Research
| Volume 8(1), Article 10, 17 Apr 2025
Sherifah Nabikande1, Juliana Namutundu1, Joanita Nangendo2, Steven Ndugwa Kabwama1, Anne Ruhweza Katahoire3
1School of Public Health, College of Health Sciences, Makerere University, Kampala, Uganda School of Medicine, 2School of Medicine, College of Health Sciences, Makerere University, Kampala, Uganda, 3Child Health and Development Centre, College of Health Sciences, Makerere University, Kampala, Uganda
&Corresponding author: Sherifah Nabikande, School of Public Health, College of Health Sciences, Makerere University, Kampala, Uganda School of Medicine, Email: nabikandesharifah@live.com
Received: 31 May 2024 – Accepted: 15 Apr 2025 – Published: 17 Apr 2025
Domain: HIV Epidemiology
Keywords: Delayed initiation, HIV care, men, factors associated
©Sherifah Nabikande et al Journal of Interventional Epidemiology and Public Health (ISSN: 2664-2824). This is an Open Access article distributed under the terms of the Creative Commons Attribution International 4.0 License (https://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
Cite this article: Sherifah Nabikande et al Prevalence and factors associated with late presentation for HIV care among adult men at a large HIV clinic in Eastern Uganda: A cross-sectional study. Journal of Interventional Epidemiology and Public Health. 2025;8(1):10. https://doi.org/10.37432/jieph.2025.8.2.170
Introduction: In Uganda, men diagnosed with HIV still present late for care. Understanding the drivers of late presentation among men is a critical step towards achieving the full potential of HIV treatment scale-up. This study aimed to determine the prevalence and factors associated with late presentation for HIV care among adult men in Jinja District, Eastern Uganda.
Methods: We conducted a cross-sectional study in Jinja District from October to November 2020. We defined late presentation for HIV/AIDS care as persons presenting for care with a CD4 cell count below 350 cells/μl or presenting with an AIDS defining event, regardless of the CD4 cell count. We used semi-structured questionnaires to interview 394 HIV positive adult men receiving care at Family Hope Centre, and reviewed patient files to collect data on baseline CD4 cell count. We used modified Poisson regression analysis to determine factors associated with late presentation for HIV care.
Results: The proportion of adult men who presented late for HIV care was 313/394 (79.4%), 95% CI: [0.754,0.834]. Men were less likely to present late for care if aged 25-34 years; [Adj. PR 0.13; 95%CI: 0.03-0.60], 35-49 years; [Adj. PR 0.47; 95%CI: 0.24-0.91] or had been supported by family; [Adj. PR 0.36; 95%CI: 0.18-0.73] compared to their counterparts.
Conclusion: This study highlights a notably high rate of late HIV care presentation among men in the facility’s catchment area. To address this issue, a comprehensive approach is necessary. Key strategies should include developing services specifically designed for young adults and those without familial support, as these groups are more likely to experience delays. Incorporating family counseling into treatment programs can provide crucial support for newly diagnosed individuals. Encouraging open conversations about HIV status and reshaping perceptions of masculinity to promote health-seeking behaviors will also help reduce stigma. Future research should focus on cultural and behavioral factors influencing delayed care, particularly among younger men and those without family support, while evaluating the effectiveness of specialized services in improving outcomes.
Late presentation for care among people living with HIV/AIDS remains a significant problem in Sub-Saharan Africa (SSA) with a prevalence of 35–89% [1] Belay GM, Endalamaw A, Ayele AD. Late presentation of HIV positive adults and its predictors to HIV/AIDS care in Ethiopia: a systematic review and meta-analysis. BMC Infect Dis [Internet]. 2019 Jun 17 [cited 2025 Apr 16];19(1):534. Available from: https://bmcinfectdis.biomedcentral.com/articles/10.1186/s12879-019-4156-3 https://doi.org/10.1186/s12879-019-4156-3 ,[2] Ingabire PM, Semitala F, Kamya MR, Nakanjako D. Delayed antiretroviral therapy (Art) initiation among hospitalized adults in a resource-limited settings: a challenge to the global target of art for 90 % of hiv-infected individuals. AIDS Research and Treatment [Internet]. 2019 Apr 1 [cited 2025 Apr 16];2019(1): 1832152. Available from: https://www.hindawi.com/journals/art/2019/1832152/ https://doi.org/10.1155/2019/1832152 and plays a major role in AIDS related in-hospital deaths of affected individuals [3] Bekker LG, Egger M, Wood R. Early antiretroviral therapy mortality in resource-limited settings: what can we do about it?: Current Opinion in HIV and AIDS [Internet]. 2007 Jul [cited 2025 Apr 16];2(4):346–51. Available from: http://journals.lww.com/01222929-200707000-00017 https://doi.org/10.1097/COH.0b013e3281e72cbd Subscription or purchase required to view full text . In South Africa and Kenya, 78% and 66% of patients were reported to present late with a CD4 count of ≤500 cells/mm³ [4] Fomundam HN, Tesfay AR, Mushipe SA, Mosina MB, Boshielo CT, Nyambi HT, Larsen A, Cheyip M, Getahun A, Pillay Y. Prevalence and predictors of late presentation for HIV care in South Africa. S Afr Med J [Internet]. 2017 Nov 27 [cited 2025 Apr 16];107(12):1058-64. Available from: http://www.samj.org.za/index.php/samj/article/view/12136 https://doi.org/10.7196/SAMJ.2017.v107i12.12358 and ≤350 cells/mm³ [5] Haskew J, Turner K, Rø G, Ho A, Kimanga D, Sharif S. Stage of HIV presentation at initial clinic visit following a community-based HIV testing campaign in rural Kenya. BMC Public Health [Internet]. 2015 Jan 21 [cited 2025 Apr 16];15(1):16. Available from: https://bmcpublichealth.biomedcentral.com/articles/10.1186/s12889-015-1367-4 https://doi.org/10.1186/s12889-015-1367-4 respectively. Ethiopian studies have reported 67% and 60% late presentation with CD4 counts <200 cells/mm³ [6] Gesesew HA, Ward P, Woldemichael K, Mwanri L. Late presentation for HIV care in Southwest Ethiopia in 2003–2015: prevalence, trend, outcomes and risk factors. BMC Infect Dis [Internet]. 2018 Jan 30 [cited 2025 Apr 16];18(1):59. Available from: https://bmcinfectdis.biomedcentral.com/articles/10.1186/s12879-018-2971-6 https://doi.org/10.1186/s12879-018-2971-6 ,[7] Lifson AR, Workneh S, Hailemichael A, MacLehose RF, Horvath KJ, Hilk R, Sites AR, Shenie T. Advanced hiv disease among males and females initiating hiv care in rural ethiopia. J Int Assoc Provid AIDS Care [Internet]. 2019 May 20 [cited 2025 Apr 16];18:2325958219847199. Available from: https://journals.sagepub.com/doi/10.1177/2325958219847199 https://doi.org/10.1177/2325958219847199 .
