Factors associated with initiation of primary medical care for HIV-infected persons

Factors Associated with Ever Being HIV-Tested in Zimbabwe: An Extended Analysis of the Zimbabwe Demographic and Health Survey (2010-2011)

INTRODUCTION

Zimbabwe has a high human immunodeficiency virus (HIV) burden. It is therefore important to scale up HIV-testing and counseling (HTC) as a gateway to HIV prevention, treatment and care.

OBJECTIVE

To determine factors associated with being HIV-tested among adult men and women in Zimbabwe.

METHODS

Secondary analysis was done using data from 7,313 women and 6,584 men who completed interviewer-administered questionnaires and provided blood specimens for HIV testing during the Zimbabwe Demographic and Health Survey (ZDHS) 2010-11. Factors associated with ever being HIV-tested were determined using multivariate logistic regression.

RESULTS

HIV-testing was higher among women compared to men (61% versus 39%). HIV-infected respondents were more likely to be tested compared to those who were HIV-negative for both men [adjusted odds ratio (AOR) = 1.53; 95% confidence interval (CI) (1.27-1.84)] and women [AOR = 1.42; 95% CI (1.20-1.69)]. However, only 55% and 74% of these HIV-infected men and women respectively had ever been tested. Among women, visiting antenatal care (ANC) [AOR = 5.48, 95% CI (4.08-7.36)] was the most significant predictor of being tested whilst a novel finding for men was higher odds of testing among those reporting a sexually transmitted infection (STI) in the past 12 months [AOR = 1.86, 95%CI (1.26-2.74)]. Among men, the odds of ever being tested increased with age ≥ 20 years, particularly those 45-49 years [AOR = 4.21; 95% CI (2.74-6.48)] whilst for women testing was highest among those aged 25-29 years [AOR = 2.01; 95% CI (1.63-2.48)]. Other significant factors for both sexes were increasing education level, higher wealth status and currently/formerly being in union.

CONCLUSIONS

There remains a high proportion of undiagnosed HIV-infected persons and hence there is a need for innovative strategies aimed at increasing HIV-testing, particularly for men and in lower-income and lower-educated populations. Promotion of STI services can be an important gateway for testing more men whilst ANC still remains an important option for HIV-testing among pregnant women.

Gender-related differences in outcomes and attrition on antiretroviral treatment among an HIV-infected patient cohort in Zimbabwe: 2007-2010

Objectives

To determine (1) gender-related differences in antiretroviral therapy (ART) outcomes, and (2) gender-specific characteristics associated with attrition.

Methods

This was a retrospective patient record review of 3919 HIV-infected patients aged ≥15 years who initiated ART between 2007 and 2009 in 40 randomly selected ART facilities countrywide.

Results

Compared to females, males had more documented active tuberculosis (12% vs. 9%; p < 0.02) and a lower median CD4 cell count (117 cells/μl vs. 143 cells/μl; p < 0.001) at ART initiation. Males had a higher risk of attrition (adjusted hazard ratio (AHR) 1.28, 95% confidence interval (CI) 1.10–1.49) and mortality (AHR 1.56, 95% CI 1.10–2.20). Factors associated with attrition for both sexes were lower baseline weight (<45 kg and 45–60 kg vs. >60 kg), initiating ART at an urban health facility, and care at central/provincial or district/mission hospitals vs. primary healthcare facilities.

Conclusions

Our findings show that males presented late for ART initiation compared to females. Similar to other studies, males had higher patient attrition and mortality compared to females and this may be attributed in part to late presentation for HIV treatment and care. These observations highlight the need to encourage early HIV testing and enrolment into HIV treatment and care, and eventually patient retention on ART, particularly amongst men.

