11</pub-id><pub-id pub-id-type="pmid">21226905</pub-id></element-citation></ref><ref id="CR21"><label>21.</label><element-citation publication-type="journal"><person-group person-group-type="author"><name><surname>Agaba</surname><given-names>PA</given-names></name><etal></etal></person-group><article-title>Patients who present late to HIV care and associated risk factors in Nigeria</article-title><source>HIV Med</source><year>2014</year><volume>15</volume><issue>7</issue><fpage>396</fpage><lpage>405</lpage><pub-id pub-id-type="doi">10.1111/hiv.12125</pub-id><pub-id pub-id-type="pmid">24580742</pub-id></element-citation></ref><ref id="CR22"><label>22.</label><element-citation publication-type="journal"><person-group person-group-type="author"><name><surname>Alvarez-Uria</surname><given-names>G</given-names></name></person-group><article-title>Factors associated with delayed entry into HIV medical care after HIV diagnosis in a resource-limited setting: data from a cohort study in India</article-title><source>PeerJ</source><year>2013</year><volume>1</volume><fpage>e90</fpage><pub-id pub-id-type="doi">10.7717/peerj.90</pub-id><pub-id pub-id-type="pmid">23802091</pub-id></element-citation></ref><ref id="CR23"><label>23.</label><mixed-citation publication-type="other">Nyblade L, et al. Disentangling HIV and AIDS stigma in Ethiopia, Tanzania and Zambia; 2003.</mixed-citation></ref><ref id="CR24"><label>24.</label><element-citation publication-type="journal"><person-group person-group-type="author"><name><surname>Peltzer</surname><given-names>K</given-names></name><name><surname>Pengpid</surname><given-names>S</given-names></name></person-group><article-title>Socioeconomic factors in adherence to HIV therapy in low- and middle-income countries</article-title><source>J Health Popul Nutr</source><year>2013</year><volume>31</volume><issue>2</issue><fpage>150</fpage><lpage>170</lpage><pub-id pub-id-type="doi">10.3329/jhpn.v31i2.16379</pub-id><pub-id pub-id-type="pmid">23930333</pub-id></element-citation></ref><ref id="CR25"><label>25.</label><element-citation publication-type="journal"><person-group person-group-type="author"><name><surname>Kelly</surname><given-names>JD</given-names></name><name><surname>Hartman</surname><given-names>C</given-names></name><name><surname>Graham</surname><given-names>J</given-names></name><name><surname>Kallen</surname><given-names>MA</given-names></name><name><surname>Giordano</surname><given-names>TP</given-names></name></person-group><article-title>Social support as a predictor of early diagnosis, linkage, retention, and adherence to HIV care: results from the steps study</article-title><source>J Assoc Nurses AIDS Care</source><year>2014</year><volume>25</volume><issue>5</issue><fpage>405</fpage><lpage>413</lpage><pub-id pub-id-type="doi">10.1016/j.jana.2013.12.002</pub-id><pub-id pub-id-type="pmid">24508174</pub-id></element-citation></ref><ref id="CR26"><label>26.</label><element-citation publication-type="journal"><person-group person-group-type="author"><name><surname>Medley</surname><given-names>AA</given-names></name><etal></etal></person-group><article-title>Early uptake of HIV clinical care after testing HIV-positive during home-based testing and counseling in western Kenya</article-title><source>Curr HIV/AIDS Rep</source><year>2011</year><volume>8</volume><issue>3</issue><fpage>172</fpage><lpage>180</lpage><pub-id pub-id-type="doi">10.1007/s11904-011-0088-2</pub-id><pub-id pub-id-type="pmid">21713433</pub-id></element-citation></ref><ref id="CR27"><label>27.</label><element-citation publication-type="journal"><person-group person-group-type="author"><name><surname>Jenness</surname><given-names>SM</given-names></name><etal></etal></person-group><article-title>Delayed entry into HIV medical care after HIV diagnosis: Risk factors and research methods</article-title><source>AIDS Care</source><year>2012</year><volume>24</volume><issue>10</issue><fpage>1240</fpage><lpage>1248</lpage><pub-id pub-id-type="doi">10.1080/09540121.2012.656569</pub-id><pub-id pub-id-type="pmid">22316090</pub-id></element-citation></ref><ref id="CR28"><label>28.</label><element-citation publication-type="journal"><person-group person-group-type="author"><name><surname>Getnet</surname><given-names>MK</given-names></name><name><surname>Damen</surname><given-names>HM</given-names></name></person-group><article-title>Level of stigma among female sex workers: comparison of two surveys of HIV behavioral data, Ethiopia</article-title><source>Afr Health Sci</source><year>2011</year><volume>11</volume><issue>4</issue><fpage>543</fpage><lpage>549</lpage><pub-id pub-id-type="pmid">22649433</pub-id></element-citation></ref><ref id="CR29"><label>29.