Late Diagnosis of HIV Infection: Epidemiological Features, Consequences and Strategies to Encourage Earlier Testing

No association found between traditional healer use and delayed antiretroviral initiation in rural Uganda

Traditional healer and/or spiritual counselor (TH/SC) use has been associated with delays in HIV testing. We examined HIV-infected individuals in southwestern Uganda to test the hypothesis that TH/SC use was also associated with lower CD4 counts at antiretroviral therapy (ART) initiation. Approximately 450 individuals initiating ART through an HIV/AIDS clinic at the Mbarara University of Science and Technology (MUST) were recruited to participate. Patients were predominantly female, ranged in age from 18 to 75, and had a median CD4 count of 130. TH/SC use was not associated with lower CD4 cell count, but age and quality-of-life physical health summary score were associated with CD4 cell count at initiation while asset index was negatively associated with CD4 count at ART initiation. These findings suggest that TH/SC use does not delay initiation of ART.

Predictors of late presentation for HIV diagnosis: a literature review and suggested way forward

Early commencement of antiretroviral treatment can be beneficial and economical in the long run. Despite global advances in access to care, a significant proportion of adults presenting at HIV/AIDS care facilities present with advanced HIV disease. Understanding factors associated with late presentation for HIV/AIDS services is critical to the development of effective programs and treatment strategies. Literature on factors associated with late presentation for an HIV diagnosis is reviewed. Highlighted is the current emphasis on socio-demographic factors, the limited exploration of psychosocial correlates, and inconsistencies in the definition of late presentation that make it difficult to compare findings across different studies. Perspectives based on experiences from resource limited settings are underreported. Greater exploration of psychosocial predictors of late HIV diagnosis is advocated for, to guide future intervention research and to inform public policy and practice targeted at 'difficult to reach' populations.

Risk factors and outcomes for late presentation for HIV-positive persons in Europe: results from the Collaboration of Observational HIV Epidemiological Research Europe Study (COHERE)

BACKGROUND

Few studies have monitored late presentation (LP) of HIV infection over the European continent, including Eastern Europe. Study objectives were to explore the impact of LP on AIDS and mortality.

METHODS AND FINDINGS

LP was defined in Collaboration of Observational HIV Epidemiological Research Europe (COHERE) as HIV diagnosis with a CD4 count <350/mm(3) or an AIDS diagnosis within 6 months of HIV diagnosis among persons presenting for care between 1 January 2000 and 30 June 2011. Logistic regression was used to identify factors associated with LP and Poisson regression to explore the impact on AIDS/death. 84,524 individuals from 23 cohorts in 35 countries contributed data; 45,488 were LP (53.8%). LP was highest in heterosexual males (66.1%), Southern European countries (57.0%), and persons originating from Africa (65.1%). LP decreased from 57.3% in 2000 to 51.7% in 2010/2011 (adjusted odds ratio [aOR] 0.96; 95% CI 0.95-0.97). LP decreased over time in both Central and Northern Europe among homosexual men, and male and female heterosexuals, but increased over time for female heterosexuals and male intravenous drug users (IDUs) from Southern Europe and in male and female IDUs from Eastern Europe. 8,187 AIDS/deaths occurred during 327,003 person-years of follow-up. In the first year after HIV diagnosis, LP was associated with over a 13-fold increased incidence of AIDS/death in Southern Europe (adjusted incidence rate ratio [aIRR] 13.02; 95% CI 8.19-20.70) and over a 6-fold increased rate in Eastern Europe (aIRR 6.64; 95% CI 3.55-12.43).

CONCLUSIONS

LP has decreased over time across Europe, but remains a significant issue in the region in all HIV exposure groups. LP increased in male IDUs and female heterosexuals from Southern Europe and IDUs in Eastern Europe. LP was associated with an increased rate of AIDS/deaths, particularly in the first year after HIV diagnosis, with significant variation across Europe. Earlier and more widespread testing, timely referrals after testing positive, and improved retention in care strategies are required to further reduce the incidence of LP.

HIV among immigrants living in high-income countries: a realist review of evidence to guide targeted approaches to behavioural HIV prevention

BACKGROUND

Immigrants from developing and middle-income countries are an emerging priority in HIV prevention in high-income countries. This may be explained in part by accelerating international migration and population mobility. However, it may also be due to the vulnerabilities of immigrants including social exclusion along with socioeconomic, cultural and language barriers to HIV prevention. Contemporary thinking on effective HIV prevention stresses the need for targeted approaches that adapt HIV prevention interventions according to the cultural context and population being addressed. This review of evidence sought to generate insights into targeted approaches in this emerging area of HIV prevention.

METHODS

We undertook a realist review to answer the research question: 'How are HIV prevention interventions in high-income countries adapted to suit immigrants' needs?' A key goal was to uncover underlying theories or mechanisms operating in behavioural HIV prevention interventions with immigrants, to uncover explanations as how and why they work (or not) for particular groups in particular contexts, and thus to refine the underlying theories. The realist review mapped seven initial mechanisms underlying culturally appropriate HIV prevention with immigrants. Evidence from intervention studies and qualitative studies found in systematic searches was then used to test and refine these seven mechanisms.

RESULTS

Thirty-four intervention studies and 40 qualitative studies contributed to the analysis and synthesis of evidence. The strongest evidence supported the role of 'consonance' mechanisms, indicating the pivotal need to incorporate cultural values into the intervention content. Moderate evidence was found to support the role of three other mechanisms - 'understanding', 'specificity' and 'embeddedness' - which indicated that using the language of immigrants, usually the 'mother tongue', targeting (in terms of ethnicity) and the use of settings were also critical elements in culturally appropriate HIV prevention. There was mixed evidence for the roles of 'authenticity' and 'framing' mechanisms and only partial evidence to support role of 'endorsement' mechanisms.

CONCLUSIONS

This realist review contributes to the explanatory framework of behavioural HIV prevention among immigrants living in high-income countries and, in particular, builds a greater understanding of the suite of mechanisms that underpin adaptations of interventions by the cultural context and population being targeted.

When to start ART in the setting of acute AIDS-related opportunistic infections: the time is now!

Despite the substantial benefits of combination antiretroviral therapy (ART), a significant proportion of HIV-infected individuals still present with advanced disease and active AIDS-related opportunistic infections (OIs). The weight of evidence from recent studies supports the early initiation of ART (ie, within 2 weeks of initiating treatment for the acute OIs). Initiating ART early in acutely ill patients can reduce AIDS-related progression and death. Early ART has not been associated with increased rates of immune reconstitution inflammatory syndrome in prospective studies of non-tuberculosis OIs, although this concern is frequently cited as a reason to delay ART. Nor has early ART been associated with increased adverse outcomes. Nonetheless, initiating ART early in acute care settings can be challenging to implement and requires a well-coordinated multidisciplinary team with expertise in ART management.