First presentation for care of HIV-infected patients with low CD4 cell count in Lyon, France: risk factors and consequences for survival

To identify the risk factors associated with presentation for care with CD4 cell count ≤ 200 cells/mm(3) and death in HIV-infected patients in Lyon, France. Data were analyzed on participants from mid-1992 to December 2006 in the Lyon section of the French Hospital Database on HIV Infection. Patients were stratified into two categories according to CD4 cell count at first presentation for care in University of Lyon hospitals: Group 1 (Gr1) patients with CD4 ≤ 200 cells/mm(3) and Group 2 (Gr2) patients with CD4 >200 cells/mm(3). Multivariate logistic regression assessed the risk factors associated with first presentation for care with CD4 ≤ 200 cells/mm(3). Survival was analyzed according to the Cox regression model. Among 3569 eligible patients (838 females and 2731 males, mean age: 36.3 ± 10.3 years), 1139 (31.9%) were categorized as Gr1. The factors associated with first presentation for care with CD4 ≤ 200 cells/mm(3) were: older age, male gender, route of HIV transmission, migrant populations, geographical areas other than Rhône-Alpes, and access to care in 1992-1997. Overall mortality was higher in Gr1 than in Gr2 (24.4% [278/1139] vs. 4.1% [101/2430]; p<0.001). The risk of death was 5.81 [4.61-7.32] in Gr1 compared to Gr2. In addition to CD4 cell count, age and enrollment periods for care were factors independently related to death. Despite public health efforts in Lyon, one-third of HIV-infected patients reach the health care system with CD4 cell count ≤ 200 cells/mm(3), which was linked with higher mortality.

Challenges and successes in linking HIV-infected women to care in the United States

Women currently account for 27% of new human immunodeficiency virus (HIV) infections in the United States, the majority of which are acquired through heterosexual transmission. In the United States, black and Latino persons are disproportionately affected by the HIV epidemic, a disparity that is most dramatically present among HIV-infected women. Many of these women face significant discrimination as a result of race or ethnicity and sex, and they suffer disproportionately from poverty, low health literacy, and lack of access to high-quality HIV care. As a consequence, despite the availability of highly active antiretroviral therapy (HAART), women with HIV often have delayed entry into care and experience poor outcomes. This article reviews risk factors for HIV infection in women, barriers to engagement in care, and strategies to improve linkage to HIV-related medical and social care.

Use of HIV primary care by HIV-positive Haitian immigrants in Miami, Florida

Little is known about the use of HIV primary care among Haitian immigrants in the USA. The present study utilizes data from a survey of HIV-positive Haitians recruited from an HIV primary care clinic in Miami, Florida, to examine barriers and facilitators of regular use of HIV care by this population. Selection of measures was guided by the Andersen Model of Health Services Utilization for Vulnerable Populations. The dependent variable, regular use of HIV primary care, was operationalized as completion of four or more HIV primary care visits during the previous 12 months. Of the 96 participants surveyed, approximately three-fourths did not graduate from high school and reported an annual income of up to $5000. Seventy-nine percent of participants completed four or more visits in the past year. On univariate as well as multivariate analyses, participants without formal education or those with high psychological distress were significantly less likely to have used HIV primary care regularly than those who attended school or who were less distressed, respectively. The findings emphasize the need for health care practitioners to pay close attention to the education level and the mental health status of their Haitian HIV patients. The data also suggest that once these individuals are linked to care and offered assistance with their daily challenges, they are very likely to stay connected to care and to take their antiretroviral medicines.

[Initiation of antiretroviral therapy in HIV-infected patients with severe immunodeficiency in Belo Horizonte, Minas Gerais State, Brazil]

The main objective was to assess the proportion of delayed initiation of antiretroviral therapy (ART) and associated factors. This was a cross-sectional study of 310 patients enrolled in two public health centers in Belo Horizonte, Minas Gerais State, Brazil. Delayed ART initiation was defined as starting treatment with a CD4 count lower than 200 cells/mm(3) or clinical symptoms of severe immunodepression at the time of first antiretroviral prescription. The majority of participants were males (63.9%), had no health insurance (76.1%), and started ART less than 120 days after the first medical visit (75.2%). The proportion of delayed ART initiation was 68.4%. Unemployment, referral by a health professional for HIV testing, fewer than two medical visits in the six months prior to ART initiation, and time between first medical visit and ART initiation less than 120 days were independently associated with the outcome. Our results suggest that every patient 13 to 64 years of age should be offered HIV testing, which could increase the rate of early HIV diagnosis, and thus patients that tested positive could benefit from timely follow-up and antiretroviral therapy.