</label><element-citation publication-type="journal"><person-group person-group-type="author"><name><surname>Bonjour</surname><given-names>MA</given-names></name><name><surname>Montagne</surname><given-names>M</given-names></name><name><surname>Zambrano</surname><given-names>M</given-names></name><name><surname>Molina</surname><given-names>G</given-names></name><name><surname>Lippuner</surname><given-names>C</given-names></name><name><surname>Wadskier</surname><given-names>FG</given-names></name><etal></etal></person-group><article-title>Determinants of late disease-stage presentation at diagnosis of HIV infection in Venezuela: a case–case comparison</article-title><source>AIDS Res Ther</source><year>2008</year><volume>5</volume><fpage>6</fpage><pub-id pub-id-type="doi">10.1186/1742-6405-5-6</pub-id><pub-id pub-id-type="pmid">18416849</pub-id></element-citation></ref><ref id="CR30"><label>30.</label><element-citation publication-type="journal"><person-group person-group-type="author"><name><surname>Sidibé</surname><given-names>M</given-names></name><name><surname>Goosby</surname><given-names>EP</given-names></name></person-group><article-title>Global action to reduce HIV stigma and discrimination</article-title><source>J Int AIDS Soc</source><year>2013</year><volume>16</volume><issue>3Suppl 2</issue><fpage>18893</fpage><pub-id pub-id-type="pmid">24242270</pub-id></element-citation></ref><ref id="CR31"><label>31.</label><element-citation publication-type="journal"><person-group person-group-type="author"><name><surname>Alemu</surname><given-names>T</given-names></name><etal></etal></person-group><article-title>Experience of stigma and discrimination and the implications for healthcare seeking behavior among people living with HIV/AIDS in resource-limited setting</article-title><source>SAHARA J</source><year>2013</year><volume>10</volume><issue>1</issue><fpage>1</fpage><lpage>7</lpage><pub-id pub-id-type="doi">10.1080/17290376.2013.806645</pub-id><pub-id pub-id-type="pmid">23721543</pub-id></element-citation></ref><ref id="CR32"><label>32.</label><element-citation publication-type="journal"><person-group person-group-type="author"><name><surname>Govindasamy</surname><given-names>D</given-names></name><name><surname>Ford</surname><given-names>N</given-names></name><name><surname>Kranzer</surname><given-names>K</given-names></name></person-group><article-title>Risk factors, barriers and facilitators for linkage to antiretroviral therapy care: a systematic review</article-title><source>AIDS</source><year>2012</year><volume>26</volume><issue>16</issue><fpage>2059</fpage><lpage>2067</lpage><pub-id pub-id-type="doi">10.1097/QAD.0b013e3283578b9b</pub-id><pub-id pub-id-type="pmid">22781227</pub-id></element-citation></ref><ref id="CR33"><label>33.</label><mixed-citation publication-type="other">Seyoum E, et al. ART scale-up in Ethiopia: success and challenges; 2009.</mixed-citation></ref><ref id="CR34"><label>34.</label><element-citation publication-type="journal"><person-group person-group-type="author"><name><surname>Waters</surname><given-names>L</given-names></name><name><surname>Sabin</surname><given-names>CA</given-names></name></person-group><article-title>Late HIV presentation: epidemiology, clinical implications and management</article-title><source>Expert Rev Anti Infect Ther</source><year>2011</year><volume>9</volume><issue>10</issue><fpage>877</fpage><lpage>889</lpage><pub-id pub-id-type="doi">10.1586/eri.11.106</pub-id><pub-id pub-id-type="pmid">21973300</pub-id></element-citation></ref><ref id="CR35"><label>35.</label><element-citation publication-type="journal"><person-group person-group-type="author"><name><surname>Makasi</surname><given-names>T</given-names></name><name><surname>Modiba</surname><given-names>L</given-names></name></person-group><article-title>Factors associated with delayed entry into HIV medical care among HIV positive people who are aware of their status in Bulawayo, Zimbabwe</article-title><source>Online J Med Med Sci Res</source><year>2012</year><volume>1</volume><issue>4</issue><fpage>55</fpage><lpage>62</lpage></element-citation></ref></ref-list></back></pmc></record>Pour manipuler ce document sous Unix (Dilib)
EXPLOR_STEP=$WICRI_ROOT/Wicri/Sante/explor/SidaSubSaharaV1/Data/Pmc/Corpus
HfdSelect -h $EXPLOR_STEP/biblio.hfd -nk 0005440 | SxmlIndent | more
Ou
HfdSelect -h $EXPLOR_AREA/Data/Pmc/Corpus/biblio.hfd -nk 0005440 | SxmlIndent | more
Pour mettre un lien sur cette page dans le réseau Wicri
{{Explor lien
|wiki= Wicri/Sante
|area= SidaSubSaharaV1
|flux= Pmc
|étape= Corpus
|type= RBID
|clé=
|texte=
}}
| This area was generated with Dilib version V0.6.32. |  |