Accessing HIV testing and care

Baseline CD4 cell counts of newly diagnosed HIV cases in China: 2006-2012

BACKGROUND

Late diagnosis of HIV infection is common. We aim to assess the proportion of newly diagnosed HIV cases receiving timely baseline CD4 count testing and the associated factors in China.

METHODS

Data were extracted from the Chinese HIV/AIDS Comprehensive Response Information Management System. Adult patients over 15 years old who had been newly diagnosed with HIV infection in China between 2006 and 2012 were identified. The study cohort comprised individuals who had a measured baseline CD4 count.

RESULTS

Among 388,496 newly identified HIV cases, the median baseline CD4 count was 294 cells/µl (IQR: 130-454), and over half (N = 130,442, 58.8%) were less than 350 cells/µl. The median baseline CD4 count increased from 221 (IQR: 63-410) in 2006 to 314 (IQR: 159-460) in 2012. A slight majority of patients (N = 221,980, 57.1%) received baseline CD4 count testing within 6 months of diagnosis. The proportion of individuals who received timely baseline CD4 count testing increased significantly from 20.0% in 2006 to 76.9% in 2012. Factors associated with failing to receiving timely CD4 count testing were: being male (OR: 1.17, 95% CI: 1.15-1.19), age 55 years or older (OR:1.03, 95% CI: 1.00-1.06), educational attainment of primary school education or below (OR: 1.30, 95% CI: 1.28-1.32), infection with HIV through injection drug use (OR: 2.07, 95% CI: 2.02-2.12) or sexual contact and injection drug use (OR: 1.87, 95% CI: 1.76-1.99), diagnosis in a hospital (OR: 1.91, 95% CI: 1.88-1.95) or in a detention center (OR: 1.75, 95% CI: 1.70-1.80), and employment as a migrant worker (OR:1.55, 95% CI:1.53-1.58).

CONCLUSION

The proportion of newly identified HIV patients receiving timely baseline CD4 testing has increased significantly in China from 2006-2012. Continued effort is needed for further promotion of early HIV diagnosis and timely baseline CD4 cell count testing.

HIV prevention: What have we learned from community experiences in concentrated epidemics?

Drawing on lessons learned from community experiences in concentrated epidemics, this paper explores three imperatives in the effort to reduce the sexual transmission of HIV: combat prevention fatigue, diversify HIV testing and combat stigma and discrimination. The paper argues for a non-judgmental harm reduction approach to the prevention of sexual transmission of HIV that takes into account the interpretation of risk by diverse individuals and communities in the era of antiretroviral therapy. This approach requires greater attention to increasing access to opportunities to know one's serostatus, especially among key populations at greater risk. Novel approaches to diversifying HIV testing approaches at community level are needed. Finally, the paper makes a plea for bold measures to combat stigma and discrimination, which continues to represent a formidable barrier for access to services for affected populations and may contribute to HIV-related risk behaviours. A "triple therapy" approach to address stigma and discrimination is discussed, which includes greater acceptance of people living with HIV and AIDS (PLWHA), improving relevant laws and policies, and involving prevention users- working with people rather than for people-.Note: this paper corresponds to the plenary talk of Bruno Spire at the XVIIth World AIDS Conference, August 8th, Mexico city: http://www.kaisernetwork.org/health_cast/player.cfm?id=4383.

Late HIV diagnosis and delay in CD4 count measurement among HIV-infected patients in Southern Thailand