Factors associated with late presentation for HIV care include older age [8] Moreira A, Fronteira I, Augusto G, Martins M. Unmatched case-control study on late presentation of hiv infection in santiago, cape verde(2004–2011). IJERPH [Internet]. 2016 Mar 15 [cited 2025 Apr 16];13(3):320. Available from: https://www.mdpi.com/1660-4601/13/3/320 https://doi.org/10.3390/ijerph13030320 , living with families, frequent alcohol use [1] Belay GM, Endalamaw A, Ayele AD. Late presentation of HIV positive adults and its predictors to HIV/AIDS care in Ethiopia: a systematic review and meta-analysis. BMC Infect Dis [Internet]. 2019 Jun 17 [cited 2025 Apr 16];19(1):534. Available from: https://bmcinfectdis.biomedcentral.com/articles/10.1186/s12879-019-4156-3 https://doi.org/10.1186/s12879-019-4156-3 ,[9] Abaynew Y, Deribew A, Deribe K. Factors associated with late presentation to HIV/AIDS care in South Wollo ZoneEthiopia: a case-control study. AIDS Res Ther [Internet]. 2011 Feb 28 [cited 2025 Apr 16];8(1):8. Available from: https://aidsrestherapy.biomedcentral.com/articles/10.1186/1742-6405-8-8 https://doi.org/10.1186/1742-6405-8-8 , fear of stigma, having symptoms at the time of HIV diagnosis, presence of chronic illnesses [1] Belay GM, Endalamaw A, Ayele AD. Late presentation of HIV positive adults and its predictors to HIV/AIDS care in Ethiopia: a systematic review and meta-analysis. BMC Infect Dis [Internet]. 2019 Jun 17 [cited 2025 Apr 16];19(1):534. Available from: https://bmcinfectdis.biomedcentral.com/articles/10.1186/s12879-019-4156-3 https://doi.org/10.1186/s12879-019-4156-3 and socio-economic status. In addition, men are reported to more likely present late for care compared to women [9] Abaynew Y, Deribew A, Deribe K. Factors associated with late presentation to HIV/AIDS care in South Wollo ZoneEthiopia: a case-control study. AIDS Res Ther [Internet]. 2011 Feb 28 [cited 2025 Apr 16];8(1):8. Available from: https://aidsrestherapy.biomedcentral.com/articles/10.1186/1742-6405-8-8 https://doi.org/10.1186/1742-6405-8-8 ,[10] Beyene MB, Beyene HB. Predictors of late hiv diagnosis among adult people living with hiv/aids who undertake an initial cd4 t cell evaluation, Northern Ethiopia: a case-control study. Paraskevis D, editor. PLoS ONE [Internet]. 2015 Oct 8 [cited 2025 Apr 16];10(10):e0140004. Available from: https://dx.plos.org/10.1371/journal.pone.0140004 https://doi.org/10.1371/journal.pone.0140004 ,[11] Mohammed Y, Gebrehiwot EM, Mekonnen A. Determining factors of late HIV diagnosis in Northern Ethiopia. International Journal of Current Research in Life Sciences [Internet]. 2015 Apr 30 [cited 2025 Apr 16];4(4):187-92. Available from: https://www.journalijcrls.com/sites/default/files/issues-pdf/00089.pdf which could partly be attributed to men’s poor health seeking behaviour. Studies in SSA have reported that compared with women, men are less likely to get tested for HIV and receive treatment, and more likely to die once they begin treatment [12] Druyts E, Dybul M, Kanters S, Nachega J, Birungi J, Ford N, Thorlund K, Negin J, Lester R, Yaya S, Mills EJ. Male sex and the risk of mortality among individuals enrolled in antiretroviral therapy programs in Africa: a systematic review and meta-analysis. AIDS [Internet]. 2013 Jan 28 [cited 2025 Apr 17];27(3):417–25. Available from: https://journals.lww.com/00002030-201301280-00012 https://doi.org/10.1097/qad.0b013e328359b89b Subscription or purchase required to view full text ,[13] 13. Johnson LF, Rehle TM, Jooste S, Bekker LG. Rates of HIV testing and diagnosis in South Africa: successes and challenges. AIDS [Internet]. 2015 Jul 17 [cited 2025 Apr 17];29(11):1401–9. Available from: https://journals.lww.com/00002030-201507170-00015 https://doi.org/10.1097/qad.0000000000000721 . It is also reported that men do not seek testing and counselling services on a routine basis, thus leading to late diagnosis of HIV when they are already in late stage disease progression [14] Haskew J, Turner K, Rø G, Ho A, Kimanga D, Sharif S. Stage of HIV presentation at initial clinic visit following a community-based HIV testing campaign in rural Kenya. BMC Public Health [Internet]. 2015 Jan 21 [cited 2025 Apr 17];15(1):16. Available from: https://bmcpublichealth.biomedcentral.com/articles/10.1186/s12889-015-1367-4 https://doi.org/10.1186/s12889-015-1367-4 .