Intensification of antiretroviral therapy through addition of enfuvirtide in naive HIV-1-infected patients with severe immunosuppression does not improve immunological response: results of a randomized multicenter trial (ANRS 130 Apollo)

We studied whether addition of enfuvirtide (ENF) to a background combination antiretroviral therapy (cART) would improve the CD4 cell count response at week 24 in naive patients with advanced HIV disease. ANRS 130 Apollo is a randomized study, conducted in naive HIV-1-infected patients, either asymptomatic with CD4 counts of <100/mm(3) or stage B/C disease with CD4 counts of <200/mm(3). Patients received tenofovir-emtricitabine with lopinavir-ritonavir (LPV/r) or efavirenz and were randomized to receive ENF for 24 weeks (ENF arm) or not (control arm). The primary endpoint was the proportion of patients with CD4 counts of ≥ 200/mm(3) at week 24. A total of 195 patients were randomized: 73% had stage C disease, 78% were male, the mean age was 44 years, the median CD4 count was 30/mm(3), and the median HIV-1 RNA load was 5.4 log(10) copies/ml. Eighty-one percent of patients received LPV/r. One patient was lost to follow-up, and eight discontinued the study (four in each arm). The proportions of patients with CD4 counts of ≥ 200/mm(3) at week 24 were 34% and 38% in the ENF and control arms, respectively (P = 0.53). The proportions of patients with HIV-1 RNA loads of <50 copies/ml were 74% and 58% at week 24 in the ENF and control arms, respectively (P < 0.02), and the proportion reached 79% in both arms at week 48. Twenty (20%) and 12 patients (13%) in the ENF and control arms, respectively, experienced at least one AIDS event during follow-up (P = 0.17). Although inducing a more rapid virological response, addition of ENF to a standard cART does not improve the immunological outcome in naive HIV-infected patients with severe immunosuppression.

Optimal timing for initiation of highly active antiretroviral therapy in treatment-naïve human immunodeficiency virus-1-infected individuals presenting with AIDS-defining diseases: the experience of the PISCIS Cohort

In this prospective, multicentre cohort study, we analysed specific prognostic factors and the impact of timing of highly active antiretroviral therapy (HAART) on disease progression and death among 625 human immunodeficiency virus (HIV)-1-infected, treatment-naïve patients diagnosed with an AIDS-defining disease. HAART was classified as early (<30 days) or late (30-270 days). Deferring HAART was significantly associated with faster progression to a new AIDS-defining event/death overall (p 0.009) and in patients with Pneumocystis jiroveci pneumonia (p 0.017). In the multivariate analysis, deferring HAART was associated with a higher risk of a new AIDS-defining event/death (p 0.002; hazard ratio 1.83; 95% CI 1.25-2.68). Other independent risk factors for poorer outcome were baseline diagnosis of AIDS-defining lymphoma, age >35 years, and low CD4(+) count (<50 cells/μL).

Predictors of linkage to care following community-based HIV counseling and testing in rural Kenya

Despite innovations in HIV counseling and testing (HCT), important gaps remain in understanding linkage to care. We followed a cohort diagnosed with HIV through a community-based HCT campaign that trained persons living with HIV/AIDS (PLHA) as navigators. Individual, interpersonal, and institutional predictors of linkage were assessed using survival analysis of self-reported time to enrollment. Of 483 persons consenting to follow-up, 305 (63.2%) enrolled in HIV care within 3 months. Proportions linking to care were similar across sexes, barring a sub-sample of men aged 18-25 years who were highly unlikely to enroll. Men were more likely to enroll if they had disclosed to their spouse, and women if they had disclosed to family. Women who anticipated violence or relationship breakup were less likely to link to care. Enrollment rates were significantly higher among participants receiving a PLHA visit, suggesting that a navigator approach may improve linkage from community-based HCT campaigns.

Molecular epidemiology of HIV-1 transmission in a cohort of HIV-1 concordant heterosexual couples from Dakar, Senegal

Background

A large number of HIV-1 infections in Africa occur in married couples. The predominant direction of intracouple transmission and the principal external origins of infection remain important issues of debate.

Methods

We investigated HIV-1 transmission in 46 HIV-1 concordant positive couples from Dakar, Senegal. Intracouple transmission was confirmed by maximum-likelihood phylogenetic analysis and pairwise distance comparisons of HIV-1 env gp41 sequences from both partners. Standardized interview data were used to deduce the direction as well as the external sources of the intracouple transmissions.

Results

Conservative molecular analyses showed linked viruses in 34 (74%) couples, unlinked viruses in 6 (13%) couples, and indeterminate results for 6 (13%) couples. The interview data corresponded completely with the molecular analyses: all linked couples reported internal transmission and all unlinked couples reported external sources of infection. The majority of linked couples (93%) reported the husband as internal source of infection. These husbands most frequently (82%) reported an occasional sexual relationship as external source of infection. Pairwise comparisons of the CD4 count, antiretroviral therapy status, and the proportion of gp41 ambiguous base pairs within transmission pairs correlated with the reported order of infection events.

Conclusions

In this suburban Senegalese population, a majority of HIV-1 concordant couples showed linked HIV-1 transmission with the husband as likely index partner. Our data emphasize the risk of married women for acquiring HIV-1 as a result of the occasional sexual relationships of their husbands.

Factors Associated with Late Presentation of HIV and Estimation of Antiretroviral Treatment Need according to CD4 Lymphocyte Count in a Resource-Limited Setting: Data from an HIV Cohort Study in India

We describe the CD4 lymphocyte count at HIV presentation in an HIV cohort from a rural district of India. The majority of patients were diagnosed for their HIV-related symptoms, although a sizeable proportion of women were diagnosed because of antenatal screening or for having an HIV-positive partner. Patients diagnosed of HIV for antenatal screening or having an HIV-positive sexual partner had higher CD4 lymphocyte count than patients having tuberculosis or HIV-related symptoms. The proportion of patients diagnosed with CD4 count <200 and <350 cells/mm³ were 46% and 68.7%, respectively, and these figures did not change during the five years of the study. Factors associated with late presentations were male sex, older age, not having a permanent house, and, in women, lower education and being a widow or separated. With the implementation of 2010 WHO guidelines, the number of newly diagnosed patients who will require HIV treatment will increase 13.8%. If the CD4 count threshold for initiating HIV treatment is increased from 350 to 500 cells/mm³, the number of patients in need of treatment would increase 15.7%. Therefore, new strategies for avoiding HIV late presentation are urgently needed in developing countries.

