Risk Factors for Late-Stage HIV Disease Presentation at Initial HIV Diagnosis in Durban, South Africa

PLOS ONE, Jan 2013

Background After observing persistently low CD4 counts at initial HIV diagnosis in South Africa, we sought to determine risk factors for late-stage HIV disease presentation among adults. Methods We surveyed adults prior to HIV testing at four outpatient clinics in Durban from August 2010 to November 2011. All HIV-infected adults were offered CD4 testing, and late-stage HIV disease was defined as a CD4 count <100 cells/mm3. We used multivariate regression models to determine the effects of sex, emotional health, social support, distance from clinic, employment, perceived barriers to receiving healthcare, and foregoing healthcare to use money for food, clothing, or housing (“competing needs to healthcare”) on presentation with late-stage HIV disease. Results Among 3,669 adults screened, 830 were enrolled, newly-diagnosed with HIV and obtained a CD4 result. Among those, 279 (33.6%) presented with late-stage HIV disease. In multivariate analyses, participants who lived ≥5 kilometers from the test site [adjusted odds ratio (AOR) 2.8, 95% CI 1.7–4.7], reported competing needs to healthcare (AOR 1.7, 95% CI 1.2–2.4), were male (AOR 1.7, 95% CI 1.2–2.3), worked outside the home (AOR 1.5, 95% CI 1.1–2.1), perceived health service delivery barriers (AOR 1.5, 95% CI 1.1–2.1), and/or had poor emotional health (AOR 1.4, 95% CI 1.0–1.9) had higher odds of late-stage HIV disease presentation. Conclusions Independent risk factors for late-stage HIV disease presentation were from diverse domains, including geographic, economic, demographic, social, and psychosocial. These findings can inform various interventions, such as mobile testing or financial assistance, to reduce the risk of presentation with late-stage HIV disease.

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Risk Factors for Late-Stage HIV Disease Presentation at Initial HIV Diagnosis in Durban, South Africa

South Africa. PLoS ONE 8(1): e55305. doi:10.1371/journal.pone.0055305 Risk Factors for Late-Stage HIV Disease Presentation at Initial HIV Diagnosis in Durban, South Africa Paul K. Drain 0 Elena Losina 0 Gary Parker 0 Janet Giddy 0 Douglas Ross 0 Jeffrey N. Katz 0 Sharon M. Coleman 0 Laura M. Bogart 0 Kenneth A. Freedberg 0 Rochelle P. Walensky 0 Ingrid V. Bassett 0 Julian W. Tang, Alberta Provincial Laboratory for Public Health/ University of Alberta, Canada 0 1 Division of Infectious Diseases, Massachusetts General Hospital , Boston , Massachusetts, United States of America, 2 Division of General Medicine, Massachusetts General Hospital , Boston , Massachusetts, United States of America, 3 Medical Practice Evaluation Center, Massachusetts General Hospital , Boston , Massachusetts, United States of America, 4 Department of Medicine, Brigham and Women's Hospital , Boston , Massachusetts, United States of America, 5 Department of Orthopedic Surgery, Brigham and Women's Hospital , Boston , Massachusetts, United States of America, 6 Division of Rheumatology, Brigham and Women's Hospital , Boston , Massachusetts, United States of America, 7 Center for AIDS Research, Harvard Medical School , Boston , Massachusetts, United States of America, 8 Department of Pediatrics, Harvard Medical School , Boston , Massachusetts, United States of America, 9 Departments of Epidemiology and Health Policy and Management, Harvard School of Public Health, Boston, Massachusetts, United States of America, 10 Department of Biostatistics, Boston University School of Public Health, Boston, Massachusetts, United States of America, 11 Department of Epidemiology, Boston University School of Public Health, Boston, Massachusetts, United States of America, 12 Data Coordinating Center, Boston University School of Public Health, Boston, Massachusetts, United States of America, 13 Boston Children's Hospital , Boston , Massachusetts, United States of America, 14 Department of Medicine, McCord Hospital , Durban , South Africa , 15 Department of Medicine, St. Mary's Hospital , Durban , South Africa Background: After observing persistently low CD4 counts at initial HIV diagnosis in South Africa, we sought to determine risk factors for late-stage HIV disease presentation among adults. Methods: We surveyed adults prior to HIV testing at four outpatient clinics in Durban from August 2010 to November 2011. 