Late-disease stage at presentation to an HIV clinic in the era of free antiretroviral therapy in Sub-Saharan Africa

BACKGROUND

Access to free antiretroviral therapy in sub-Saharan Africa has been steadily increasing, and the success of large-scale antiretroviral therapy programs depends on early initiation of HIV care. However, little is known about the stage at which those infected with HIV present for treatment in sub-Saharan Africa.

METHODS

We conducted a cross-sectional analysis of initial visits to the Immune Suppression Syndrome Clinic of the Mbarara University Teaching Hospital, including patients who had their initial visit between February 2007 and February 2008 (N = 2311).

RESULTS

The median age of the patients was 33 years (range 16-81 years), and 64% were female. More than one third (40%) were categorized as late presenters, that is, World Health Organization disease stage 3 or 4. Male gender, age 46-60 years (vs. younger), lower education level, being unemployed, living in a household with others, being unmarried, and lack of spousal HIV status disclosure were independently associated with late presentation, whereas being pregnant, having young children, and consuming alcohol in the prior year were associated with early presentation.

CONCLUSIONS

Targeted public health interventions to facilitate earlier entry into HIV care are needed, as well as additional study to determine whether late presentation is due to delays in testing vs. delays in accessing care.

Differences in HIV-related hospitalization trends between Haitian-born blacks and US-born blacks

OBJECTIVES

To examine the HIV care needs and hospital admission patterns of HIV-positive Haitian-born blacks (Haitians) and compare them with those of US-born blacks (Blacks).

METHODS

We abstracted the medical records of 635 Blacks and Haitians consecutively admitted to the adult HIV Service at Jackson Memorial Hospital during 2004 for information on demographics, use of antiretroviral therapy, CD4 cell counts, primary and secondary diagnoses at admission, and substance use. The probability of being prescribed highly active antiretroviral therapy (HAART) was examined by country of origin.

RESULTS

There was no statistically significant difference between the groups in likelihood to be prescribed HAART. In controlled analyses, however, Haitians were 76% more likely than Blacks to have a CD4 count <51 cells/mm3 and tended to be more recently diagnosed with HIV Moreover, tuberculosis was the most prevalent opportunistic infection for Haitians compared with candidiasis for Blacks.

CONCLUSIONS

Findings suggest that barriers to medical care may exist for Haitians at an early stage of the access continuum and that prevention efforts among the Haitian HIV-positive population should be directed at promoting the need for timely use of health services.

HIV morbidity and mortality in Jamaica: analysis of national surveillance data, 1993--2005

OBJECTIVES

Pre-antiretroviral therapy (ART) HIV-related survival and timing of HIV identification have not been reported from the Caribbean. Using Jamaican national surveillance data, we estimated overall, AIDS-free, and AIDS survival, identified factors influencing HIV-related mortality, and examined factors associated with late HIV/AIDS identification.

METHODS

The Jamaican HIV/AIDS tracking system (HATS) national surveillance data included timing of first positive HIV test, stage at identification, date of AIDS diagnosis, and death. We estimated overall and AIDS-free survival by initial stage, using a proportional hazard model to identify factors associated with worse survival, and logistic regression to examine factors related to later case identification.

RESULTS

Of 10674 reported HIV cases, 48% were asymptomatic, 14% symptomatic, and 38% first reported with AIDS. Five-year AIDS-free survival was 77% for asymptomatic persons and 63% for symptomatic. Median survival after AIDS diagnosis was 1.02 years. Age, number of opportunistic diseases, and initial stage were strongly associated with mortality. Older age, drug use, and sex with a commercial sex worker were associated with later identification.

CONCLUSIONS

In the pre-ART era, over one-third of HIV-infected persons in Jamaica were first identified with advanced disease. This highlights the need for earlier diagnosis as ART programs roll out in the Caribbean.

Late presentation for HIV care in central Haiti: factors limiting access to care

OBJECTIVE

Many patients with HIV infection present for care late in the course of their disease, a factor which is associated with poor prognosis. Our objective was to identify factors associated with late presentation for HIV care among patients in central Haiti.

METHODS/DESIGN

Thirty-one HIV-positive adults, approximately 10% of the HIV-infected population followed at a central Haiti hospital, participated in this research study. A two-part research tool that included a structured questionnaire and an ethnographic life history interview was used to collect quantitative as well as qualitative data about demographic factors related to presentation for HIV care.