HIV testing and willingness to get HIV testing at a peer-run drop-in centre for people who inject drugs in Bangkok, Thailand

BACKGROUND

Regular HIV testing among people who inject drugs is an essential component of HIV prevention and treatment efforts. We explored HIV testing behaviour among a community-recruited sample of injection drug users (IDU) in Bangkok, Thailand.

METHODS

Data collected through the Mitsampan Community Research Project were used to examine correlates of HIV testing behaviour among IDU and to explore reasons for not being tested. Multivariate logistic regression was used to examine factors associated with willingness to access HIV testing at the drug-user-run Mitsampan Harm Reduction Centre (MSHRC).

RESULTS

Among the 244 IDU who participated in this study, 186 (76.2%) reported receiving HIV testing in the previous six months. Enrolment in voluntary drug treatment (odds ratio [OR] = 2.34; 95% confidence interval [CI]: 1.18-4.63) and the tenofovir trial (OR = 44.81; 95%CI: 13.44-149.45) were positively associated with having been tested, whereas MSHRC use (OR = 1.78; 95%CI: 0.96-3.29) was marginally associated with having been tested. 56.9% of those who had not been tested reported in engaging in HIV risk behaviour in the past six months. 181 (74.2%) participants were willing to be tested at the MSHRC if testing were offered there. In multivariate analyses, willingness to get HIV testing at the MSHRC was positively associated with ever having been to the MSHRC (adjusted odds ratio [AOR] = 2.42; 95%CI: 1.21-4.85) and, among females, being enrolled in voluntary drug treatment services (AOR = 9.38; 95%CI: 1.14-76.98).

CONCLUSIONS

More than three-quarters of IDU received HIV testing in the previous six months. However, HIV risk behaviour was common among those who had not been tested. Additionally, 74.2% of participants were willing to receive HIV testing at the MSHRC. These findings provide evidence for ongoing HIV prevention education, as well potential benefits of incorporating HIV testing for IDU within peer-led harm reduction programs.

Mapping late testers for HIV in Texas

Understanding the spatial patterns of late testing for HIV infection is critically important for designing and evaluating intervention strategies to reduce the social and economic burdens of HIV/AIDS. Traditional mapping methods that rely on frequency counts or rates in predefined areal units are known to be problematic due to issues of small numbers and visual biases. Additionally, confidentiality requirements associated with health data further restrict the ability to produce cartographic representations at fine geographic scales. While kernel density estimation methods produce stable and geographically detailed patterns of the late testing burden, the resulting pattern depends critically on the definition of the at-risk population. Using three definitions of at risk groups, we examine the cartographic representation of HIV late testers in Texas and show that the resulting spatial patterns and the interpretation of disease burdens are different based on the choice of the at-risk population. Disease mappers should exercise considerable caution in selecting the denominator population for mapping.

Barriers to HIV testing among HIV/AIDS concurrently diagnosed persons in New York City

OBJECTIVES

To assess barriers to human immunodeficiency virus (HIV) testing, health care contacts history, and HIV testing history among patients diagnosed concurrently with HIV and acquired immunodeficiency syndrome (AIDS).

METHODS

We surveyed patients concurrently diagnosed with HIV/AIDS who had participated in the partner notification program of the New York City Department of Health and Mental Hygiene, between January 2008 and December 2008.

RESULTS

The most common reason interviewees volunteered for delaying testing (64%) was that they did not believe they were at risk for HIV. When read a list of potential barriers, 69% of interviewees replied affirmatively that they did not test for HIV because they did not believe they were at risk, and 52% replied affirmatively that they did not test because they thought their behaviors kept them safe from getting HIV. Half of all interviewees reported having insurance during part or all of the year before they were diagnosed with HIV/AIDS, and 70% had at least 1 health care visit in the year before they were diagnosed with HIV/AIDS.

CONCLUSIONS

A lack of perception of risk was the most common reason for not testing for HIV sooner among these concurrently diagnosed patients. The majority of these patients were accessing medical care, indicating that this population could have benefited from routine HIV testing.

Late HIV presentation: epidemiology, clinical implications and management

Late presentation of HIV is common and is associated with several adverse outcomes including an increased risk of clinical progression, blunted immune recovery on highly active antiretroviral therapy and a greater risk of drug toxicity. Late presenters may have higher rates of poor adherence, exacerbated by the same factors that contribute to their late diagnosis, such as lack of knowledge about HIV and the benefits of highly active antiretroviral therapy. We review the definitions of, risk factors for and subsequent impact of late presentation. Evidence regarding how and when to start antiretroviral therapy, and with which agents, will be discussed, as well as issues surrounding vaccination and opportunistic infection prophylaxis for individuals with a low CD4 count. Finally, strategies to increase HIV testing uptake to reduce late presentation will be summarized.

Adding fuel to the fire: alcohol's effect on the HIV epidemic in Sub-Saharan Africa

Alcohol consumption adds fuel to the HIV epidemic in sub-Saharan Africa (SSA). SSA has the highest prevalence of HIV infection and heavy episodic drinking in the world. Alcohol consumption is associated with behaviors such as unprotected sex and poor medication adherence, and biological factors such as increased susceptibility to infection, comorbid conditions, and infectiousness, which may synergistically increase HIV acquisition and onward transmission. Few interventions to decrease alcohol consumption and alcohol-related sexual risk behaviors have been developed or implemented in SSA, and few HIV or health policies or services in SSA address alcohol consumption. Structural interventions, such as regulating the availability, price, and advertising of alcohol, are challenging to implement due to the preponderance of homemade alcohol and beverage industry resistance. This article reviews the current knowledge on how alcohol impacts the HIV epidemic in SSA, summarizes current interventions and policies, and identifies areas for increased research and development.

HIV partner notification is effective and feasible in sub-Saharan Africa: opportunities for HIV treatment and prevention

BACKGROUND

Sexual partners of persons with newly diagnosed HIV infection require HIV counseling, testing and, if necessary, evaluation for therapy. However, many African countries do not have a standardized protocol for partner notification, and the effectiveness of partner notification has not been evaluated in developing countries .

METHODS

Individuals with newly diagnosed HIV infection presenting to sexually transmitted infection clinics in Lilongwe, Malawi, were randomized to 1 of 3 methods of partner notification: passive referral, contract referral, or provider referral. The passive referral group was responsible for notifying their partners themselves. The contract referral group was given seven days to notify their partners, after which a health care provider contacted partners who had not reported for counseling and testing. In the provider referral group, a health care provider notified partners directly.