As one of the ways to improve early initiation to care, the World Health Organization (WHO) recommended immediate initiation of Antiretroviral Therapy (ART) for everyone living with HIV [15] WHO. Guideline on when to start antiretroviral therapy and on pre-exposure prophylaxis for HIV [Internet]. Geneva (Switzerland): World Health Organization; 2015 Sep 1 [cited 2025 Apr 17]; 76p. Available from: https://www.who.int/publications/i/item/9789241509565 Download PDF to view full text and most national guidelines including those in Uganda adopted this recommendation [16] Ministry of Health, Uganda. Consolidated guidelines for prevention and treatment of HIV in Uganda [Internet]. Kampala (Uganda): Ministry of Health, Uganda; 2016 Dec [updated 2022 Aug 19: cited 2025 Apr 17]; Available from: https://library.health.go.ug/communicable-disease/hivaids/consolidated-guidelines-prevention-and-treatment-hiv-uganda Download PDF to view full text . In line with this, the country continued to implement various policies and national guidelines that include: the Uganda National AIDS Policy and the HIV Counselling and Testing (HCT) policy. In addition, testing all men aged 25 years and above at high yield testing points coupled with same day ART initiation has been put in place in several districts [17] Ministry of Health, Uganda. PEPFAR HIV Surge Implementing Partners’ Performance [Internet]. Kampala (Uganda): Ministry of Health, Uganda; 2018 Nov 27 [cited 2025 Apr 17]; 29p. Available from: https://library.health.go.ug/communicable-disease/hivaids/pepfar-hiv-surge-implementing-partners-performance Download PDF to view full text . Despite the several strategies, approximately more than half of adult men newly initiated on ART in Jinja District were reported to present late for care in 2019. This study therefore set out to determine the prevalence and factors associated with men’s late presentation for HIV care in Jinja District.
Study setting and design
This was a cross-sectional study that employed quantitative methods of data collection. The study was conducted in Jinja District, Eastern Uganda between October and November 2020 at Family Hope Centre, a private healthcare facility in the district supported by the Children’s Aids Fund Uganda (CAFU). It’s a medium-sized healthcare facility that serves a diverse population from both urban and rural areas within its catchment area. The catchment area extends across several communities in Jinja District, encompassing both local residents and individuals from surrounding areas who seek care at the facility. Around 11,597 persons living with HIV receive care from the center, along with other facilities like TASO Jinja and the AIDS Information Centre [18] Mugisha D, Alwodo G, Mudiope MG, Alima H, Muhumuza A, Nalwadda B, Masiko J. Strengthening Tuberculosis (TB) case finding through community outreaches in the Busoga sub region in Uganda During the COVID-19 Era [Abstract]. Kampala (Uganda): Uganda Protestant Medical Bureau; [cited 2025 Apr 27]; 1p. Available from: https://upmb.co.ug/wp-content/uploads/2022/05/Strengthening-Tuberculosis-TB-case-finding-through-community-outreaches-in-the-Busoga-sub-region-in-Uganda-during-the-COVID-19-era_Poster-Presentation.pdf . The centre provides various services to its clients including; Antiretroviral therapy (ART), Tuberculosis/HIV, Prevention of Mother-To-Child Transmission (PMTCT), Early Infant Diagnosis (EID) as well as community outreach and complementary services for sexual and reproductive health (SRN) and Maternal Child Health (MCH). The Centre was purposively selected because at the time of the study, its new clients were tested to ascertain baseline CD4 cell count unlike the government health facilities.
We conducted interviews among adult men who were enrolled on ART at Family Hope Centre between January 2018 and June 2020. Clients were included in the study if they were aged 18 years and above at the time of enrolment to HIV care and active in care at the time of the study. Being “Active in care” refered to individuals who were engaged in treatment/receiving ART and follow-up at the facility at the time of the study.
Clients were excluded if they were too ill and weak to respond to questions at the time of the study. Clients were considered to be too ill or weak if they or their caretakers informed the researchers via a phone call that the client was not physically healthy to come to facility to participate in the study.
Sampling criteria and sample size estimation
Participants were recruited using simple random sampling technique. An electronic list from Family Hope Centre of all male clients enrolled on ART was used as the sampling frame. A final list was generated with client ART numbers and contact information. Selected study participants were then contacted via mobile phones and if they consented to participate in the study, were invited to report to the health facility for the interviews. Those with no contact information were traced by the help of linkage facilitators and peer supporters.