RESULTS

Sixty-five percent of the patients in this study presented late for HIV care, as defined by CD4 cell count below 350 cells/mm3. Factors associated with late presentation included male sex, older age, patient belief that symptoms are not caused by a medical condition, greater distance from the medical clinic, lack of prior access to effective medical care, previous requirement to pay for medical care, and prior negative experience at local hospitals. Harsh poverty was a striking theme among all patients interviewed.

CONCLUSIONS

Delays in presentation for HIV care in rural Haiti are linked to demographic, socioeconomic and structural factors, many of which are rooted in poverty. These data suggest that a multifaceted approach is needed to overcome barriers to early presentation for care. This approach might include poverty alleviation strategies; provision of effective, reliable and free medical care; patient outreach through community health workers and collaboration with traditional healers.

Gender distribution of adult patients on highly active antiretroviral therapy (HAART) in Southern Africa: a systematic review

Background

HIV and AIDS are significant and growing public health concerns in southern Africa. The majority of countries in the region have national adult HIV prevalence estimates exceeding 10 percent. The increasing availability of highly active antiretroviral therapy (HAART) has potential to mitigate the situation. There is however concern that women may experience more barriers in accessing treatment programs than men.

Methods

A systematic review of the literature was carried out to describe the gender distribution of patients accessing highly active antiretroviral therapy (HAART) in Southern Africa. Data on number of patients on treatment, their mean or median age and gender were obtained and compared across studies and reports.

Results

The median or mean age of patients in the studies ranged from 33 to 39 years. While female to male HIV infection prevalence ratios in the southern African countries ranged from 1.2:1 to 1.6:1, female to male ratios on HAART ranged from 0.8: 1 to 2.3: 1. The majority of the reports had female: male ratio in treatment exceeding 1.6. Overall, there were more females on HAART than there were males and this was not solely explained by the higher HIV prevalence among females compared to males.

Conclusion

In most Southern African countries, proportionally more females are on HIV antiretroviral treatment than men, even when the higher HIV infection prevalence in females is accounted for. There is need to identify the factors that are facilitating women's accessibility to HIV treatment. As more patients access HAART in the region, it will be important to continue assessing the gender distribution of patients on HAART.

Chronic binge ethanol consumption accelerates progression of simian immunodeficiency virus disease

BACKGROUND

While alcohol consumption is known to increase the incidence and severity of infections, the impact of alcohol consumption on human immunodeficiency virus (HIV) disease progression has been difficult to assess. Therefore, we examined the effect of ethanol on simian immunodeficiency virus (SIV) disease progression in a well-defined model utilizing rhesus macaques.

METHODS

Alcohol was administered for 5 hours via an indwelling intragastric catheter to achieve an alcohol concentration of 50 to 60 mM for 4 consecutive days per week for the duration of the study. Control animals received isocaloric sucrose. After 3 months, animals were inoculated intravenously with 10,000 times the ID(50) of SIV(DeltaB670) and followed to end-stage disease.

RESULTS

Plasma SIV ribonucleic acid (RNA) was higher in alcohol-consuming animals compared with sucrose-treated animals during the early asymptomatic stage of disease but not at later time points. This increase in viral set point was associated with more rapid progression to end-stage disease in macaques administered alcohol (median=374 days) compared with sucrose (median=900 days). The decline in blood CD4+ cells was similar in both groups of animals.

CONCLUSIONS

This study indicates that frequent episodes of alcohol intoxication in SIV+ macaques increase viral set point in association with more rapid development of end-stage disease.

Factors associated with delayed initiation of HIV medical care among infected persons attending a southern HIV/AIDS clinic

BACKGROUND

Despite the proven benefits conferred by early human immunodeficiency virus (HIV) diagnosis and presentation to care, delays in HIV medical care are common; these delays are not fully understood, especially in the southern United States.

METHODS

We evaluated the extent of, and characteristics associated with, delayed presentation to HIV care among 1,209 patients at an HIV/AIDS Outpatient Clinic in Birmingham, Alabama between 1996 and 2005.