RESULTS

Two hundred forty-five index patients named 302 sexual partners and provided locator information for 252. Among locatable partners, 107 returned for HIV counseling and testing; 20 of 82 [24%; 95% confidence interval (CI): 15% to 34%] partners returned in the passive referral arm, 45 of 88 (51%; 95% CI: 41% to 62%) in the contract referral arm, and 42 of 82 (51%; 95% CI: 40% to 62%) in the provider referral arm (P < 0.001). Among returning partners (n = 107), 67 (64%) of were HIV infected with 54 (81%) newly diagnosed.

DISCUSSION

This study provides the first evidence of the effectiveness of partner notification in sub-Saharan Africa. Active partner notification was feasible, acceptable, and effective among sexually transmitted infections clinic patients. Partner notification will increase early referral to care and facilitate risk reduction among high-risk uninfected partners.

Comparing Measures of Late HIV Diagnosis in Washington State

As more US HIV surveillance programs routinely use late HIV diagnosis to monitor and characterize HIV testing patterns, there is an increasing need to standardize how late HIV diagnosis is measured. In this study, we compared two measures of late HIV diagnosis, one based on time between HIV and AIDS, the other based on initial CD4⁺ results. Using data from Washington's HIV/AIDS Reporting System, we used multivariate logistic regression to identify predictors of late HIV diagnosis. We also conducted tests for trend to determine whether the proportion of cases diagnosed late has changed over time. Both measures lead us to similar conclusions about late HIV diagnosis, suggesting that being male, older, foreign-born, or heterosexual increase the likelihood of late HIV diagnosis. Our findings reaffirm the validity of a time-based definition of late HIV diagnosis, while at the same time demonstrating the potential value of a lab-based measure.

Reduced Central Memory CD4+ T Cells and Increased T-Cell Activation Characterise Treatment-Naive Patients Newly Diagnosed at Late Stage of HIV Infection

Objectives. We investigated immune phenotypes of HIV+ patients who present late, considering late presenters (LPs, CD4+ < 350/μL and/or AIDS), advanced HIV disease (AHD, CD4+ < 200/μL and/or AIDS), and AIDS presenters (AIDS-defining condition at presentation, independently from CD4+). Methods. Patients newly diagnosed with HIV at our clinic between 2007–2011 were enrolled. Mann-Whitney/Chi-squared tests and logistic regression were used for statistics. Results. 275 patients were newly diagnosed with HIV between January/2007–March/2011. 130 (47%) were LPs, 79 (29%) showed AHD, and 49 (18%) were AIDS presenters. LP, AHD, and AIDS presenters were older and more frequently heterosexuals. Higher CD8+%, lower CD127+CD4+%, higher CD95+CD8+%, CD38+CD8+%, and CD45R0+CD38+CD8+% characterized LP/AHD/AIDS presentation. In multivariate analysis, older age, heterosexuality, higher CD8+%, and lower CD127+CD4+% were confirmed associated with LP/AHD. Lower CD4+ and higher CD38+CD8+% resulted independently associated with AIDS presentation. Conclusions. CD127 downregulation and immune activation characterize HIV+ patients presenting late and would be studied as additional markers of late presentation.

Survival outcomes and effect of early vs. deferred cART among HIV-infected patients diagnosed at the time of an AIDS-defining event: a cohort analysis

Objectives

We analyzed clinical progression among persons diagnosed with HIV at the time of an AIDS-defining event, and assessed the impact on outcome of timing of combined antiretroviral treatment (cART).

Methods

Retrospective, European and Canadian multicohort study.. Patients were diagnosed with HIV from 1997–2004 and had clinical AIDS from 30 days before to 14 days after diagnosis. Clinical progression (new AIDS event, death) was described using Kaplan-Meier analysis stratifying by type of AIDS event. Factors associated with progression were identified with multivariable Cox regression. Progression rates were compared between those starting early (<30 days after AIDS event) or deferred (30–270 days after AIDS event) cART.

Results

The median (interquartile range) CD4 count and viral load (VL) at diagnosis of the 584 patients were 42 (16, 119) cells/µL and 5.2 (4.5, 5.7) log₁₀ copies/mL. Clinical progression was observed in 165 (28.3%) patients. Older age, a higher VL at diagnosis, and a diagnosis of non-Hodgkin lymphoma (NHL) (vs. other AIDS events) were independently associated with disease progression. Of 366 patients with an opportunistic infection, 178 (48.6%) received early cART. There was no significant difference in clinical progression between those initiating cART early and those deferring treatment (adjusted hazard ratio 1.32 [95% confidence interval 0.87, 2.00], p = 0.20).

Conclusions

Older patients and patients with high VL or NHL at diagnosis had a worse outcome. Our data suggest that earlier initiation of cART may be beneficial among HIV-infected patients diagnosed with clinical AIDS in our setting.

Immune status at presentation for HIV clinical care in Rio de Janeiro and Baltimore

BACKGROUND

Late presentation to HIV clinical care increases individual risk for (multiple) clinical events and death, and decreases successful response to highly active antiretroviral therapy (HAART). In Brazil, provision of HAART free of charge to all individuals infected with HIV could lead to increased testing and linkage to care.

METHODS

We assessed the immune status of 2555 patients who newly presented for HIV clinical care between 1997 and 2009 at the Johns Hopkins Clinical Cohort, in Baltimore, Md, and at the Instituto de Pesquisa Clinica Evandro Chagas Clinical Cohort, in Rio de Janeiro, Brazil. The mean change in the CD4 cell count per year was estimated using multivariate linear regression models.

RESULTS

Overall, from 1997 to 2009, 56% and 54% of the patients presented for HIV clinical care with CD4 count ≤350 cells per cubic millimeter in Baltimore and Rio de Janeiro, respectively. On average, 75% of the patients presented with viral load >10,000 copies per millimeter. In Rio de Janeiro only, the overall adjusted per year increase in the mean CD4 cell count was statistically significant (5 cells/mm, 95% confidence interval: 1 to 10 cells/mm).

CONCLUSIONS

We found that, over years, the majority of patients presented late, that is, with a CD4 count <350 cells per cubic millimeter. Our findings indicate that, despite the availability of HAART for more than a decade, and mass media campaigns stimulating HIV testing in both countries, the proportion of patients who start therapy at an advanced stage of the disease is still high.

HIV testing in women: missed opportunities

OBJECTIVE

To investigate opportunities for early human immunodeficiency virus (HIV) testing of women.