3 All HIV-infected adults were offered CD4 testing, and late-stage HIV disease was defined as a CD4 count ,100 cells/mm . We used multivariate regression models to determine the effects of sex, emotional health, social support, distance from clinic, employment, perceived barriers to receiving healthcare, and foregoing healthcare to use money for food, clothing, or housing (''competing needs to healthcare'') on presentation with late-stage HIV disease. Results: Among 3,669 adults screened, 830 were enrolled, newly-diagnosed with HIV and obtained a CD4 result. Among those, 279 (33.6%) presented with late-stage HIV disease. In multivariate analyses, participants who lived $5 kilometers from the test site [adjusted odds ratio (AOR) 2.8, 95% CI 1.7-4.7], reported competing needs to healthcare (AOR 1.7, 95% CI 1.2-2.4), were male (AOR 1.7, 95% CI 1.2-2.3), worked outside the home (AOR 1.5, 95% CI 1.1-2.1), perceived health service delivery barriers (AOR 1.5, 95% CI 1.1-2.1), and/or had poor emotional health (AOR 1.4, 95% CI 1.0-1.9) had higher odds of late-stage HIV disease presentation. Conclusions: Independent risk factors for late-stage HIV disease presentation were from diverse domains, including geographic, economic, demographic, social, and psychosocial. These findings can inform various interventions, such as mobile testing or financial assistance, to reduce the risk of presentation with late-stage HIV disease. - Funding: This research was supported by the Harvard Institute for Global Health (PKD); the Fogarty International Clinical Research Scholars and Fellows Program at Vanderbilt University R24 TW007988 (PKD); the National Institute of Mental Health R01 MH090326 (IVB) and R01 MH073445 (RPW); the National Institute of Allergy and Infectious Disease K24 AI062476 (KAF); the Harvard University Center for AIDS Research P30 AI060354; the National Institute of Arthritis and Musculoskeletal and Skin Diseases K24 AR057827 (EL); the National Center for Research Resources (the Harvard Catalyst UL1 RR 025758); the Burke Global Health Fellowship (IVB); and the Claflin Distinguished Scholar Award (IVB). The funders had no role in 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. South Africa has more HIV-infected people than any other country, and over 1.4 million South Africans are now receiving antiretroviral therapy (ART) [1,2]. However, despite this progress, 4551% of ART-eligible people are still not receiving treatment [1,3]. Not only do these HIV-infected people constitute nearly one-quarter of all AIDS-related deaths in sub-Saharan Africa, but they also transmit HIV to others [1]. Furthermore, late-stage HIV disease at initial HIV diagnosis has been associated with poor treatment response rates and higher mortality [411]. In August 2011, the South African Department of Health increased the ART initiation threshold from CD4,200 to ,350 cells/mm3 to help reduce AIDS-related deaths [12]. However, the median CD4 Demographics Age $40 years 249 (30.0) Age ,40 years 581 (70.0) Male 415 (50.0) Female 415 (50.0) Education Did not complete high school 449 (54.1) Did complete high school 381 (45.9) Marital Status Never married 666 (80.2) Currently married 123 (14.8) Divorced/separated 13 (1.6) Widowed 28 (3.4) If not married, in current relationship? No 226 (32.0) Yes, ,6 months 84 (11.9) Yes, $6 months 397 (56.2) Employment Currently working outside home 469 (56.5) Not currently working outside home 361 (43.5) Working ,20 hours outside home 32 (6.8) Working $20 hours outside home 437 (93.2) Proximity to the HIV Clinic Distance to clinic $5 kilometers 688 (82.9) Distance to clinic ,5 kilometers 142 (17.1) Travel time to clinic $30 minutes 303 (36.5) Travel time to clinic ,30 minutes 527 (63.5) Health Care Usage No prior HIV testing 661 (79.7) Any prior HIV testing 168 (20.3) Any overnight hospital stay in last year 60 (7.2) No overnight hospital stay in last year 770 (92.8) Emotional Health and Social Support Poor Emotional Health (, median value) 399 (48.1) Good Emotional Health ($ median value) 431 (51.9) Poor Social Support (, median value) 416 (50.1) Good Social Support ($ median value) 414 (49.9) Competing Needs to Healthcare Gone without healthcare because needed 227 (27.3) money for food, clothing, or housing Never gone without healthcare because needed 603 (72.6) money for food, clothing, or housing Foregone food, clothing, or housing because 196 (23.6) needed money for healthcare Never foregone food, clothing, or housing 634 (76.4) because needed money for healthcare Study Site McCord Hospital 437 (52.7) St. Marys Hospital count at the time of ART initiation was 111 cells/mm3 in a recent large South African cohort [4]. Increasing the CD4 count treatment threshold will have little benefit if the majority of people continue to present with dangerously low CD4 counts and late-stage HIV disease. Strategies to reduce AIDS-related mortality and decrease HIV transmission must include earlier diagnosis of HIV [13], which has been shown to improve survival [14]. Intensified efforts to promote early diagnosis of HIV-infected people in resource-limited settings are needed, but little is known about how to best target people in HIV testing campaigns [15,16]. We conducted a large, prospective study to assess both the real and perceived barriers to presenting for HIV care in South Africa. Sites and participants We studied adults who presented for voluntary HIV counseling and testing at four outpatient clinical sites in Durban from August 2010 to November 2011. McCord Hospital is an urban, stateaided general hospital that serves the greater