A sample size of 410 participants was estimated using the Kish Leslie formula (1965) as follows; n=Z2pq/d2 assuming 40% of enrolled adult male clients had presented late for HIV care (p) [19] Kigozi IM, Dobkin LM, Martin JN, Geng EH, Muyindike W, Emenyonu NI, Bangsberg DR, Hahn JA. Late-disease stage at presentation to an HIV clinic in the era of free antiretroviral therapy in Sub-Saharan Africa. JAIDS Journal of Acquired Immune Deficiency Syndromes [Internet]. 2009 Oct [cited 2025 Apr 17];52(2):280–9. Available from: https://journals.lww.com/00126334-200910010-00018 https://doi.org/10.1097/QAI.0b013e3181ab6eab Subscription or purchase required to view full text , with an acceptable error (d) of 5% at 95% CI and a 10% non-response rate.
Data collection procedures
Three Research Assistants fluent in English and Lusoga, with at least a Bachelor’s degree in any health-related discipline were trained for two days by the Principal Investigator (PI). Pretesting of data collection tools was done for one day at two health centre level IV facilities in the district and adjustments were done to the data collection tool. The pre-test data was not included in the final results. Face to face interviews using structured questionnaires were conducted among study participants receiving care at Family Hope Centre, and data abstraction forms were used to collect data on baseline CD4 cell count from patient individual files.
Study variables
The dependent variable was presentation for HIV care which was measured as a binary outcome; late presentation for HIV care (having enrolled on ART with a CD4 cell count of <350 cells) and early presentation for HIV care (having enrolled on ART with a CD4 cell count of 350 cells/μl and above). This classification was based on a definition established in a previous study [20] Antinori A, Coenen T, Costagiola D, Dedes N, Ellefson M, Gatell J, Girardi E, Johnson M, Kirk O, Lundgren J, Mocroft A, D’Arminio Monforte A, Phillips A, Raben D, Rockstroh J, Sabin C, Sönnerborg A, De Wolf F, for the European Late Presenter Consensus working group. Late presentation of HIV infection: a consensus definition: Consensus definition of late presentation. HIV Medicine [Internet]. 2010 Dec 3 [cited 2025 Apr 17];12(1):61–4. Available from: https://onlinelibrary.wiley.com/doi/10.1111/j.1468-1293.2010.00857.x https://doi.org/10.1111/j.1468-1293.2010.00857.x .
For the independent variables, the study adopted Andersen’s Behavioural model of health services utilization which focuses on three core factors to explain healthcare utilization: predisposing, enabling and need factors.
The independent variables included: Pre-disposing factors such as age, residence and highest educational level attained at presentation for HIV care. Enabling factors such as marital status, employment status, alcohol use and frequency of alcohol use at presentation for HIV care. Need factors such as presence of signs and symptoms (perceived health status) and perceived ART side effects at presentation for HIV care.
Participants were asked about the site of HIV testing, whether they had been counselled before and after HIV testing, given HIV results the same day they were tested, same day ART initiation and if they had faced any challenges accessing HIV services. Participants were also asked if they had perceived HIV as a stigmatizing disease, experienced any form of stigma and if they had any support of others at presentation for HIV care.
Participants’ beliefs in masculinity norms were also assessed. Measures that were used to capture masculine norms were developed from a study that did a scoping review of qualitative studies across 10 countries in sub-Saharan Africa on the role of masculine norms in men’s HIV care engagement [21] Sileo KM, Fielding-Miller R, Dworkin SL, Fleming PJ. A scoping review on the role of masculine norms in men’s engagement in the HIV care continuum in sub-Saharan Africa. AIDS Care [Internet]. 2019 25 Mar [cited 2025 Apr 17];31(11):1435–46. Available from: https://www.tandfonline.com/doi/full/10.1080/09540121.2019.1595509 https://doi.org/10.1080/09540121.2019.1595509 Subscription or purchase required to view full text . From this study, key themes included: the intersection of HIV stigma and masculine norms, masculine norms related to strength and men’s role as a provider as a facilitator to HIV care, as well as men’s self-reliance and agency as a barrier to HIV care.
For this study, we focused on masculine norms related to strength and men’s self-reliance and agency. Five statements/items were used to represent these norms. These included: “men should not seek treatment early”, “men should not go to the doctor unless their situation is serious”, “seeking treatment is a sign of weakness”, “men should not ask help from others” and “men should always be independent.” Participants reported their level of identification with each statement/item on a 5-point Likert scale. Responses ranged from 1 (strongly disagree) to 5 (strongly agree). Items for each participant were summed together, with higher scores indicating high belief in masculinity norms [22] Molenaar C. Masculinity: Exploring Relevant Cues to Promote Help Seeking Intentions in College Men [dissertation]. Bethlehem (PA): Lehigh University; 2017 May. 129 p. Available from: https://preserve.lehigh.edu/lehigh-scholarship/graduate-publications-theses-dissertations/theses-dissertations/masculinity . This scale showed good internal consistency (Cronbach’s alpha = 0.778).
Data management and analysis
Data were cross-checked for missing information and irregularities daily. Data were entered into the SPSS statistics software version 23.0 and then exported to STATA version 14 for analysis. Descriptive statistics were used to present participant characteristics. We summarized the categorical variables as proportions and continuous variables such as age was summarized as mean with its standard deviation and then later categorized. At bivariate analysis modified Poisson regression with robust standard errors was carried out to estimate prevalence ratios (PR), and their 95% confidence intervals (CI) to examine the associations between late presentation for HIV care and independent variables.