METHODS

A retrospective cohort study design linked case reports from HIV surveillance to several statewide health-care databases. Medical encounters occurring before the first positive HIV test (missed opportunities) were categorized by diagnosis/procedure codes to distinguish visits that were likely to have prompted an HIV test. Women were categorized as late testers (AIDS diagnosis <12 months from first HIV test date), non-late testers (no AIDS diagnosis during study period or diagnosis of AIDS >12 months of HIV diagnosis), of reproductive age (13-44 years old), and not of reproductive age (>44 years old). Adjusted odds ratios (aOR) and 95% confidence intervals (CI) were used to estimate risk and its statistical significance.

RESULTS

Of 3303 HIV-infected women diagnosed during the study period, 2408 (73%) had missed opportunity visits. Late testers (39%) were more likely to be black than white (aOR 1.48, 95% CI 1.12-1.95), be older (>44 years old; aOR 7.85, 95% CI 4.49-13.7), and have >10 missed opportunity visits (aOR 2.17, 95% CI 1.62-2.91). Fifty-four percent of women >44 years old were also late testers. Women >44 years old had lower median initial CD4 counts (p<0.001). The top two procedures were the same for all groups of women but mammography was ranked fourth for women >44 years old and Papanicolau smear was ranked fourth for late testers.

CONCLUSIONS

Feasibility and acceptability of routine HIV testing in nontraditional health-care settings, such as mammography and Papanicolau screenings, should be explored to identify late testers and older (not of reproductive age) HIV-infected women.

The Direct Medical Costs of Late Presentation (<350/mm) of HIV Infection over a 15-Year Period

We describe the immediate- and longer-term direct medical costs of care for individuals diagnosed with HIV at CD4 counts <350/mm(3) ("late presenters"). We collected and stratified by initial CD4 count all inpatient, outpatient, and drug costs for all newly diagnosed patients accessing HIV care within Southern Alberta from 1/1/1995 to 1/1/2010. 59% of new patients were late presenters. We found significantly higher costs for late presenters, especially inpatient costs, during the first year after accessing care. Direct medical costs remained almost twice as high for late presenters in subsequent years compared to patients presenting with CD4 counts >350/mm(3) despite significantly their improved CD4 counts. The sustained high cost for late presenters has implications for recent recommendations for wider routine HIV testing and the earlier initiation of cART. Earlier diagnosis and treatment, while increasing the immediate expenditures within a population, may produce both direct and indirect cost savings in the longer term.

Comparison of missed opportunities for earlier HIV diagnosis in 3 geographically proximate emergency departments

OBJECTIVE

Differences in the prevalence of undiagnosed HIV between different types of emergency departments (EDs) are not well understood. We seek to define missed opportunities for HIV diagnosis within 3 geographically proximate EDs serving different patient populations in a single metropolitan area.

METHODS

For an urban academic, an urban community, and a suburban community ED located within 10 miles of one another, we reviewed visit records for a cohort of patients who received a new diagnosis of HIV between July 1999 and June 2003. Missed opportunities for earlier HIV diagnosis were defined as ED visits in the year before diagnosis, during which there was no documented ED HIV testing offer or test. Outcomes were the number of missed opportunity visits and the number of patients with a missed opportunity for each ED. We secondarily reviewed medical records for missed opportunity encounters, using an extensive list of indications that might conceivably trigger testing.

RESULTS

Among 276 patients with a new HIV diagnosis, 123 (44.5%) visited an ED in the year before diagnosis or received a diagnosis in the ED. The urban academic ED HIV testing program diagnosed 23 (8.3%) cases and offered testing to 24 (8.7%) patients who declined. Missed opportunities occurred during 187 visits made by 76 (27.5%) patients. These included 70 patients with 157 visits at the urban academic ED, 9 patients with 24 visits at the urban community ED, and 4 patients with 6 visits at the suburban community ED. Medical records were available for 172 of the 187 missed opportunity visits. Visits were characterized by the following potential testing indicators: HIV risk factors (58; 34%), related diagnosis indicating risk (7; 4%), AIDS-defining illness (8; 5%), physician suspicion of HIV (29; 17%), and nonspecific signs or symptoms of illness potentially consistent with HIV (126; 73%).

CONCLUSION

Geographically proximate EDs differ in their opportunities for earlier HIV diagnosis, but all 3 sites had missed opportunities. Many ED patients with undiagnosed HIV have potential indications for testing documented even in the absence of a dedicated risk assessment, although most of these are nonspecific signs or symptoms of illness that may not be clinically useful selection criteria.

Late presentation and transmitted drug resistance mutations in new HIV-1 diagnoses in Detroit

OBJECTIVE

To characterize the epidemiology and transmitted drug resistance mutation (TDRM) patterns among individuals with newly diagnosed HIV-1 infection seen at Henry Ford Hospital in Detroit from 2006 to 2008.

METHODS

This was a retrospective analysis of medical records from individuals aged ≥ 18 years with a new diagnosis of HIV-1 infection. Individuals who underwent genotypic resistance testing were included in the study.

RESULTS

One hundred thirty-three individuals were included; 99 (74%) were males, 104 (78%) were African-Americans, and 61 (46%) had a CD4+ count of ≤ 200 cells/μl. The prevalence of TDRM was 17% (23/133). Non-nucleoside reverse transcriptase mutations occurred in 11 (8%), nucleoside reverse transcriptase mutations in 13 (10%), and protease inhibitor mutations in 10 (8%). CD4+ count >350 cells/μl and HIV viral load on presentation were associated with TDRM in the multivariate analysis (p=0.004 and p<0.001 respectively).

CONCLUSIONS

Late diagnosis of HIV-1 and transmitted antiretroviral resistance are relatively common in Detroit. While most newly diagnosed persons were candidates for antiretroviral therapy on presentation, the high prevalence of TDRM has significant implications in the selection of first-line highly active antiretroviral therapy (HAART).

Epidemiological characteristics and predictors of late presentation of HIV infection in Barcelona (Spain) during the period 2001-2009

Background

Early diagnosis of HIV infection can prevent morbidity and mortality as well as reduce HIV transmission. The aim of the present study was to assess prevalence, describe trends and identify factors associated with late presentation of HIV infection in Barcelona (Spain) during the period 2001-09.

Methods

Demographic and epidemiological characteristics of cases reported to the Barcelona HIV surveillance system were analysed. Late presentation was defined for individuals with a CD4 count below 350 cells/ml upon HIV diagnosis or diagnosis of AIDS within 3 months of HIV diagnosis. Multivariate logistic regression were used to identify predictors of late presentation.