Durban area. St. Marys Hospital in Mariannhill is a state-aided general hospital that serves a resource-limited population in a peri-urban area of Durban. Both McCord Hospital and St. Marys Hospital have high-volume outpatient HIV clinics that have been providing ART since 2001 and 2003, respectively, and receiving Presidents Emergency Plan for AIDS Relief (PEPFAR) support since 2004. The other two sites, Tshelimnyama and Marianridge, are municipal primary health clinics located within the catchment Have to wait too long to see the nurse/doctor 261 (31.4) Could not afford medications Could not afford the cost of transportation Could not arrange transport to the clinic Could not get time off work Did not know where to find care Had to take care of someone else The nurse/doctor does not speak my language 71 (8.6) Were not treated with respect by the nurse/doctor area of St. Marys Hospital. Throughout the course of the study, all four outpatient sites offered free HIV counseling and testing during normal working business hours. We offered enrollment to all adults $18 years of age prior to HIV counseling and testing. We excluded those already known to be HIV-infected, pregnant, or unwilling to share their HIV test result with the research team. HIV testing, as well as participation in the study, carried no financial costs to the participant. All participants provided written informed consent either in English or Zulu. The study was approved by the ethics committees of McCord Hospital and St. Marys Hospital in Durban, and Partners HealthCare (Protocol #: 2006-P-001379) in Boston. Data collection We asked participants about personal demographics, proximity to the HIV clinic, and prior healthcare usage and HIV testing. We recorded responses to 12 questions related to perceived personal barriers for seeking HIV testing and medical care during the prior 6 months [17]. We asked 5 questions about emotional health over the previous month with each response rated on a 6-point Likert scale (ranging from 1 being all of the time or always to 6 being none of the time or never). These questions, which were adapted from the 5-item Mental Health Inventory (MHI-5) screening test, were used to calculate a mental health composite (MHC) score [18]. We asked 13 questions about availability of personal social support with each response rated on a 5-point Likert scale (ranging from 1 being none of the time to 5 being all of the time). These questions incorporate four social support scales (emotional/informational, tangible, positive interaction, affectionate), and were used to calculate the Social Support Index (SSI), from the Medical Outcomes Study [19]. Both the MHC and SSI scores were independently averaged and then transformed to scores ranging from 1 to 100, with higher numbers signifying better emotional health and more social support. We asked participants if they had gone without food, clothing, or housing (basic necessities) during the prior 6 months because they needed money for healthcare, or if they had foregone healthcare during the prior 6 months because they needed money for food, clothing, or housing [20]. After completing the survey, participants were offered free HIV counseling and testing, and HIV-infected participants were offered free CD4 count testing. Those who tested positive for HIV were referred for appropriate care and treatment. All HIV testing, care, and treatment was provided in accordance with current South African Department of Health HIV testing and treatment guidelines [3]. Statistical analyses Late-stage HIV disease presentation was defined as a CD4 count ,100 cells/mm3 at the time of initial HIV diagnosis. To allow incorporation of the perceived barriers into multivariate models, while also minimizing possible collinearity, we categorized the 12 barriers into 5 groups (service delivery, financial, personal health perception, logistical, and structural). Service delivery barriers included have to wait too long to see the nurse/doctor, the nurse/doctor does not speak my language, and not treated with respect by the nurse/doctor. Financial barriers included could not afford medications and could not afford the cost of transportation. Personal health perception barriers included didnt think it was necessary, because didnt feel sick and felt too sick. Logistical barriers included could not get time off work and had to take care of someone else. Structural barriers included could not get to the clinic during the hours it was open, could not arrange transport to the clinic, and did not know where to find care. Poor emotional health and poor social support were defined as an MHC and SSI score below the median value, respectively. We used Chi-squared and Fishers Exact tests to compare potential risk factors between those presenting with and without late-stage HIV disease. We used an iterative model building approach to construct a series of logistic regression models to identify factors associated with late-stage disease