Independent variables with a p<0.2 at bivariate analysis were included in the multivariable model. We tested for multicollinearity before considering factors for the multivariable analysis and used the stepwise method in model building while monitoring the Akaike Information Criterion (AIC) of the model, until a lowest AIC of 1.067 was obtained. PRs and their 95% confidence intervals were used to assess the strength of association. A p-value of p<0.05 was used to determine statistical significance.
We obtained ethical approval from Makerere University School of Public Health Research and Ethics Committee (FWA00011353). We also obtained administrative authorization from the Chief Administrative Officer, District Health Officer of Jinja district, and the management of Family Hope Centre. All study participants either gave written informed consent or used a thumbprint before interviews.
Characteristics of study participants
More than half of the participants 225/394 (57.1%) presented for HIV care when they were aged 35-49 years; the median age (IQR) was 40 years (18-72). Majority 332/394 (84.3%) were married and most of them 245/394 (62.2%) were residing in urban areas at that time. Less than half of the participants 172/394 (43.7%) had attained a secondary level of education and 186/394 (47.2%) were Anglican. More than half 306/394 (77.7%) were employed at presentation for HIV care (Table 1).
Proportion of adult men who presented late for HIV care
Overall, the proportion of adult men who presented late for HIV care at Family Hope Centre was 313/394 (79.4%), [95% CI: 0.754,0.834].
Factors associated with late presentation for HIV care among adult men
Men were less likely to present late for HIV care if they were; aged 25-34 years [Adj. PR 0.13; 95%CI: 0.03-0.60], 35-49 years [Adj. PR 0.47; 95%CI: 0.24-0.91] compared to those aged 18-25 years and having been supported by family [Adj. PR 0.36; 95%CI: 0.18-0.73] compared to those who received support from the community outside the family (Table 2 (a) and 2 (b)).
There was evidence of confounding in several variables, including age (particularly in the 25-34 years and ≥50 years groups), religion, and alcohol intake, as indicated by the greater than 10% change in the prevalence ratios between the unadjusted and adjusted values.
This study aimed to determine the prevalence and factors associated with men’s late presentation for HIV care in Jinja District. Our findings showed a high overall prevalence of late presentation. Factors found to be associated with late presentation included age and source of support at the time of HIV diagnosis.
The prevalence of late presentation in this study was higher than the 40% used in the sample size calculation. This disparity may be attributed to differences in how the outcome variable was measured. In the previous research, the categorization of WHO clinical stages was dichotomized into non-severe (stages 1 and 2) and severe (stages 3 and 4), with clinic presentation classified as early or late based on these stages [19] Kigozi IM, Dobkin LM, Martin JN, Geng EH, Muyindike W, Emenyonu NI, Bangsberg DR, Hahn JA. Late-disease stage at presentation to an HIV clinic in the era of free antiretroviral therapy in Sub-Saharan Africa. JAIDS Journal of Acquired Immune Deficiency Syndromes [Internet]. 2009 Oct [cited 2025 Apr 17];52(2):280–9. Available from: https://journals.lww.com/00126334-200910010-00018 https://doi.org/10.1097/QAI.0b013e3181ab6eab Subscription or purchase required to view full text . In contrast, our study used CD4 cell count for categorization which may have captured a broader group of individuals, leading to a higher reported prevalence. Additionally, variations in the population, healthcare access, and diagnostic practices between the two studies could further account for this difference in findings.
However, our finding is similar to what was reported by other studies conducted in the African region [23] Evangeli M, Newell ML, McGrath N. Factors associated with pre-ART loss-to-follow up in adults in rural KwaZulu-Natal, South Africa: a prospective cohort study. BMC Public Health [Internet]. 2016 Apr 27 [cited 2025 Apr 17];16(1):358. Available from: http://bmcpublichealth.biomedcentral.com/articles/10.1186/s12889-016-3025-x https://doi.org/10.1186/s12889-016-3025-x ,[24] Lahuerta M, Wu Y, Hoffman S, Elul B, Kulkarni SG, Remien RH, Nuwagaba-Biribonwoha H, El-Sadr W, Nash D, for the Multi-level determinants of late ART initiation in sub-Saharan Africa Team and the Identifying Optimal Models of HIV Care in sub-Saharan Africa Collaboration. Advanced hiv disease at entry into hiv care and initiation of antiretroviral therapy during 2006-2011: findings from four sub-saharan african countries. Clinical Infectious Diseases [Internet]. 2014 Feb 1 [cited 2025 Apr 17];58(3):432–41. Available from: https://academic.oup.com/cid/article-lookup/doi/10.1093/cid/cit724 https://doi.org/10.1093/cid/cit724 ,[25] Wanyenze RK, Kamya MR, Fatch R, Mayanja-Kizza H, Baveewo S, Sawires S, Bangsberg DR, Coates T, Hahn JA. Missed opportunities for hiv testing and late-stage diagnosis among hiv-infected patients in uganda. Myer L, editor. PLoS ONE [Internet]. 2011 Jul 5 [cited 2025 Apr 17];6(7):e21794. Available from: https://dx.plos.org/10.1371/journal.pone.0021794 https://doi.org/10.1371/journal.pone.0021794 which found late presentation for HIV care to be exceptionally high among males compared to their female counterparts. Another study conducted in rural Kenya [14] Haskew J, Turner K, Rø G, Ho A, Kimanga D, Sharif S. Stage of HIV presentation at initial clinic visit following a community-based HIV testing campaign in rural Kenya. BMC Public Health [Internet]. 2015 Jan 21 [cited 2025 Apr 17];15(1):16. Available from: https://bmcpublichealth.biomedcentral.com/articles/10.1186/s12889-015-1367-4 https://doi.org/10.1186/s12889-015-1367-4 reported that men had 1.4 times higher odds of presenting to the clinic late in the course of HIV infection compared to women. These findings support the notion that men have poor health seeking behaviours. This could also be due to competing working hours and/or seeking care might be seen as a threat to masculine norms. Masculine norms that have been found to serve as barriers to care engagement include strength and self-reliance, emotional inexpressiveness and sexual success with women [21] Sileo KM, Fielding-Miller R, Dworkin SL, Fleming PJ. A scoping review on the role of masculine norms in men’s engagement in the HIV care continuum in sub-Saharan Africa. AIDS Care [Internet]. 2019 25 Mar [cited 2025 Apr 17];31(11):1435–46. Available from: https://www.tandfonline.com/doi/full/10.1080/09540121.2019.1595509 https://doi.org/10.1080/09540121.2019.1595509 Subscription or purchase required to view full text .