Results

Of the 2,938 newly diagnosed HIV-infected individuals, 2,507 (85,3%) had either a CD4 cell count or an AIDS diagnosis available. A total of 1,139 (55.6%) of the 2,507 studied cases over these nine years were late presenters varying from 48% among men who have sex with men to 70% among heterosexual men. The proportion of late presentation was 62.7% in 2001-2003, 51.9% in 2004-2005, 52.6% in 2006-2007 and 52.1% in 2008-2009. A decrease over time only was observed between 2001-2003 and 2004-2005 (p = 0.001) but remained constant thereafter (p = 0.9). Independent risk factors for late presentation were older age at diagnosis (p < 0.0001), use of injected drugs by men (p < 0.0001), being a heterosexual men (p < 0.0001), and being born in South America (p < 0.0001) or sub-Saharan Africa (p = 0.002).

Conclusion

Late presentation of HIV is still too frequent in all transmission groups in spite of a strong commitment with HIV prevention in our city. It is necessary to develop interventions that increase HIV testing and facilitate earlier entry into HIV care.

Missed opportunities for HIV testing and late-stage diagnosis among HIV-infected patients in Uganda

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.

Who are California's late HIV testers? An analysis of state AIDS surveillance data, 2000-2006

OBJECTIVES

Late HIV testing leads to preventable, severe clinical and public health outcomes. California, lacking a mature HIV surveillance system, has been excluded from documented analyses of late HIV testers in the United States. We identified factors associated with late HIV testing in the California AIDS surveillance data to inform programs of HIV testing and access to treatment.

METHODS

We analyzed data from California AIDS cases diagnosed between 2000 and 2006 and reported through November 1, 2007. Late testers were people diagnosed with HIV within 12 months before their AIDS diagnosis. We identified factors significantly associated with late HIV testing using multivariable logistic regression.

RESULTS

Among 28,382 AIDS cases, 61.2% were late HIV testers. Late testing was significantly associated with those > or = 35 years of age, heterosexual contact or unknown/other reported transmission risk, and being born outside of the U.S. When further classified by country of birth, people born in Mexico were most likely to be HIV late testers who progressed to AIDS.

CONCLUSIONS

Our findings support wider implementation of opt-out HIV testing and HIV testing based in emergency departments. Services for HIV testing and treatment should be inclusive of all populations, but especially targeted to populations that may have more limited access.

Late presentation of HIV disease and its associated factors among newly diagnosed patients before and after abolition of a government policy of mass mandatory screening

OBJECTIVE

To investigate the risk factors for late presentation in the Republic of Korea, where massive mandatory screening for HIV infection was conducted by the government until the late 1990s.

METHODS

Data over the period 1987-2008 were analyzed from HIV patients for whom records of CD4 cell counts within 3 months of HIV diagnosis were available. Using multivariate logistic regression analysis including demographic and clinical variables, we examined factors associated with late presentation, defined as having a CD4 cell count of less than 200 cells/mm(3) at the time of diagnosis.

RESULTS

Of a total of 994 patients with a new diagnosis of HIV infection, 405 (41%) were late presenters. As the proportion of patients diagnosed by mandatory screening decreased over time (31% in 1987-1998 versus 8% in 1999-2008, P < 0.001), the proportion of late presenters increased (31% in 1987-1998 versus 43% in 1999-2008, P = 0.007). The independent risk factors for late presentation were older age (adjusted odds ratio [aOR], per increase of 10 years, 1.31; 95% confidence interval [CI], 1.15-1.49; P < 0.001), male sex (aOR, 1.74; 95% CI, 1.03-2.95; P = 0.040), negativity for VDRL (aOR, 1.58; 95% CI, 1.16-2.14; P = 0.003), and diagnosis after 1999 (aOR, 1.64; 95% CI, 1.05-2.56; P = 0.031).

CONCLUSIONS

Older age, male sex, negativity for VDRL, and diagnosis after 1999, were associated with late presentation, and the proportion of late presenters increased after the mandatory testing policy was abolished.

Patterns and implications of medical pluralism among HIV/AIDS patients in rural South Africa

In some societies, medical pluralism has been demonstrated to delay access to care. We identified sources of health care, and explored utilization patterns and triggers of care-seeking behavior among HIV/AIDS patients in rural South Africa. A longitudinal qualitative study consisting of in-depth interviews was conducted. We purposively sampled thirty-two adult HIV clinic attendees. A high degree of medical pluralism occurred among participants before initiation of antiretroviral treatment (ART). After ART initiation, participants predominantly used the HIV/ART clinic, and utilization of private and traditional facilities decreased. Patterns included both concurrent and sequential pathways to public, private and traditional health sectors. HIV diagnosis and treatment were delayed despite early contact with health systems. Therefore, use of multiple health care modalities before ART initiation can lead to delayed HIV testing and ART initiation. Integrated-care has the potential to mitigate the impact of medical pluralism on access to HIV-related services over the longer term.

Toxoplasmic encephalitis in AIDS-patients before and after the introduction of highly active antiretroviral therapy (HAART)

Toxoplasmic encephalitis (TE) continues to be a severe health problem despite the introduction of highly active antiretroviral therapy (HAART). To identify predictors for development of TE we compared demographic, clinical and diagnostic variables in AIDS patients with TE before (n = 102) or after the introduction (n = 70) of HAART at the Charité University Medicine in Berlin, Germany. Interestingly, patient characteristics did not differ significantly in the pre- and post-HAART groups. Sixty-eight percent of patients had CD4-cell counts of <50/μl. Outcome after treatment with pyrimethamin plus sulfonamides or clindamycin (47% each) did not differ; adverse reactions were more frequent in patients receiving sulfonamides than in those receiving clindamycin (25% vs. 10.5%; p = 0.02). Interestingly, patients in the post HAART group had not received (82.9%) or had not taken HAART adequately (17.1%). Concurrent diagnosis of TE and HIV was significantly more often in the post- compared to the pre-HAART group (49 vs. 26%, respectively; p > 0.001). Thus, despite the introduction of HAART, awareness of opportunistic infections in HIV patients is warranted. High rates of unawareness of HIV infection should make public health efforts focus on early identification of HIV infection and initiation of and compliance with HAART.