presentation. First, we used bivariate logistic regression models to determine odds ratios (OR) of presenting with late-stage HIV disease. To ,0.001 0.432 0.003 ,0.001 0.049 0.049 0.060 Adjusted Odds Ratio (95% CI) Odds Ratio (95% CI) 0.019 ,0.001 0.084 N Living .5 kilometers from the test site N Reported competing needs to healthcare N Worked outside the home N Perceived health service delivery barrier N Poor emotional health build a multivariate logistic regression model and generate adjusted odds ratios (AOR), we included age, sex, and any variable with a p-value ,0.15 in bivariate analyses into a single model. We then removed one variable at a time for those variables with a p-value .0.15, and after each variable was removed, the model was refit to evaluate the remaining variables. Finally, variables not selected based on the initial unadjusted analyses were included in the multivariate model to assess their significance in the presence of other variables, and all variables were retained if they had p-values ,0.15. To minimize the potential for collinearity, we assessed the correlation between all pairs of independent variables and verified that no pair of variables included in the same regression model was highly correlated with a Spearman r .0.60. All reported p-values were two-tailed, and a pvalue ,0.05 was considered statistically significant. We conducted analyses using SAS software (version 9.2; SAS Institute, Cary, NC). Cohort characteristics Among 3,669 people screened for the study, 2,694 met eligibility criteria and enrolled in the study. Among those enrolled, 1,026 (38.1%) tested positive for HIV, of which 830 adults (80.9% of HIV-infected participants) completed both CD4 testing and the study survey. Among those, the median CD4 count was 186 cells/ mm3 (interquartile range 70345 cells/mm3), and 279 (33.6%) participants had late-stage HIV disease at the time of their initial HIV diagnosis. Within the cohort, 249 (30.0%) were .40 years of age, 415 (50.0%) were male, and 449 (54.1%) had not completed high school (Table 1). Over half (56.5%) worked outside the home, and 688 (82.9%) participants reported living $5 kilometers from the clinic. Most participants (79.7%) had never previously been tested for HIV, including 54 of the 60 participants (90.0%) who had spent an overnight in a hospital during the prior year. Reported HIV testing of participants hospitalized during the prior year (6/60 or 10.0%) was significantly lower than the reported HIV testing among participants who had not been hospitalized during the prior year (162/769 or 21.1%) (p = 0.04). Competing needs to healthcare Overall, 227 (27.3%) participants had ever gone without healthcare because they needed money for basic necessities (food, clothing, or housing). In bivariate analysis, this was more common among those presenting with late-stage HIV disease (p = 0.02). Participants who presented with late-stage disease were also more likely to have gone without healthcare to pay for food (23.3% vs. 16.3%, p = 0.02), housing (22.5% vs. 15.6%, p = 0.04), N Provide mobile HIV testing services N Provide financial assistance to those at risk N Offer periodic HIV screening at employment and business locations N Expand clinic HIV testing hours to include nights and weekends N Provide travel vouchers to those presenting for HIV testing N Increase depression screening in the community N Strengthen integration of mental health services into primary health care and food and housing (13.3% vs. 7.6%, p = 0.009) (Figure 1, top). Similarly, 196 participants (23.6%) had ever foregone basic necessities because they needed money for healthcare. Participants who presented with late-stage disease were more likely to have foregone housing (18.6% vs. 13.2%, p = 0.04), and food and housing (10.8% vs. 6.4%, p = 0.03) to pay for healthcare (Figure 1, bottom). Perceived barriers to medical care The most commonly reported perceived barriers to medical care were have to wait too long to see the nurse or doctor (31.4%), could not afford medications (26.0%), and didnt think it was necessary, because didnt feel sick (24.7%) (Table 2). Participants who reported a perceived barrier of felt too sick had a 2.97-fold higher odds (95% CI 2.004.41) of late-stage HIV disease presentation. Perceived barriers of could not afford the cost of transportation (OR 1.80, 95% CI 1.292.29), could not afford medications (OR 1.79, 95% CI 1.302.46), could not arrange transport to the clinic (OR 1.71, 95% CI 1.20 2.43), have to wait too long to see the nurse/doctor (OR 1.49, 95% CI 1.102.02), and could not get to the clinic during the hours it was open (OR 1.46, 95% CI 1.042.05) were also more commonly reported among those presenting with late-stage HIV disease. Factors associated with late-stage HIV disease presentation In the multivariate logistic regression model (Table 3), factors associated with presentation to care with late-stage HIV disease were living $5 kilometers from the clinic, having gone without healthcare