One of the most noticeable barriers to early presentation for HIV care in a study among adult men in Eastern Uganda [26] Nabikande S, Namutundu J, Nangendo J, Okello T, Agwang W, Tusabe J, Kabwama SN, Katahoire AR. Men’s late presentation for HIV care in Eastern Uganda: The role of masculinity norms. Fauk NK, editor. PLoS ONE [Internet]. 2022 Nov 17 [cited 2025 Apr 17];17(11):e0277534. Available from: https://dx.plos.org/10.1371/journal.pone.0277534 https://doi.org/10.1371/journal.pone.0277534 was the fear of losing masculine respect ability. Men expressed fear of being marked HIV positive and shamed as a result of being seen presenting at an HIV treatment center. A study in Dar es Salaam, Tanzania [27] Nyamhanga TM, Muhondwa EPY, Shayo R. Masculine attitudes of superiority deter men from accessing antiretroviral therapy in Dar es Salaam, Tanzania. Global Health Action [Internet]. 2013 Oct 22 [cited 2025 Apr 17];6(1):21812. Available from: https://www.tandfonline.com/doi/full/10.3402/gha.v6i0.21812 https://doi.org/10.3402/gha.v6i0.21812 also reported a similar finding, where it was found that men avoided going to the treatment clinics because doing so would amount to making one’s HIV status known. Since society expects men to be wiser and exercise self-control in sexual decision making, being seen at an HIV clinic is interpreted as a failure in the man’s sense of judgment, which undermines the respect and approval by others [28] Siu GE, Wight D, Seeley J. How a masculine work ethic and economic circumstances affect uptake of HIV treatment: experiences of men from an artisanal gold mining community in rural eastern Uganda. Journal of the International AIDS Society [Internet]. 2012 Jun 14 [cited 2025 Apr 17];15(S1):17368. Available from: https://onlinelibrary.wiley.com/doi/10.7448/IAS.15.3.17368 https://doi.org/10.7448/IAS.15.3.17368 .
Participant’s age was associated with late presentation for HIV care with adult men aged (25-34) and (35-49) years being less likely to present late compared to those aged (18-24) years. This could be due to the several strategies employed by the Ugandan government to test all men aged 25 years and above at high yield testing points coupled with same day ART initiation under the test and treat policy in order to increase the number of males enrolled on ART early in the course of infection [20] Antinori A, Coenen T, Costagiola D, Dedes N, Ellefson M, Gatell J, Girardi E, Johnson M, Kirk O, Lundgren J, Mocroft A, D’Arminio Monforte A, Phillips A, Raben D, Rockstroh J, Sabin C, Sönnerborg A, De Wolf F, for the European Late Presenter Consensus working group. Late presentation of HIV infection: a consensus definition: Consensus definition of late presentation. HIV Medicine [Internet]. 2010 Dec 3 [cited 2025 Apr 17];12(1):61–4. Available from: https://onlinelibrary.wiley.com/doi/10.1111/j.1468-1293.2010.00857.x https://doi.org/10.1111/j.1468-1293.2010.00857.x . In addition, a study in Malawi and Uganda [29] Izugbara CO, Undie CC, Mudege NN, Ezeh AC. Male youth and voluntary counseling and hiv-testing: the case of malawi and uganda. Sex Education [Internet]. 2009 Aug 12 [cited 2025 Apr 17];9(3):243–59. Available from: http://www.tandfonline.com/doi/abs/10.1080/14681810903059078 https://doi.org/10.1080/14681810903059078 Subscription or purchase required to view full text found that young male adolescents resisted getting tested for HIV as they felt it signaled lack of self-confidence and an acknowledgement of their vulnerability, traits that conflicted with their male youth identity. This could also be one of the reasons they present late for HIV care.
Participants’ source of support was significantly associated with late presentation for HIV care. Men who received support from their families were less likely to present late for HIV care compared to those who received support from friends or the community outside the family. This finding is supported by a study conducted in Eastern Uganda [30] Lubogo D, Ddamulira JB, Tweheyo R, Wamani H. Factors associated with access to HIV care services in eastern Uganda: the Kumi home based HIV counseling and testing program experience. BMC Fam Pract [Internet]. 2015 Nov 3 [cited 2025 Apr 17];16(1):162. Available from: http://bmcfampract.biomedcentral.com/articles/10.1186/s12875-015-0379-6 https://doi.org/10.1186/s12875-015-0379-6 which found that respondents who did not receive support from their families were less likely to access HIV care services than those who received support from their families. A possible explanation could be that families provide transportation to the health facilities, emotional support among others. Healthcare workers should conduct private counselling sessions with family members of newly diagnosed HIV positive clients to elicit emotional support.
