Late HIV Diagnosis: Proposed Common Definitions and Associations With Short-Term Mortality

An audit of HIV testing practice in people aged 50 years and over presenting with a known clinical indicator condition in secondary care

OBJECTIVES

To evaluate HIV testing of patients aged ≥50 years presenting to secondary care with clinical indicator conditions (CICs) for HIV.

METHODS

Retrospective audit of electronic records for patients aged ≥50 years discharged from hospital between January 1st and July 31st 2019 who had at least one documented CIC. Patient demographics and HIV testing data were collected from clinical systems (excluding sexual health databases).

RESULTS

2478 patients with a CIC were identified. 222 (9.0%) received an HIV test within 31 days of discharge. Patients receiving a test were significantly younger (mean 68.6 versus 75.3 years; P < 0.001) and significantly more men underwent testing than women (60.4% versus 39.6%; P = 0.001). 32 CICs were identified across nine disease systems. By system, those with a haematological CIC were significantly more likely to undergo testing compared with all other CICs combined (P < 0.001). Of individual CICs, patients with Kaposi's sarcoma, hepatitis C, neutropenia, lymphadenopathy, pyrexia of unknown origin and thrombocytopenia (P < 0.001), and seborrhoeic dermatitis, hepatitis B, other unexplained blood dyscrasia, and non-Hodgkin's lymphoma (P < 0.05) were more likely to undergo testing than those presenting with other CICs. Patients with dementia and lung cancer were less likely to undergo testing (P < 0.001). Patients presenting with a greater number of CICs were significantly more likely to undergo testing (P = 0.002).

CONCLUSIONS

HIV testing among patients aged ≥50 years presenting to secondary care with a CIC is low. Work is needed to improve HIV testing practice in this patient group.

A Systematic Review and Meta-analysis to Estimate the Time from HIV Infection to Diagnosis for People with HIV

Timely HIV diagnosis is critical to minimizing transmission events. We sought to estimate the meantime from HIV infection to diagnosis and its temporal trend among people with HIV. Following Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, a search of MEDLINE, Embase, and Google Scholar, supplemented by a hand search of bibliographies of articles, was conducted. Study information and outcome measures of time from HIV infection to diagnosis were synthesized. Random-effects metaanalyses were performed. The search identified 12 articles from 4541 unduplicated citations. Studies were conducted in the UK (k = 3), US (k = 3), France (k = 2), Australia (k = 1), Switzerland (k = 1), Netherlands (k = 1), and China (k = 1). The pooled meantime from HIV infection to diagnosis was 3.00 years (95% confidence interval: 2.16-3.84). From 1996 to 2002, meantime reduced from 4.68 to 2.66 years. Subsequently, it increased to 3.20 years in 2003 and remained relatively stable until 2015. In sub-group meta-analyses, men who have sex with men (MSM) had a meantime of 2.62 years (1.91-3.34), while for heterosexuals and people who inject drugs, it was 5.00 (4.15-5.86) and 4.98 (3.97-5.98) years, respectively. In the high- and upper-middle-income countries included in this study, persons live with undiagnosed HIV for about 3 year before being diagnosed. This period is shorter for MSM relative to people with infections attributable to other risk factors.

Timeliness of diagnosis of HIV in Newfoundland and Labrador, Canada: A mixed-methods study

BACKGROUND

Late diagnosis of HIV is associated with poor outcomes and increased cost. Novel HIV testing promotion strategies may reduce late diagnosis. The purpose of this study was to determine the timeliness of HIV testing in Newfoundland and Labrador (NL), missed opportunities for testing, and barriers to HIV testing.

METHODS

Demographic and clinical information from individuals diagnosed with HIV in NL from 2006-2016 was retrospectively reviewed. Patients were also invited to participate in semi-structured interviews regarding knowledge about HIV transmission, risk associated with their behaviour, testing decision making, and testing opportunities.

RESULTS

Fifty-eight new HIV diagnoses occurred during the study period: 53/58 (91.4%) were male and 33/58 (56.9%) were men who have sex with men. The mean age at diagnosis was 40.6 (SD 11.05) years. CD4 count at diagnosis ranged from 2 to 1,408 cells/mm³, with a mean of 387 cells/mm³. For 39/58 (67.2%) of individuals, the first-ever HIV test was positive. Of the 58 patients, 55 (94.8%) had had health care contact within the 5 years prior to diagnosis (mean 13.7 contacts). Heterosexual men were more likely to present with a late diagnosis (p = 0.049). Ten (17.2%) individuals agreed to an interview. Thematic analysis revealed that barriers to testing were stigma, negative health care interactions, denial, and fear of the diagnosis.

CONCLUSIONS

HIV diagnosis is made later in NL than in other Canadian provinces. Late diagnosis may be prevented if HIV testing became a routine testing procedure.

Late presentation to HIV/AIDS care at the Douala general hospital, Cameroon: its associated factors, and consequences

Background

The introduction of anti-retroviral treatment (ART) has significantly reduced mortality and morbidity associated with HIV/AIDS. While treatment at early stages of the disease is related to a better prognosis, late presentation (LP) to care is harmful to the infected person, the society and is more costly. We aimed to describe late presentation to HIV care, its associated factors and consequences in patients followed up in a tertiary hospital in Cameroon.

