Missed Opportunities for HIV Testing and Late-Stage Diagnosis among HIV-Infected Patients in Uganda Rhoda K. Wanyenze 1 *, Moses R. Kamya 2 , Robin Fatch 3 , Harriet Mayanja-Kizza 2 , Steven Baveewo 2 , Sharif Sawires 4 , David R. Bangsberg 5 , Thomas Coates 4 , Judith A. Hahn 3 1 Department of Disease Control and Environmental Health, Makerere University School of Public Health, Kampala, Uganda, 2 Department of Medicine, Makerere University School of Medicine, Kampala, Uganda, 3 Department of Medicine, San Francisco General Hospital, University of California San Francisco, San Francisco, California, United States of America, 4 Division of Infectious Diseases, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, California, United States of America, 5 Massachusetts General Hospital Center for Global Health and Harvard Medical School, Boston, Massachusetts, United States of America Abstract Background: Late diagnosis of HIV infection is a major challenge to the scale-up of HIV prevention and treatment. In 2005 Uganda adopted provider-initiated HIV testing in the health care setting to ensure earlier HIV diagnosis and linkage to care. We provided HIV testing to patients at Mulago hospital in Uganda, and performed CD4 tests to assess disease stage at diagnosis. Methods: Patients who had never tested for HIV or tested negative over one year prior to recruitment were enrolled between May 2008 and March 2010. Participants who tested HIV positive had a blood draw for CD4. Late HIV diagnosis was defined as CD4#250 cells/mm. Predictors of late HIV diagnosis were analyzed using multi-variable logistic regression. Results: Of 1966 participants, 616 (31.3%) were HIV infected; 47.6% of these (291) had CD4 counts #250. Overall, 66.7% (408) of the HIV infected participants had never received care in a medical clinic. Receiving care in a non-medical setting (home, traditional healer and drug stores) had a threefold increase in the odds of late diagnosis (OR = 3.2; 95%CI: 2.1–4.9) compared to receiving no health care. Conclusions: Late HIV diagnosis remains prevalent five years after introducing provider-initiated HIV testing in Uganda. Many individuals diagnosed with advanced HIV did not have prior exposure to medical clinics and could not have benefitted from the expansion of provider initiated HIV testing within health facilities. In addition to provider-initiated testing, approaches that reach individuals using non-hospital based encounters should be expanded to ensure early HIV diagnosis. Citation: Wanyenze RK, Kamya MR, Fatch R, Mayanja-Kizza H, Baveewo S, et al. (2011) Missed Opportunities for HIV Testing and Late-Stage Diagnosis among HIV- Infected Patients in Uganda. PLoS ONE 6(7): e21794. doi:10.1371/journal.pone.0021794 Editor: Landon Myer, University of Cape Town, South Africa Received November 25, 2010; Accepted June 11, 2011; Published July 5, 2011 Copyright: ß 2011 Wanyenze et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. Funding: This study was funded by National Institute of Mental Health (1 R01 MH077512), Division of AIDS and Health and Behavior Research, Center for Mental Health Research on AIDS. The funders had no role in the study design, data collection and analysis, decision to publish, or preparation of the manuscript. Competing Interests: The authors have declared that no competing interests exist. * E-mail: rwanyenze@hotmail.com Introduction Early diagnosis of HIV infection is critical for improvement of HIV treatment outcomes [1–4]. Early diagnosis and treatment also reduces the cost of medical care [5]. Additionally, studies have suggested that early initiation of HIV treatment may have important prevention benefits [6–8]. As such, the recent World Health Organization (WHO) treatment guidelines recommend initiation of HIV treatment at CD4#350, and several countries have adopted these new guidelines [9,10]. However, treatment of all individuals with CD4#350 will require earlier diagnosis of HIV infection. There has been a drive to scale-up HIV Counseling and Testing (HCT) services in order to ensure early diagnosis and access to HIV services including care and treatment as well as prevention [11]. Increased access to HIV services is important for the attainment of the Millennium Development Goals for HIV as well as maternal and child health in sub-Saharan Africa [12]. Recent reports show improvement in access to HCT, yet over 60% of infected individuals globally remain unaware of their sero-status [11]. In 2005, it was estimated that 80% of HIV infected individuals in Uganda were unaware of their HIV status [13]. Research studies also reported late diagnosis and treatment of HIV infected individuals [14]. Late initiation of HIV treatment in sub-Saharan Africa has been associated with limited access to treatment but could also be attributed to delays in diagnosis of HIV infection and to delayed linkage to care after diagnosis [14,15]. In an effort to scale-up access to HIV testing and linkage to care many countries have adopted new HCT approaches, including provider-initiated HIV testing and counseling (PITC) in the health care setting and home based HIV counseling and testing (HBHCT) [11,16,17]. In 2005, Uganda revised its HCT policy to include PITC and HBHCT [18]. The proportion of individuals who have tested and received HIV results in Uganda has increased over time; estimated at 10% in 2003, 23% in 2006, and 38% in PLoS ONE | www.plosone.org 1 July 2011 | Volume 6 | Issue 7 | e21794