Time to Initiation of Antiretroviral Therapy Among Patients Who Are ART Eligible in Rwanda

BACKGROUND: Delayed initiation of antiretroviral therapy (ART) in eligible patients is a concern in resource-limited countries. METHODS: We analyzed data on HIV-positive patients >/=15 years enrolled at 41 ICAP-supported health care facilities in Rwanda 2005-2010 to determine time to ART initiation among patients eligible at enrollment compared with those ineligible or of indeterminate eligibility who become eligible during follow-up. ART eligibility was based on CD4 cell count (CD4) and WHO staging; patients lacking CD4 and WHO stage were considered indeterminate. Cumulative incidence of reaching ART eligibility and to ART initiation after eligibility was generated using competing risk estimators. RESULTS: A total of 31033 ART-naive adults were enrolled; 64.2% were female. At enrollment 10158 (32.7%) patients were ART eligible 13372 (43.1%) were ineligible for ART and 7503 (24.2%) patients were indeterminate. Among patients retained in care pre-ART eligibility 17.9% [95% confidence interval (CI): 17.2 to 18.6] of ineligible and 22.8% (95% CI: 21.7 to 23.8) of indeterminate patients at enrollment reached ART eligibility within 12 months. Cumulative incidence of ART initiation within 3 months for patients eligible at enrollment was 77.2% (95% CI: 76.4 to 78.0) compared with 67.9% (95% CI: 66.4 to 69.3) for ineligible and 63.8% (95% CI: 61.9 to 65.8) for patients with indeterminate eligibility at enrollment (P < 0.05). Over the study period there was more rapid ART initiation for patients who became ART eligible. CONCLUSIONS: We found higher rates of ART initiation within 3 months among patients who were ART eligible at enrollment compared with those who reached eligibility during follow-up. From 2006 to 2011 earlier initiation of ART after eligibility was observed likely reflecting improved program quality.