RESULTS

Two out of five (41.2%) patients first engaged care only after they had progressed to CDC-defined AIDS. Among these, 53.6% were diagnosed with HIV in the year preceding entry to care. Recent presentation (2002 - 2005), male sex, age > or = 25, Medicare or Medicaid insurance coverage, and presentation within six months of HIV diagnosis were independently associated with initiating care after progression to AIDS.

CONCLUSIONS

A high proportion of patients entered clinical care after experiencing substantial disease progression. Interventions that effectively improve the timing of HIV diagnosis and presentation to care are needed.

Advanced immunosuppression at entry to HIV care in the southeastern United States and associated risk factors

In this study we characterized factors associated with the late initiation of HIV care in the southeastern United States. At initiation of care, antiretroviral therapy was indicated for 75% of patients, 50% had a CD4 cell count of less than 200 cells/mul, and 27% presented with an AIDS-defining illness. Male sex was an independent predictor in multivariable analysis. These results indicate an urgent need to increase HIV testing for earlier diagnosis in the southeastern USA.

Delayed access to HIV diagnosis and care: Special concerns for the Southern United States

HIV diagnosis and presentation to appropriate medical care during early stages of disease has substantial clinical and public health benefits. However, a large proportion of HIV-infected Americans experience diagnosis and treatment related delays. Prior research evaluating barriers to early HIV diagnosis and care presentation have been published primarily from large East and West coast urban centers. Therefore, predictors of delayed presentation to HIV care identified by these studies may not be generalizable to the South where infected persons are increasingly non-white, female, poor, non-urban, and possibly exposed to HIV heterosexually. We review here the benefits conferred by HIV care, descriptive epidemiology of delayed HIV diagnosis and care, and potential barriers to early medical care with special reference to conditions prevalent in the South.

Perceptions of Human Immunodeficiency Virus (HIV) Testing Services Among HIV-Positive Persons Not in Medical Care

BACKGROUND AND OBJECTIVES

Human immunodeficiency virus (HIV) counseling, testing, and referral (CTR) are provided in a wide variety of settings.

GOAL

To compare, by test setting, the perceptions of the testing experience among HIV-positive persons who were not receiving medical care.

DESIGN

A baseline questionnaire was administered at enrollment into the Antiretroviral Treatment Access Study by the use of audio computer-assisted self-interview.

RESULTS

Of 316 respondents, 27% reported that the counselor did not spend enough time with them and 22% that the counselor did not answer all questions. The odds were higher that persons in the following settings, compared with those at HIV test sites, would report that the counselor did not spend enough time with them: office of private physician or health maintenance organization (HMO) (adjusted odds ratio [AOR], 5.24; 95% confidence interval, 1.26-21.7), jail (AOR, 5.10; 95% CI, 1.06-24.6), and emergency room (ER) or hospital overnight visit (AOR, 2.93; 95% CI, 1.15-7.44). Similarly, the odds were higher that persons in the following settings compared with those at HIV test sites would report that the counselor did not answer all questions: office of private physician or HMO (AOR, 9.62; 95% CI, 2.22-41.7), jail (AOR, 7.87; 95% CI, 1.50-41.4), and ER or hospital overnight visit (AOR, 3.32; 95% CI, 1.11-9.90).

CONCLUSION

Further training and quality assurance in HIV CTR may be needed in some test settings.

Assessing missed opportunities for HIV testing in medical settings

BACKGROUND

Many HIV-infected persons learn about their diagnosis years after initial infection. The extent to which missed opportunities for HIV testing occur in medical evaluations prior to one's HIV diagnosis is not known.

DESIGN

We performed a 10-year retrospective chart review of patients seen at an HIV intake clinic between January 1994 and June 2001 who 1). tested positive for HIV during the 12 months prior to their presentation at the intake clinic and 2). had at least one encounter recorded in the medical record prior to their HIV-positive status. Data collection included demographics, clinical presentation, and whether HIV testing was recommended to the patient or addressed in any way in the clinical note. Prespecified triggers for physicians to recommend HIV testing, such as specific patient characteristics, symptoms, and physical findings, were recorded for each visit. Multivariable logistic regression was used to identify factors associated with missed opportunities for discussion of HIV testing. Generalized estimating equations were used to account for multiple visits per subject.