because money was needed for basic necessities, being male, working outside the home, having a perception of health service delivery barriers, and poor emotional health. Living $5 kilometers from the clinic conferred a 2.80-fold (95% CI 1.684.67) higher odds of presenting with late-stage HIV disease. Having gone without healthcare because money was needed for basic necessities (AOR 1.67, 95% CI 1.172.37), being male (AOR 1.66, 95% CI 1.222.26), and working outside the home (AOR 1.48, 95% CI 1.072.05) had higher odds of late-stage HIV disease presentation. Among the categories of perceived barriers to medical care, only a perception of barriers related to health service delivery (AOR 1.48, 95% CI 1.072.05), which included have to wait too long to see the nurse/doctor, was significantly associated with late-stage HIV disease presentation in multivariate analyses. Finally, while both poor emotional health and poor social support were significant in bivariate analyses, only poor emotional health (AOR 1.41, 95% CI 1.031.94) was significant in the multivariate model. As both guidelines and data increasingly support earlier HIV treatment, it is imperative to understand why patients continue to present with advanced HIV. In a large cohort of outpatient clinic attendees newly diagnosed with HIV in South Africa, the main risk factors for presenting with late-stage HIV disease were living further from the clinic, being male, and having gone without healthcare to pay for basic living necessities. Other variables associated with late-stage disease presentation were working outside the home, having a perception of barriers to health service delivery, such as long wait times, and having poor emotional health. These findings provide focused targets for improving HIV testing programs in order to diagnose people earlier and reduce the number of adults presenting to care with late-stage HIV disease. Several studies have examined risk factors for late-stage disease presentation in sub-Saharan Africa. In Uganda, studies by Kigozi et al. and Wanyenze et al. found significant risk factors were being male, older, and having no secondary education, similar to our findings [21,22]. They additionally found that people receiving healthcare in a non-medical setting (pharmacy, home, or by traditional healer) or having many sexual partners, both of which were variables we did not obtain, were more likely to present with late-stage disease. In Ethiopia, which has a very different cultural population than South Africa, non-pregnant women, frequent alcohol users, those in a long-term relationship, and people who perceived ART to have many side effects or HIV as a stigmatizing disease were more likely to present with late-stage disease [23]. In our cohort, relationships longer than 6 months had no impact on late-stage presentation, and we did not assess alcohol use or perception of HIV as a stigmatizing disease. The current study is unique from these previous studies by assessing distance to the clinic, perceived barriers to healthcare, competing needs to healthcare, and emotional health and social support structures, before participants were aware of their HIV-infected status. In our cohort, several structural barriers, such as longer distance to the clinic, a perception of poor service delivery, and working outside the home, were among the strongest risk factors for latestage HIV disease. Other studies in Africa have shown similar structural barriers, such as longer distances and higher transportation costs, to be related to loss-to-care before ART initiation [2428]. One potential approach to ensuring better service delivery and earlier HIV diagnosis could be the use of active, mobile HIV testing strategies [2931]. Despite the frequent occurrence of late-stage HIV disease presentation in sub-Saharan Africa, there has been an incomplete and inconsistent understanding of the perceived personal barriers to HIV testing [32]. In Botswana, perceived barriers to HIV testing included fear of learning ones status, lack of perceived HIV risk, and fear of having to change sexual practices if positive [33]. In Ethiopia, a perception of HIV as a highly stigmatizing disease was common among people who presented with late-stage disease [23]. Although we did not assess HIV-related stigma, our findings indicate that a perception of service delivery, structural, or financial barriers are obstacles that prevented people from learning their HIV-infected status. Over one-quarter of those in our cohort reported having gone without healthcare because they needed money for basic necessities, and they were more likely to present with late-stage disease. In several sub-Saharan African studies, food insecurity has been associated with poor ART adherence, more opportunistic infections, missed clinic visits, and increased hospitalizations [34 36]. Food insecurity is more common among older, unmarried, HIV-infected adults [34], and thus food insecurity should be addressed as part of comprehensive