We found that half of the newly diagnosed HIV infected patients at the national referral hospital in Uganda had late stage HIV infection. Upon multivariate analysis, older age and ever having received health care from a non-medical provider were associated with higher odds of late presentation, while being sexually active was associated with earlier presentation. Individuals within the 31–45 year age group were more likely to be diagnosed late possibly because they had been infected earlier. Similarly, those who had received care from a non-medical provider were more likely to be diagnosed late because the illness for which they sought care could have been HIV related, or because they did not go to medical facilities that offered HIV testing. Individuals who reported two sexual partners were less likely to have late HIV infection compared to those who reported no partners, possibly because such persons may also have experienced previous sexually transmitted infections and therefore had more contact with health facilities.
A significant proportion of those with late stage HIV (27.8%) had received care at a medical clinic and a similar proportion (29.9%) had previously received treatment from a pharmacy/drug store. Fewer individuals had prior encounters with traditional healers (7.8%) or home health workers (2.0%). These findings highlight several gaps and missed opportunities for HIV diagnosis, including: 1) Failure to diagnose HIV infection for infected individuals who attended medical clinics; and 2) A missed opportunity to make a diagnosis for HIV (or any other illness) for those who received care at the pharmacies and drug shops, since these outlets only sell drugs largely on request from sick individuals. Strengthening and expansion of PITC to all health units may reduce missed opportunities for HIV diagnosis, for those individuals who do make contact with these facilities. The initial scale-up of PITC focused more on the high HIV prevalence facilities, including medical and tuberculosis wards 
. We found that two thirds of the participants in the medical wards had late stage HIV compared to one third of the outpatients. In comparison to the medical wards, HIV testing in outpatient units may provide a better opportunity for earlier HIV diagnosis 
Notably, two thirds of the newly diagnosed HIV infected individuals had never attended a medical clinic at all and could therefore not have benefitted from the expansion of provider initiated HIV testing within health facilities. Late stage diagnosis was also associated with receiving care from a non-medical facility. This indicates that a significant proportion of HIV infected individuals may not make contact with health facilities until late in their illness. Facility based interventions may not reach out to all individuals that require HCT because those who do not have health problems or are not ill will not go to health facilities. Also, some individuals with health problems may opt to seek care elsewhere. An estimated 13% of Ugandans who need and seek healthcare do so from drugstores 
. The scale-up of PITC also initially targeted public facilities. Yet, only 29% of Ugandans seek healthcare at public facilities while 46% go to private clinics 
. Scale-up of PITC and other facility based interventions should involve the private sector. Augmentation of PITC with community and home based HIV testing approaches will also be critical in expanding access to early diagnosis and care. A study that compared four HCT approaches in Uganda found that the HCT approaches were complementary. While a larger proportion of infected individuals was identified through PITC, HBHCT identified HIV infected individuals at an earlier stage of infection 
. Additionally, providers at pharmacies, drug stores, and traditional healers should encourage people to seek additional services including HIV testing at medical facilities. Strategies to improve early diagnosis will be critical to the current efforts of early initiation of HIV treatment – most of the participants in this study (59%) had CD4 counts of <350.
Several previous studies showed that low perception of risk of being infected with HIV may be associated with failure to utilise HIV testing services 
. We found an inverse relationship between risk perception and CD4 count on univariate analysis, suggesting that many do not feel that they are at risk until they become ill. However, risk perception was not statistically significant in the multivariate models, possibly due to an association with seeking medical care. In addition to the suspicion that they could be HIV infected, over 95% of the participants in this study noted the medical benefits of HIV diagnosis, including improved care and access to HIV treatment. Many also expected increased support from their families if they were to test positive. Although the proportion of participants mentioning each of the negative social outcomes of HIV disclosure was quite small, ranging between 6%–14%, about 46% anticipated at least one negative social outcome. It is possible that these negative social issues may have been a deterrent to testing 
. In a related study conducted in the same hospital, we found that the frequency of negative social outcomes was actually quite low 
. However, these fears, real or exaggerated, need to be addressed through efforts to minimize stigma and discrimination, so that they do not hinder uptake of HIV services.
These data show significant HIV risk behavior. Most of the newly diagnosed HIV infected individuals were still sexually active and had partners who were either known HIV negative or of unknown HIV status. Yet, consistent condom use was very low. Diagnosis of HIV infection may lead to increased condom use since studies have shown less risky behavior including increased condom use following HIV diagnosis 
. Better still, initiation of HIV treatment may reduce the risk of HIV transmission to sexual partners 
While we had a high response rate, our sample of individuals at a national referral hospital in an urban setting may not represent the larger Ugandan population. Also, these data were derived from a study which was not primarily designed to assess reasons for delayed diagnosis, and do not fully address some potential reasons for delayed diagnosis, including access to HIV testing. We believe that the lack of strong associations may be due to the fact that many of the participants in this study came to the hospital primarily to seek medical care rather than HIV testing. It is possible that the predictors of late diagnosis would be different if individuals who seek HIV testing late were compared with those who seek testing early. However, the study highlights issues that are critical to the mix of HIV testing approaches for the scale-up of early HIV diagnosis and linkage to HIV prevention and treatment.
In summary, this study highlights the need to strengthen PITC, and to augment the current PITC scale-up with community or other non-health facility based HCT approaches, as well as providing an environment that minimises the negative social outcomes of HIV diagnosis and disclosure of HIV status.