Pilot assessment of HIV gene therapy-hematopoietic stem cell clinical trial acceptability among minority patients and their advisors

Clinical trials involving technologically involved novel treatments such as gene therapy delivered through hematopoietic stem cells as human immunodeficiency virus (HIV) treatment will need to recruit ethnically diverse patients to ensure the acceptance among broad groups of individuals and generalizability of research findings. Five focus groups of 47 HIV-positive men and women, religious and community leaders and health providers, mostly from African American and low-income communities, were conducted to examine knowledge about gene therapy and stem cell research and to assess the moral and ethical beliefs that might influence participation in clinical trials. Three themes emerged from these groups: (1) the need for clarification of terminology and the ethics of understanding gene therapy-stem cell research, (2) strategies to avoid mistrust of medical procedures and provider mistrust, and (3) the conflict between science and religious beliefs as it pertains to gene therapy-stem cell research.

Are men testing? Sex differentials in HIV testing in Mpumalanga Province, South Africa

HIV testing is the centerpiece of the national AIDS program in South Africa and many HIV-endemic countries, yet there is surprisingly little published data on who uses testing services. In 2006, we conducted a census of HIV-testing records in all 282 public and non-governmental voluntary counseling and testing (VCT) sites in Mpumalanga (MP), South Africa, the province with the highest HIV prevalence in the country. We secured data on the age and sex of all those tested in 260 sites since the year testing was initiated, as far back as 1998 in some sites. For the year 2006, we also secured data on whether a client came to VCT through self-referral, antenatal services (prevent mother-to-child transmission (PMTCT)), or medical referral. The results characterize the rapid uptake of testing as facilities increased, with the number of people testing in MP more than doubling each year between 2002 and 2006. However, there is a persistent 3:1 differential of females:males testing, with 72.7% of all testing among females. When pregnancy-related testing (via PMTCT) is excluded, females still account for 65.1% of all testing in MP. The data also suggest men are more likely to test at older ages and as a result of medical referral. In summary, females in MP are far more likely to use HIV testing than males, even after accounting for increased access to testing during pregnancy. Sex differentials in HIV testing warrant closer policy attention.

Syphilis with HIV in Florence, 2003–2009: a 7-year epidemiological study

The aims of this study were to describe the trend of acquired syphilis in the city of Florence and its province over a 7-year period, to investigate sexual behaviours in the syphilis-infected population and to analyse syphilis/HIV co-infection. A total of 259 patients were classified according to age, sex and HIV infection. We estimated that from 2004 to 2008 cases increased by 248%. Most patients with concurrent HIV infection were male (31–45 years), but 40- to 60-year-old men who had sex with men predominated in both male and HIV-positive patients. Oral sex was identified as the most significant route of transmission, although most patients did not consider it so. Late-presenters with HIV accounted for 33% of HIV-positive patients: they were unaware of their HIV status and showed syphilis lesions only. In these cases, syphilis heralded the presence of HIV infection and allowed earlier diagnosis.

Factors associated with presentation to care with advanced HIV disease in Brussels and Northern France: 1997-2007

Background

Our objective was to determine the frequency and determinants of presentation to care with advanced HIV disease in patients who discover their HIV diagnosis at this stage as well as those with delayed presentation to care after HIV diagnosis in earlier stages.

Methods

We collected data on 1,819 HIV-infected patients in Brussels (Belgium) and Northern France from January 1997 to December 2007. "Advanced HIV disease" was defined as CD4 count <200/mm³ or clinically-defined AIDS at study inclusion and was stratified into two groups: (a) late testing, defined as presentation to care with advanced HIV disease and HIV diagnosis ≤6 months before initiation of HIV care; and (b) delayed presentation to care, defined as presentation to care with advanced HIV disease and HIV diagnosis >6 months before initiation of HIV care. We used multinomial logistic regression to determine the factors associated with delayed presentation to care and late testing.

Results

Of the 570 patients initiating care with advanced HIV disease, 475 (83.3%) were tested late and 95 (16.7%) had delayed presentation to care. Risk factors for delayed presentation to care were: age 30-50 years, injection drug use, and follow-up in Brussels. Risk factors for late testing were: sub-Saharan African origin, male gender, and older age. HIV transmission through heterosexual contact was associated with an increased risk of both delayed presentation to care and late testing. Patients who initiated HIV care in 2003-2007 were less likely to have been tested late or to have a delayed presentation to care than patients who initiated care before 2003.

Conclusion

A considerable proportion of HIV-infected patients present to care with advanced HIV disease. Late testing, rather than a delay in initiating care after earlier HIV testing, is the main determinant of presentation to care with advanced HIV disease. The factors associated with delay presentation to care differ from those associated with late testing. Different strategies should be developed to optimize early access to care in these two groups.

Expanding HIV testing efforts in concentrated epidemic settings: a population-based survey from rural Vietnam

Background

To improve HIV prevention and care programs, it is important to understand the uptake of HIV testing and to identify population segments in need of increased HIV testing. This is particularly crucial in countries with concentrated HIV epidemics, where HIV prevalence continues to rise in the general population. This study analyzes determinants of HIV testing in a rural Vietnamese population in order to identify potential access barriers and areas for promoting HIV testing services.

Methods

A population-based cross-sectional survey of 1874 randomly sampled adults was linked to pregnancy, migration and economic cohort data from a demographic surveillance site (DSS). Multivariate logistic regression analysis was used to determine which factors were associated with having tested for HIV.

Results

The age-adjusted prevalence of ever-testing for HIV was 7.6%; however 79% of those who reported feeling at-risk of contracting HIV had never tested. In multivariate analysis, younger age (aOR 1.85, 95% CI 1.14–3.01), higher economic status (aOR 3.4, 95% CI 2.21–5.22), and semi-urban residence (aOR 2.37, 95% CI 1.53–3.66) were associated with having been tested for HIV. HIV testing rates did not differ between women of reproductive age who had recently been pregnant and those who had not.

Conclusions

We found low testing uptake (6%) among pregnant women despite an existing prevention of mother-to-child HIV testing policy, and lower-than-expected testing among persons who felt that they were at-risk of HIV. Poverty and residence in a more geographically remote location were associated with less HIV testing. In addition to current HIV testing strategies focusing on high-risk groups, we recommend targeting HIV testing in concentrated HIV epidemic settings to focus on a scaled-up provision of antenatal testing. Additional recommendations include removing financial and geographic access barriers to client-initiated testing, and encouraging provider-initiated testing of those who believe that they are at-risk of HIV.

The economic burden of late entry into medical care for patients with HIV infection

CONTEXT

A large proportion of people with human immunodeficiency virus (HIV) infection enter care late in the HIV disease course. Late entry can increase expenditures for care.

OBJECTIVE

To estimate direct medical care expenditures for HIV patients as a function of disease status at initial presentation to care. Late entry is defined as initial CD4 test result ≤ 200 cells/mm3, intermediate entry as initial CD4 counts >200, and ≤ 500 cells/mm3; and early entry as initial CD4 count >500.