RESULTS

Among the 221 patients meeting eligibility criteria, all had triggers for HIV testing found in an encounter note. Triggers were found in 50% (1702/3424) of these 221 patients' medical visits. The median number of visits per patient prior to HIV diagnosis to this single institution was 5; 40% of these visits were to either the emergency department or urgent care clinic. HIV was addressed in 27% of visits in which triggers were identified. The multivariable regression model indicated that patients were more likely to have testing addressed in urgent care clinic (39%), sexually transmitted disease clinic (78%), primary care clinics (32%), and during hospitalization (47%), compared to the emergency department (11%), obstetrics/gynecology (9%), and other specialty clinics (10%) (P <.0001). More recent clinical visits (1997-2001) were more likely to have HIV addressed than earlier visits (P <.0001). Women were offered testing less often than men (P =.07).

CONCLUSIONS

Missed opportunities for addressing HIV testing remain unacceptably high when patients seek medical care in the period before their HIV diagnosis. Despite improvement in recent years, variation by site of care remained important. In particular, the emergency department merits consideration for increased resource commitment to facilitate HIV testing. In order to detect HIV infection prior to advanced immunosuppression, clinicians must become more aware of clinical triggers that suggest a patient's increased risk for this infection and lower the threshold at which HIV testing is recommended.

Facteurs associés à une prise en charge tardive des patients infectés par le VIH : revue de la littérature

In the United States, Australia and Europe, many HIV infected individuals are still diagnosed and/or treated late in the course of the disease. This literature review of studies published over a ten year period between 1993 and 2003 has identified the following principle factors associated with the late diagnosis of HIV: male gender, aged older than 45 years, heterosexual intercourse, the lack of previous screening. It also identified the factors linked to the delay in beginning anti-retroviral treatment as being male gender, the lack of awareness or denial of the possibility of HIV infection, intravenous drug use, lack of post-screening follow-up or counseling, lack of social protection, and the lack of regular medical visits and care. Early detection and suitable early treatment of the HIV virus are the main determining factors which will effectively contribute to the control and maintenance of the virus in as much as they are focused upon these particular at-risk populations.

Review of medical encounters in the 5 years before a diagnosis of HIV-1 infection: implications for early detection

Early detection of HIV infection improves prognosis and reduces transmission, but 30%-40% of cases are diagnosed late. A comprehensive and systematic review of medical encounters before diagnosis has not been done. This study reviews 5 years of medical encounters before the diagnosis of HIV infection in members of a large managed care organization where access to care is reasonably good. Patient characteristics, HIV risk factors, and clinical events preceding diagnosis were examined and tested for association with late diagnosis (CD4 cell count of <200/microL at diagnosis). Of 440 HIV-infected patients, 62% had CD4 cell counts of <350/microL, 43% had CD4 cell counts of <200/microL, and 18% had CD4 cell counts of <50/microL at diagnosis. Twenty-six percent of all patients had risks documented >1 year before diagnosis. Only 22% of patients had one of eight clinical indicators suggested in the literature as reasons to test for HIV >1 year before diagnosis. In multiple logistic regression, older age, male sex, race, risk group, no prior HIV testing, physician-initiated testing, and having any of eight clinical indicators before diagnosis were each associated with late diagnosis (p <or=.05). Late diagnosis remains a challenge despite good access to care. In our setting, effective risk assessment before symptoms arise offers greater potential for raising the mean CD4 cell count at diagnosis than does increased awareness of selected HIV-associated clinical prompts.

Understanding delay to medical care for HIV infection: the long-term non-presenter

OBJECTIVE

To examine delayed presentation for HIV testing and primary care in the second decade of the AIDS epidemic.

DESIGN

Cohort study in two urban hospitals in the USA between February 1994 and April 1996.

METHODS

A total of 203 consecutive outpatients on initial HIV primary care presentation were interviewed about sociodemographic characteristics, alcohol and drug use, social support, sexual practices, HIV testing, awareness of possible HIV infection, and CD4 cell count.

MAIN OUTCOME MEASURE

Duration of delay to medical presentation in years based on CD4 cell count, factors independently associated with low CD4 cell counts, frequency of awareness of HIV risk before testing.