The objectives of this study were to evaluate timeliness of HIV testing and of getting CD4 count measured and their associated factors in Southern Thailand. Between July 2004 and February 2005, consenting HIV-positive patients from seven public hospitals in Songkhla province, Southern Thailand were interviewed. Outcomes were late HIV diagnosis (having HIV-related symptoms at the time of first positive test) and the time between HIV diagnosis and first CD4 count being measured. Of 402 study patients, 55% were late HIV-diagnosed. Factors independently associated with late HIV diagnosis were age above 30 years, male and being unemployed with respective odd ratios (95% CI) of 3.10 (1.90-5.07), 7.95 (4.52-13.99), and 2.14 (1.22-3.76). Only 34% and 47% received CD4 assessment within 6 and 12 months of HIV diagnosis, respectively. Median of first-known CD4 count was 73 (IQR 16-169) and 22 (IQR 9-85) cells/microl among asymptomatic and symptomatic HIV-diagnosed patients, respectively. Common predictors for shortened delay of CD4 count measured among symptomatic and asymptomatic HIV-diagnosed patients were: infection through sexual contact (HR=1.61; 95%CI 1.12-2.33) and receiving posttest counseling (HR 1.71; 95%CI 1.15-2.52). Among the asymptomatic, those aged >25-30 years had significantly shortened delay (HR=2.18; 95%CI 1.50-3.18) compared with the younger age group as did those aged >30 years (HR=1.94; 95%CI 1.32-2.85). Such age effect on the delay was absent in the symptomatic group. Attempts to diagnose HIV at an earlier stage and timely CD4 count measured are needed.

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

A substantial proportion of HIV-infected individuals do not present for HIV testing until late in infection; these individuals are often ill, have a high mortality risk, and are less likely to respond to treatment when initiated. Furthermore, late presentation means that opportunities to reduce onward transmission, either by reducing high-risk behaviours or by reducing an individual's infectivity, are missed. The proportion of HIV-infected individuals who present late has remained relatively stable over the past decade, despite several attempts to encourage earlier diagnosis. Late presenters tend to be those at lower perceived risk of infection, those who are not routinely offered HIV testing, and are often from marginalized groups. Strategies that encourage earlier testing, including routine HIV testing in healthcare settings where high-risk individuals attend frequently, the availability of HIV testing services in non-medical settings, and partner notification schemes or peer-led projects to encourage high-risk individuals to attend for testing, may all increase the proportion of HIV-infected individuals who are aware of their HIV status, thus helping to control the spread of the epidemic. This review summarizes recent evidence on the epidemiology of late presentation and its impact on clinical progression, and describes several key strategies that may encourage earlier diagnosis.

HIV Health Care Services For Mexican Migrants

This article reviews the literature on HIV/AIDS health care services for Mexican migrants in the United States. Because so little research has been conducted on Mexican migrants per se, we include literature on Latinos/Hispanics in the United States, because some characteristics may be shared. Furthermore, we focus special attention on data from California because it is on the front line of issues regarding health care for Mexican migrants. The types of health care services needed to improve on the quality of care provided to Mexican migrants living with HIV are highlighted, and recommendations are made for future interventions, research, and binational collaborations.

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.

Potential barriers to seeking human immunodeficiency virus testing among adults in the United States: data from the 1998 National Health Interview Survey

To assess potential barriers to seeking human immunodeficiency virus (HIV) testing among adults in the United States, data from the 1998 National Health Interview Survey (NHIS) were analyzed. The NHIS is a multistage cluster survey of the United States noninstitutionalized civilian population ages 18 years or older. The 1998 NHIS survey was conducted using the computer-assisted personal interview. Of a nationally representative sample (n = 32,440) of the U.S. noninstitutionalized civilian population, 21,410 (66%) have never been tested for HIV, 9,728 (30%) have been tested, and 1302 (4%) did not complete the survey or refused to answer the question. Among individuals who completed the survey, men (odds ratio [OR]: 1.08, 95% confidence interval [CI] = 1.04, 1,22), individuals ages 50 years or older (OR: 4.01, 95% CI = 3.16, 5.08), or 18-19 years (OR: 2.12, 95% CI = 1.71, 2.63), those who had "up to 11 grade" level of education (OR: 2.16, 95% CI = 1.74, 2.63), those who lived in nonmetropolitan areas (OR: 1.21, 95% CI = 1.14, 1.28), or lived in the Midwest (1.34, 95% CI = 1.24, 1.43) were significantly more likely than their counterparts to have not sought HIV testing. Among individuals who have never been tested for HIV, 58% had no particular reason, 38% felt they were not at risk of contracting HIV, whereas less than 1% feared adverse consequences. The high proportion of adults who never tested for HIV after two decades of HIV epidemic underscores the need for new approaches to fight the spread of HIV infection in the United States.