PATIENTS

The study included 8348 patients who received HIV primary care and who were newly enrolled between 2000 and 2006 at one of 10 HIV clinics participating in the HIV Research Network.

DESIGN

We reviewed medical record data from 2000 to 2007. We estimated costs per outpatient visit and inpatient day, and monthly medication costs (antiretroviral and opportunistic illness prophylaxis). We multiplied unit costs by utilization measures to estimate expenditures for inpatient days, outpatient visits, HIV medications, and laboratory tests. We analyzed the association between cumulative expenditures and initial CD4 count, stratified by years in care.

RESULTS

Late entrants comprised 43.1% of new patients. The number of years receiving care after enrollment did not differ significantly across initial CD4 groups. Mean cumulative treatment expenditures ranged from $27,275 to $61,615 higher for late than early presenters. After 7 to 8 years in care, the difference was still substantial.

CONCLUSIONS

Patients who enter medical care late in their HIV disease have substantially higher direct medical treatment expenditures than those who enter at earlier stages. Successful efforts to link patients with medical care earlier in the disease course may yield cost savings.

Late HIV diagnosis in Houston/Harris County, Texas, 2000-2007

This cross-sectional study aimed to evaluate the prevalence and predictive factors associated with late HIV diagnoses in Houston, Texas using surveillance data. Study subjects were Houston/Harris County residents, 13 years or older, diagnosed with HIV and reported to the Houston Department of Health and Human Services. Late HIV diagnosis was defined as an AIDS diagnosis within three months of an HIV diagnosis. Logistic regression was used to investigate the association between late HIV diagnoses and predictive factors. We found 31% of the study population had late HIV diagnoses. The Hispanic population, men, older individuals, heterosexuals, and those diagnosed in private facilities were more likely to receive late HIV diagnoses. Sensitivity analysis was conducted to evaluate the effect of time from HIV to AIDS diagnosis on the prevalence of a late diagnosis, and on the predictors of late diagnosis. The sensitivity analysis showed time affects prevalence, but not the odds ratios of the risk factors for late diagnosis. This finding suggests HIV prevention programs should specifically target these populations at risk for late HIV diagnosis to encourage frequent HIV testing.

Despite CD4 cell count rebound the higher initial costs of medical care for HIV-infected patients persist 5 years after presentation with CD4 cell counts less than 350 μl

We determined that for HIV patients presenting with CD4 cell counts less than 350 μl the initial higher costs of care persisted over 5 years. Fifty-nine percent of new patients between 1 April 1998 and 1 April 2003 had CD4 cell counts less than 350 μl. Mean first year total costs ($19 917 $Cdn) were 2.5 times higher than for presentations with CD4 cell counts more than 350 μl ($7840). Total annual costs of care subsequently decreased to $15 663 by year 5, but still remained higher ($8883) than those with CD4 cell counts more than 350 μl despite a median CD4 cell count increase from 134 to 464 μl.

Social and behavioural characteristics of a sample of AIDS Help-Line users never tested for HIV in Italy

BACKGROUND

We conducted an anonymous cross-sectional telephone survey among persons who had never undergone HIV testing to determine their socio-demographic characteristics, behaviour, risk perception and reasons for not being tested.

METHODS

A questionnaire was administered to adult callers to the Italian National AIDS Help-Line who reported that they had never been tested for HIV.

RESULTS

The study sample consisted of 539 individuals. The individual who does not undergo testing is young (median age 30 years), male (85.5%), unmarried (79.0%), employed (70.1%) and with a high educational level (81.6%). More than two-thirds of the respondents had little or no perception of risk. Among persons who had more than one sexual partner, 47.0% do not use a condom. When dividing the respondents into two groups (i.e. high risk and lower risk), the results showed that the proportion of respondents with a high risk was higher among women (73.1%), among persons >35 years (76.3%) and among persons with a low educational level (77.8%). Individuals who had hadbeen seen in health-care facilities also reported high-risk behaviour.

CONCLUSIONS

The results indicate the socio-demographic characteristics, behaviours, risk perception and reasons for not being tested among a sample of callers to Italy's National AIDS Help-Line, and they confirm the necessity of gearing prevention activities towards heterosexuals and young adults with a low perception of risk.

Routine HIV screening in France: clinical impact and cost-effectiveness

BACKGROUND

In France, roughly 40,000 HIV-infected persons are unaware of their HIV infection. Although previous studies have evaluated the cost-effectiveness of routine HIV screening in the United States, differences in both the epidemiology of infection and HIV testing behaviors warrant a setting-specific analysis for France.

METHODS/PRINCIPAL FINDINGS

We estimated the life expectancy (LE), cost and cost-effectiveness of alternative HIV screening strategies in the French general population and high-risk sub-populations using a computer model of HIV detection and treatment, coupled with French national clinical and economic data. We compared risk-factor-based HIV testing ("current practice") to universal routine, voluntary HIV screening in adults aged 18-69. Screening frequencies ranged from once to annually. Input data included mean age (42 years), undiagnosed HIV prevalence (0.10%), annual HIV incidence (0.01%), test acceptance (79%), linkage to care (75%) and cost/test (€43). We performed sensitivity analyses on HIV prevalence and incidence, cost estimates, and the transmission benefits of ART. "Current practice" produced LEs of 242.82 quality-adjusted life months (QALM) among HIV-infected persons and 268.77 QALM in the general population. Adding a one-time HIV screen increased LE by 0.01 QALM in the general population and increased costs by €50/person, for a cost-effectiveness ratio (CER) of €57,400 per quality-adjusted life year (QALY). More frequent screening in the general population increased survival, costs and CERs. Among injection drug users (prevalence 6.17%; incidence 0.17%/year) and in French Guyana (prevalence 0.41%; incidence 0.35%/year), annual screening compared to every five years produced CERs of €51,200 and €46,500/QALY.

CONCLUSIONS/SIGNIFICANCE

One-time routine HIV screening in France improves survival compared to "current practice" and compares favorably to other screening interventions recommended in Western Europe. In higher-risk groups, more frequent screening is economically justifiable.

Introduction to late presentation for HIV treatment in Europe

This publication is based on the proceedings of a meeting of European HIV experts convened in Windsor, UK, in March 2009. The meeting reviewed data in four key topics affecting the late presentation of HIV patients in Europe: the definition and epidemiology of late presentation, its medical and societal consequences, the need for earlier HIV testing and strategies for management of late-presenting patients. Each topic is discussed in detail here. A concluding article presents recommendations in each topic that were developed at the meeting to address the continuing challenge represented by late presentation for HIV treatment.