Methods

We retrospectively assessed patients’ files between 1996 and 2014 at the Douala general hospital (DGH) HIV treatment centre. Late presentation (LP) to HIV care was defined as a CD4+ T cell count< 350 cells/mm3 or advanced clinical stages of the disease (WHO stages 3/4) at first presentation for care. We used logistic regression to study factors associated with late presentation and assessed occurrence of opportunistic infections and mortality at 3, 6 and 12 months after presentation to care.

Results

Of 1866 files studied, mean age was 40 (SD: 10) years, median CD4+ T cell count was 147 (IQR: 63–270) cells/mm3, 58.2% were at HIV clinical stages 3 and 4. The prevalence of late presentation to HIV care was 89.7% (95% CI: 88.2–91.0%) and remained above 80% from 1996 to 2014. Circumstances of diagnosis: prevention of mother to child transmission program/blood donation (OR = 0.16, 95% CI 0.10–0.29), having a positive partner (OR = 0.16, 95%CI = 0.10–0.26), and routine screening (OR = 0.13, 95%CI = 0.10–0.19) reduced the odds of presenting late compared to clinical suspicion. Students had lower odds of presenting late compared to people who had an employment (OR = 0.50, 95%CI = 0.26–0.98). Calendar time OR = 1.64, 95% CI = 1.08–2.48 for ≥2010 vs. < 2005) increased the odds of late presentation. Mortality and opportunistic infections prevalence remained significantly higher in late presenters at 3, 6 and 12 months than in early presenters.

Conclusion

Late presentation to HIV care is very high at the DGH and is related to poor outcome. More screening and sensitization campaigns should be carried out in the population to diagnose the disease at an earlier stage.

Trends in baseline CD4 cell counts and risk factors for late antiretroviral therapy initiation among HIV-positive patients in Shanghai, a retrospective cross-sectional study

BACKGROUNDS

There are few studies focus on the factors underlying the late initiation of ART in China. We analyzed the trends in the median CD4 cell counts among different patient groups over time and the risk factors for the late initiation of ART in Shanghai, China.

METHODS

A retrospective cross-sectional survey was made in the Department of Infectious Disease of Shanghai Public Health Clinical Center which is a designated diagnosis and treatment center for HIV-positive patients in Shanghai during the period of January 1st, 2008--June 30th, 2014. Late ART initiation was defined as a CD4 cell count <200 cells/mm³ or having a clinical AIDS diagnosis prior to ART initiation. Trends in the median CD4 cell count at ART initiation and the proportion of late ART initiation by year were evaluated using Spearman's correlations and Chi-squared methods, respectively. We used a logistic regression model to analyze the risk factors for late ART initiation. The related factors collected in the multivariate model were the patient's age, gender, infection routes and marital status.

RESULTS

A total of 3796 patients were analyzed in this study, with a median baseline CD4 cell count of 205 cells/mm³ [interquartile range: 75-287]. The median CD4 cell counts of patients initiating ART late increased from 76 cells/mm³ in 2008 to 103 cells/mm³ in 2014 (p < 0.001), and the proportion of late ART initiation decreased from 80% to 45% (p < 0.001). The risk factors for late ART initiation were male gender, heterosexual transmission and older age (>30 years) (p < 0.001).

CONCLUSIONS

Notable improvements were made in the median CD4 cell count at ART initiation and the proportion of late ART initiation from 2008 to 2014. However, persons with high risk of HIV exposure who are male, older even heterosexual orientation should be given more opportunities to receive frequently screening, earlier diagnoses and timely treatment.

Trends in late HIV diagnosis among men who have sex with men in Jiangsu province, China: Results from four consecutive community-based surveys, 2011-2014

Objectives

To examine trends in HIV testing, late HIV diagnosis and associated factors among men who have sex with men (MSM) in Jiangsu province, China.

Methods

Four consecutive community-based cross-sectional surveys were conducted among MSM from 2011 to 2014 in eight cities in the province. Participants were recruited from MSM venues and via the internet. HIV bio-behavioral surveys were conducted to collect demographic and behavioral data and measure HIV infection. HIV-infected participants with CD4 counts less than 350 cells/uL were defined as having a late HIV diagnosis. Chi-square trend tests were used to compare temporal changes over the years and multivariable logistic regression analyses were used to identify factors associated with late diagnosis.

Results

A total of 2,441, 2,677, 2,591 and 2,610 participants were enrolled in 2011, 2012, 2013 and 2014, respectively. Testing for HIV in the last 12 months decreased over the time period, from 59.9% to 52.5% (p<0.001). Late HIV diagnosis remained high and steady, ranging from 33.3% to 44.2% over the years with no significant change over time (p = 0.418). MSM who were older than 24 years (aOR = 1.748, p = 0.020 for 25–39 years old; aOR = 3.148, p<0.001 for 40 years old or older), were recruited via internet (aOR = 1.596, p = 0.024), and did not have an HIV test in the past 12 months (aOR = 3.385, p<0.001) were more likely to be late diagnosed.

Conclusions

Our study showed a plateau in HIV testing among MSM in China, in parallel to high levels of late diagnosis. Emerging and innovative strategies such as HIV self-testing and reaching more MSM by internet, both highly acceptable to MSM in China, may reduce late diagnosis.