HIV treatment programs in resource-limited settings [37]. While our findings support the observed negative effects of food insecurity, our results suggest that housing insecurity is also a common problem and associated with late-stage HIV disease presentation. We found that poor emotional health and social support, both of which were assessed before HIV testing, were associated with a higher likelihood of presentation with late-stage HIV. Depression is common among HIV-infected adults [38,39], and mental health problems are vastly undertreated in resource-poor settings [40,41]. Rates of depression are also higher in symptomatic HIV-infected people [42]. While little data exists on outcomes among HIVinfected adults with mental health issues in developing countries, one U.S.-based study found higher rates of mortality among HIVinfected adults with depression [43]. Studies from Uganda and Ethiopia have reported conflicting results about whether poor mental health influences ART adherence [44,45]. While evidence has been lacking on the association between mental health disorders and uptake of diagnostic and treatment services for HIV [40], our findings suggest that mental health issues and poor social support structures may be important risk factors for delayed HIV testing. In our study, which excluded known HIV-infected adults, the 60 participants who had been hospitalized during the prior year represented important missed opportunities for HIV testing. Surprisingly, self-reported prior HIV testing was less common among those who had been hospitalized, since South African guidelines recommend offering HIV testing to all clients attending health-care facilities as a standard component of medical care, unless the client actively refuses [46]. Our finding suggests that either providers were not adherent to national guidelines or hospitalized patients refused HIV testing at very high rates (90%). Regardless, those missed opportunities represented 7.2% of our cohort, suggesting that HIV testing of hospitalized patients remains suboptimal. Our findings were primarily limited by the accuracy of selfreported survey data. In this cross-sectional survey, we were not able to determine causality with associations and the analysis was not designed to fully examine the social stigma of HIV as a barrier to testing. We used a definition of late-stage HIV disease of CD4,100 cells/mm3, which portends a major risk for cryptococcal meningitis, a leading cause of AIDS-related deaths in subSaharan Africa [47]. This definition allowed us to identify risk factors and perceived barriers among the people with the greatest risk for severe opportunistic infections and mortality. While we did not assess some variables shown to be associated with late-stage presentation in other African studies (alcohol consumption, number of sexual partners, or ownership of material goods), we examined many important measures not studied in other studies of late-stage HIV disease presentation in sub-Saharan Africa. Finally, a small number of HIV-infected participants either did not fully complete our survey or agree to CD4 count testing, so we cannot assess their influence on our findings. In conclusion, we found independent risk factors for presentation with late-stage HIV disease from diverse domains, including geographic, economic, demographic, social, and psychosocial. These can directly inform efforts to improve HIV testing. Such efforts should focus on various interventions, such as the use of active mobile testing strategies, financial assistance, or providing food supplementation, to reduce late-stage disease presentation in resource-poor settings (Table 4). Simply expanding HIV testing will not ensure ART-eligible people are enrolled in care or initiated on ART; innovative approaches are also needed to improve subsequent linkage to treatment [48,49]. Providing increased and targeted HIV testing to those at greatest risk for late-stage HIV disease, and subsequently linking them to HIV care should reduce AIDS-related morbidity and mortality. Acknowledgments We would like to acknowledge the excellent work and valuable contributions of our research staff and nurses. We thank each of the clinical sites for sharing their enthusiasm and space. We thank The U.S. Presidents Plan for AIDS Relief (PEPFAR), which provided funding for HIV care and services, including ART, for the participants in our study. Finally, we graciously thank all of the men and women who participated in this study. Conceived and designed the experiments: PKD EL JG DR JNK KAF RPW IVB. Performed the experiments: PKD GP JG DR IVB. 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Paul K. Drain, Elena Losina, Gary Parker, Janet Giddy, Douglas Ross, Jeffrey N. Katz, Sharon M. Coleman, Laura M. Bogart, Kenneth A. Freedberg, Rochelle P. Walensky, Ingrid V. Bassett. Risk Factors for Late-Stage HIV Disease Presentation at Initial HIV Diagnosis in Durban, South Africa, PLOS ONE, 2013, DOI: 10.1371/journal.pone.0055305