RESULTS

The estimated mean duration between acquiring HIV infection and initial presentation to primary care was 8.1 years (95% CI 7.5, 8.6) based on our cohort's median initial CD4 cell count of 280/microl. Male sex, older age, and no jail time were associated with lower CD4 cell counts; 34% reported not being aware that they were at risk of HIV before testing. Heterosexual intercourse as a risk behavior for HIV was the most statistically significant factor for personal unawareness of HIV risk. Of those who acknowledged awareness, the mean time between awareness of HIV risk and testing was 2.5 years (median 1.0 year).

CONCLUSION

In the pre-highly active antiretroviral therapy era, HIV-infected patients frequently initiated primary medical care years after initial infection, at a time of advanced immunosuppression. Over one-third of HIV-infected patients were not cognisant of their HIV risk before testing, a condition significantly associated with heterosexual intercourse as the only HIV risk behavior.

How generalizable are the results of large randomized controlled trials of antiretroviral therapy?

OBJECTIVES

To examine the generalizability of two large randomized controlled clinical trials of antiretroviral therapy in HIV-infected individuals.

METHODS

The demographic, clinical and laboratory characteristics of HIV-infected participants in two antiretroviral trials (Concorde and Delta) at three study sites were compared with those of two other groups of patients to whom the trial results would be applicable: eligible patients who were screened for the trials but who did not enrol, and eligible patients who were not approached or screened for the trials.

RESULTS

Among enrolled participants in the Concorde and Delta trials there was an under-representation of patients who had acquired HIV infection heterosexually (P = 0.014) or through injecting drug use (P = 0.03), and a greater representation of homosexual men (P < 0.001) compared to non-enrolled participants. Trial participants in Concorde had significantly less advanced immunosuppression compared to non-trial participants (P = 0.0001), while in Delta the converse was true. Concorde participants were also much less likely to be lost to follow-up for more than a year (9%) compared to eligible but unscreened patients (40%) (P < 0.001), and screened but unenrolled patients (22%) (P = 0.035).

CONCLUSIONS

In applying the findings of large randomized clinical trials, it is important to establish whether there are systematic differences between the characteristics of trial participants and eligible non-participants, which might affect the generalizability of the study results. A log of the characteristics of enrolled as well as eligible but non-enrolled patients should be maintained so that the representativeness of the trial population can be evaluated.

Unreported AIDS-defining opportunistic illnesses in persons reported with HIV-related severe immunosuppression

To better estimate the distribution of AIDS cases after the 1993 change in the case definition, we assessed the proportion of persons whose AIDS diagnosis was based on laboratory criteria for severe immunosuppression (CD4 count <200 cells/microl or <14%) and who also had an unreported opportunistic illness (OI) at the time of the CD4 report. Five U.S. reporting sites (Arizona; Los Angeles County, California; New Jersey; Oregon; and Washington State) reviewed AIDS cases reported between January 1 and June 30, 1993. From these sites, 3289 immunologic cases were reported; of these cases, 322 (9.8%; range, 1.6%-16.1%) were in persons who had an unreported OI. More of those who had an unreported OI were male, members of racial groups other than white, injection drug users, and had a CD4 count of <50 cells/microl at AIDS diagnosis. Because of recent advances in OI prophylaxis and treatment of HIV infection, studies monitoring HIV-related morbidity should assess the occurrence of OIs in a sample of persons reported with HIV and severe immunosuppression. Such assessment will ensure representative ascertainment of initial AIDS-defining OIs and thus improve the usefulness of the data for public health planning and the allocation of resources for patient care.

Optimizing care for persons with HIV infection. Society of General Internal Medicine AIDS Task Force