While this study determined key factors associated with late presentation for HIV care among adult men, it had some limitations. It being a cross-sectional study, we could not determine the cause-effect relationship; non-response by some selected participants may have induced a selection bias; and questions were based on past experiences which might have resulted in recall bias. However, the latter limitation was minimized by including participants who had enrolled into care between January 2018 and June 2020 and reviewing patients’ individual files. This was a facility-based study, therefore those that did not register at all and those that had dropped out were not included in the study so the findings cannot be generalized to all adult men living with HIV. The study only included clients receiving care at a private facility and therefore, the findings cannot be generalizable to those accessing care from public health facilities where different factors could influence late presentation for HIV care.
We also recognize that excluding participants who were too ill to participate may have introduced selection bias, particularly as this could lead to the exclusion of individuals with more advanced stages of the disease. However, this was minimized by employing simple random sampling technique which enabled reaching out to a wide range of participants and assessing their eligibility based on the defined inclusion criteria. Lastly, it’s important to note that the confidence intervals (CIs) of the associated factors are relatively wide which suggests a degree of uncertainty in these estimates and indicates that the precision of the findings may be limited. Therefore, caution should be exercised when drawing conclusions from these variables, and future studies with larger sample sizes are recommended to enhance the precision and robustness of these findings.
Despite these limitations, the study had a number of strengths: it contributes to scientific evidence on late presentation for HIV care among adult men; the large sample size (410) and high response rate of 96.1%; the variety of data collection tools used gave fairly robust data; use of primary data; use of patients’ individual files to confirm the date of enrolment into care and CD4 cell count.
Addressing the high rate of late HIV care presentation among adult men at Family Hope Centre, Jinja requires a multifaceted approach. HIV program managers and service providers must prioritize the development of men-friendly services that target young adults (18-24) and those with non-relative support, as these groups are more likely to delay seeking care. HIV treatment service providers need to leverage family support in HIV care programs by implementing family counseling initiatives that can help strengthen the role of family members in supporting newly diagnosed clients throughout their treatment journey. Additionally, fostering supportive social environments where men can openly discuss their HIV status and re-negotiate masculinities aligned with health-seeking behaviors will be crucial in reducing stigma and encouraging early care engagement. Future research should also focus on understanding the cultural and behavioral factors influencing late presentation, particularly in young men and those supported by non-relatives. Furthermore, evaluating the effectiveness of men-friendly services will be key to identifying successful strategies that can be implemented more broadly to improve HIV care outcomes for men.
What is already known about the topic
What this study adds
Research reported in this publication was supported by the Fogarty International Center, National Institute of Alcohol Abuse and Alcoholism, National Institute of Mental Health, of the National Institutes of Health under Award Number D43 TW011304. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health. SN received the funding. The funders had no role in the study design, data collection and analysis, decision to publish, or preparation of the manuscript.
Special thanks to the management and staff of Family Hope Center, Jinja for the help and support rendered to us during the whole data collection process. We acknowledge the support that was given by Angela N. Kisakye, the Scientific Writer from the African Field Epidemiology Network in reviewing drafts of this manuscript. We also appreciate the study participants for their valuable time and information, the District Health Teams for support during the whole study process, and the research assistants for their commitment and dedication to obtain quality data.
SN, JN1, SNK & ARK wrote the study protocol. SN carried out the investigation and supervised the data collection process. SN & JN2 conducted the data analysis and wrote the initial manuscript. JN1, SNK & ARK reviewed drafts of the manuscript. The manuscript was revised and approved by all authors.