Treatment advances and outcomes data have raised new concerns about how to optimize care for patients with HIV infection. This paper reviews evidence on 1) the relation between experience and type of training and patient outcomes, 2) the relation between the components of primary care and patient outcomes, and 3) primary care physicians' basic HIV knowledge and skills in screening and prevention. Several studies indicate that greater experience in HIV care leads to improved patient outcomes. The relation between outcomes and type of training (subspecialist or generalist) is less clear, and studies have not distinguished between type of training and experience. Less experienced physicians may be able to provide high-quality care if appropriate consultation from expert physicians is available. Components of primary care, including accessibility, continuity, coordination, and comprehensiveness, are associated with better patient outcomes. Optimal care of HIV infection requires a combination of disease-specific expertise and primary care skills and organization. Criteria for expertise in HIV management should focus on actual patient care experience and HIV expertise rather than on subspecialty training per se. The management of HIV has become sufficiently complex that primary care physicians cannot be routinely expected to have extensive specialized knowledge in this area. However, many primary care physicians have weaknesses in the basic HIV-related skills that are needed in most settings, such as HIV test counseling and recognition of important HIV-related symptom complexes. Primary care physicians need to strengthen these basic HIV-related medical skills.

HIV testing in substance abusers

HIV testing among substance abusers in the United States is a significant public and individual health issue in need of further examination. We analyzed interview data gathered over 15 months in 1992 and 1993 from 2315 patients on presentation for addiction treatment to determine the frequency of and factors associated with previous HIV testing. Among this group of alcohol, heroin, and cocaine abusers, 53% (1231) reported previous HIV testing. Although in bivariate and multivariable analyses those with identifiable risk factors for HIV were more likely to have been tested, 27% of injection drug users, 38% with multiple sexual partners, and 39% of those with a history of a sexually transmitted disease (STD) had not been HIV tested. Other factors associated with previous HIV testing included having a primary care physician, the primary care physician's awareness of the patient's substance abuse problem, and having received prior addiction care. However, 38% of substance abusers who had previously received addiction treatment beyond detoxification had not been tested. Of those tested, 10% (n = 122) reported a positive test, and 7% (n = 81) had not received the test results. Of those with positive test results, 37% were not injection drug users. Promotion of HIV testing among alcohol and other drug abusers in both medical and substance abuse treatment settings should be a priority.

Factors associated with HIV testing among sexually active adolescents: a Massachusetts survey

OBJECTIVE

To assess sexually active adolescents' knowledge, attitudes, and behaviors associated with human immunodeficiency virus (HIV) testing and to determine the factors important in their decision to obtain voluntary HIV testing.

DESIGN

Anonymous, random, digit-dial telephone survey undertaken in 1993.

SETTING

Massachusetts households.

PARTICIPANTS

Adolescents, 16 to 19 years of age.

RESULTS

Of the 567 adolescents surveyed who had sexual intercourse within the past year, 127 (22%) had received HIV testing, with 54 (10%) stating that this testing was for personal reasons. A "great deal" or "some" worry about getting HIV/acquired immunodeficiency syndrome (AIDS) was expressed by 51%, and 56% felt that it was at least a little likely that they will get AIDS. Misconceptions were common about aspects of HIV testing: 35% did not believe or did not know that the HIV test results were kept in confidence, 19% thought that AIDS testers informed partners if the results were positive, and 30% did not think that the HIV test was very accurate. Although 92% (452/490) had seen a physician in the past year, only 30% (136/452) had ever discussed AIDS with a doctor. Multivariable analysis identified five factors as independently associated with voluntary adolescent HIV testing: 1) having had more than one sexual partner within the past year [odds ratio (OR): 2.9; 95% confidence interval (CI): 1.5, 5.5]; 2) believing that condoms are only somewhat effective at preventing the spread of AIDS (OR: 2. 6; 95% CI: 1.4, 4.8); 3) having discussed AIDS with a doctor (OR: 2. 6; 95% CI: 1.4, 4.8); 4) not having had a teacher discuss AIDS (OR: 2.2; 95% CI: 1.2, 4.2); and 5) believing that a positive test result means one has AIDS as opposed to carrying the virus (OR: 2.0; 95% CI: 1.1, 3.7). High-risk behavior of infrequent condom use and a history of a sexually transmitted disease were not significantly associated with voluntary HIV testing.

CONCLUSION

Among sexually active Massachusetts adolescents, voluntary HIV testing is uncommon. Teens who have had multiple sexual partners and who do not believe condoms are effective in preventing transmission were most likely to have been tested. Issues requiring clearer communication to patients include the testing process, its availability, and confidentiality. Physicians can play an influential role in the promotion of HIV testing by discussing HIV risk behaviors with patients and offering those at risk voluntary HIV counseling and testing.