| Characteristic | n (%) |
|---|---|
| Age (Median=40, IQR=18,72) | |
| 18–24 years | 21 (5.3) |
| 25–34 years | 88 (22.4) |
| 35–49 years | 225 (57.1) |
| ≥ 50 years | 60 (15.2) |
| Marital Status | |
| Single | 47 (11.9) |
| Married/cohabiting | 332 (84.3) |
| Separated/widowed | 15 (3.8) |
| Place of residence | |
| Urban | 245 (62.2) |
| Rural | 149 (37.8) |
| Highest education level attained | |
| None | 14 (3.6) |
| Primary | 131 (33.3) |
| Secondary | 172 (43.7) |
| Tertiary | 77 (19.5) |
| Religion | |
| Catholic | 104 (26.4) |
| Anglican | 186 (47.2) |
| Others* | 104 (26.4) |
| Employment status (Yes) | 306 (77.7) |
| Average monthly income (Uganda shillings) | |
| <100,000 | 39 (12.7) |
| 100,000–500,000 | 247 (80.5) |
| >500,000 | 21 (6.8) |
| Alcohol intake | |
| Yes | 149 (37.8) |
| No | 245 (62.2) |
| Frequency of alcohol intake (N=149) | |
| Sometimes (1–3 times/week) | 113 (75.8) |
| Frequently (4+ times/week) | 36 (24.2) |
| HIV testing facility | |
| Government | 53 (13.4) |
| Private | 341 (86.6) |
| Received ARVs same day (Yes) | 233 (59.1) |
| Source of support | |
| Community | 9 (5.0) |
| Family | 139 (77.2) |
| Friends | 32 (17.8) |
| Belief in masculinity norms | |
| Low belief | 314 (79.7) |
| Fair belief | 60 (15.2) |
| High belief | 20 (5.1) |
| Characteristic | Late Presentation for HIV Care | Unadjusted PR [95%CI] | Adjusted PR [95%CI] | ||
|---|---|---|---|---|---|
| Yes N=313 n (%) | No N=81 n (%) | Total N=394 n (%) | |||
| Age group | |||||
| 18-24 years | 12 (57.1) | 9 (42.9) | 21 (5.3) | 1.00 | 1.00 |
| 25-34 years | 77 (87.5) | 11 (12.5) | 88 (22.4) | 0.29 [0.13-0.61] | 0.13 [0.03-0.60] |
| 35-49 years | 175 (77.8) | 50 (22.2) | 225 (57.1) | 0.51 [0.29-0.90] | 0.47 [0.24-0.91] |
| ≥ 50 years | 49 (81.7) | 11 (18.3) | 60 (15.2) | 0.42 [0.20-0.88] | 0.33 [0.10-1.10] |
| Marital status | |||||
| Single | 37 (78.7) | 10 (21.3) | 47 (11.9) | 1.00 | |
| Married/cohabiting | 264 (79.5) | 68 (20.5) | 332 (84.3) | 0.96 [0.53-1.74] | |
| Separated/widowed | 12 (80.0) | 3 (20.0) | 15 (3.8) | 0.94 [0.29-2.98] | |
| Place of residence | |||||
| Urban | 192 (78.4) | 53 (21.6) | 245 (62.2) | 1.00 | |
| Rural | 121 (81.2) | 28 (18.8) | 147 (37.8) | 0.87 [0.58-1.31] | |
| Highest education level attained | |||||
| None | 11 (78.6) | 3 (21.4) | 14 (3.6) | 1.00 | |
| Primary | 102 (77.9) | 29 (22.1) | 131 (33.3) | 1.03 [0.36-2.97] | |
| Secondary | 141 (81.9) | 31 (18.0) | 172 (43.7) | 0.84 [0.29-2.41] | |
| Tertiary | 59 (76.6) | 18 (23.4) | 77 (19.5) | 1.09 [0.37-3.22] | |
| Religion | |||||
| Catholic | 73 (70.2) | 31 (29.8) | 104 (26.4) | 1.00 | 1.00 |
| Anglican | 151 (81.2) | 35 (18.8) | 186 (47.2) | 0.63 [0.41-0.96] | 1.15 [0.54-2.46] |
| Others* | 89 (85.6) | 15 (14.4) | 104 (26.4) | 0.48 [0.27-0.84] | 0.85 [0.33-2.15] |
| Employment status | |||||
| Yes | 244 (79.7) | 62 (20.3) | 306 (77.7) | 1.00 | |
| No | 69 (78.4) | 19 (21.6) | 88 (22.4) | 1.07 [0.68-1.68] | |
| Average monthly income (Uganda Shillings) | |||||
| <100,000 | 32 (82.1) | 7 (17.9) | 39 (12.7) | 1.00 | |
| 100,000-500,000 | 199 (80.6) | 48 (19.4) | 247 (80.5) | 1.08 [0.53-2.22] | |
| >500,000 | 14 (66.7) | 7 (33.3) | 21 (6.8) | 1.86 [0.75-4.59] | |
| Health System Factors | |||||
| HIV testing facility | |||||
| Government | 36 (67.9) | 17 (32.1) | 53 (13.4) | 1.00 | 1.00 |
| Private | 277 (81.2) | 64 (18.8) | 341 (86.6) | 0.59 [0.37-0.92] | 0.59 [0.31-1.12] |
| Received ARVs same day | |||||
| Yes | 174 (74.7) | 59 (25.3) | 233 (59.1) | 1.00 | 1.00 |
| No | 139 (86.3) | 22 (13.7) | 161 (40.9) | 0.54 [0.35-0.84] | 0.64 [0.32-1.29] |
| Counselled before HIV test | |||||
| Yes | 299 (79.9) | 75 (20.1) | 375 (95.2) | 1.00 | 1.00 |
| No | 14 (70.0) | 6 (30.0) | 20 (5.1) | 1.49 [0.74-3.01] | |
| Counselled after HIV test | |||||
| Yes | 306 (79.5) | 79 (20.5) | 385 (97.7) | 1.00 | |
| No | 7 (77.8) | 2 (22.2) | 9 (2.3) | 1.08 [0.31-3.74] | |
| Received HIV results same day | |||||
| Yes | 281 (79.4) | 73 (20.6) | 354 (89.8) | 1.00 | |
| No | 32 (80.0) | 8 (20.0) | 40 (10.2) | 0.97 [0.50-1.86] | |
| Presence of chronic illness | |||||
| Yes | 58 (79.5) | 15 (20.5) | 73 (18.5) | 1.00 | |
| No | 255 (79.4) | 66 (20.6) | 321 (81.5) | 1.001 [0.61-1.65] | |
| Experienced stigma | |||||
| Yes | 80 (84.2) | 15 (15.8) | 95 (24.1) | 1.00 | |
| No | 233 (77.9) | 66 (22.1) | 299 (75.9) | 1.39 [0.84-2.33] | |
| Perceived ARVs had side effects | |||||
| Yes | 142 (78.9) | 38 (21.1) | 180 (45.7) | 1.00 | |
| No | 171 (79.9) | 43 (20.1) | 214 (54.3) | 0.95 [0.64-1.40] | |
Menu, Tables and Figures
Table 1. Baseline characteristics of study participants at presentation for HIV care (N=394)
Table 2: Socio-demographic and health system factors associated with late presentation for HIV care among adult men at Family Hope Centre, Jinja district