Late presentation to HIV/AIDS testing, treatment or continued care: clarifying the use of CD4 evaluation in the consensus definition

Is the definition of late diagnosis correct?

BACKGROUND

The study analysed 1711 patients of the Hospital for Infectious Diseases in Warsaw diagnosed with HIV infection in 2008-2010 and 2016-2018. Research was conducted examining the changes in CD4 cell counts before starting antiretroviral (ARV) treatment in order to find people who were misclassified as late-diagnosed.

METHODS

Patients with late diagnosis were distinguished on the basis of the consensus definition. The Mann-Whitney U-test was used to analyse the change in CD4 cell counts before starting ARV treatment.

RESULTS

In the years 2008-2010, the CD4 count was remeasured before starting ARV treatment in 90 late-diagnosed patients. The median change in the CD4 count was 22 cells/μL. In 49 of these, the number of CD4 cells spontaneously increased before the start of treatment. We can suspect that these patients were misclassified as late-diagnosed.

CONCLUSIONS

The consensus definition of late diagnosis often leads to overestimation of the number of late-diagnosed patients. The crucial problem is a transient decline in the CD4 lymphocyte count in the acute phase of HIV infection. A potential solution is to introduce serum HIV viral load measurement into the definition.

Determinants of Late HIV Presentation at Ndlavela Health Center in Mozambique

Background: There has been tremendous progress in the fight against HIV worldwide; however, challenges persist in the control of HIV infection. These challenges include the high prevalence of late presenters. There are many disadvantages of late presentation—from reduced survival of the infected person to the risk of transmitting the infection. This research aims to analyze the factors that influence the late presentation in patients attending Ndlavela Health Center in Mozambique. Methodology: A retrospective cross-sectional study was carried out at Ndlavela Health Center including patients diagnosed with HIV between 2015 and 2020. The European Late Presenter Consensus working group definitions were used, and univariate and multivariate logistic regression were used to identify factors associated with late presentation. Results: In total, 519 participants were included in the study, of which nearly 47% were classified as late presenters. The male gender (AOR = 2.41), clinical suspicious test (AOR = 4.03), initiated by the health professional (AOR = 2.1,9), and fear of stigma (AOR = 2.80) were the main risk factors for late HIV presentation. Conclusion: Factors that are potentially determinant for late HIV presentation were identified. Actions are needed to focus on risk factors that are most likely to delay presentation.

Perceived behavioural predictors of late initiation to HIV/AIDS care in Gurage zone public health facilities: a cohort study using health belief model

Objective

The study was aimed to measure incidence density rate and identify perceived behavioural believes of late initiation to HIV/AIDS care in Gurage zone public health facilities from September 2015 to November 2016.

Results

The incidence density rates of late initiation to HIV/AIDS care were 2.21 per 100 person-months of observation. HIV positive individuals who did not perceived susceptibility were 8.46 times more likely delay to start HIV/AIDS care than their counter parts [OR = 8.46 (95% CI 3.92, 18.26)]. HIV infected individuals who did not perceived severity of delayed ART initiation were 6.13 time more likely to delay than HIV infected individuals who perceived its severity [OR = 6.13 (95% CI 2.95, 12.73)]. HIV positive individuals who didn’t have self-efficacy were 2.35 times more likely delay to start HIV/AIDS care than HIV positive individuals who have self-efficacy [OR = 2.35 (95% CI 1.09, 5.05)].

Conclusions

The study revealed that high incidence density rates of delayed initiation for HIV care and variations were explained by poor wealth, and perceived threat and benefit. Therefore, interventions should be designed to initiate care at their diagnosis time.

Electronic supplementary material

The online version of this article (10.1186/s13104-018-3408-4) contains supplementary material, which is available to authorized users.

Late entry to HIV and AIDS care and treatment, Juba Teaching Hospital, Juba, South Sudan, 2013-2016

Late diagnosis of HIV and enrolment to care are global public health challenges. This study aimed to characterise late HIV diagnoses and initiation of treatment among patients at Juba Teaching Hospital (JTH) in South Sudan. We conducted a retrospective review of lab-confirmed HIV patients at JTH, 2013-2016. Demographic, clinical, and laboratory data were entered into and descriptive statistics were calculated using Microsoft Excel. We identified 401 patients, with mean age 33.71±4.54 years, 235 (59%) were female, 307 (77%) were late entry, 64 (16%) were lost to follow-up, and 57 (14%) died within 12 months of diagnosis. Among patients who presented late, 122 (57%) were female, and 112 (53%) were <34 years old. Among patients who died, 33 (58%) were male, and 52 (91%) had CD4 counts <350 cells/mm3 and World Health Organization (WHO) stage >2 at diagnosis. Late diagnosis of HIV infection is a significant public health problem in South Sudan, particularly for younger and female patients.

Factors associated with the level of CD4 cell counts at HIV diagnosis in a French cohort: a quantile regression approach

The consensus definition of late presentation for human immunodeficiency virus patient based on a CD4 threshold of 350 cells/mm³ has limitations concerning risk factors identification since there is growing biomedical justification for earlier initiation of treatment. The objective was to overcome this problem by simultaneously determining factors associated with different levels of CD4 counts at the time of diagnosis. Between January 2000 and July 2014, 1179 patients with a first human immunodeficiency virus diagnosis and entering care in a French human immunodeficiency virus reference center were enrolled. Factors associated with each 5 percentile from 5th to 95th quantile of CD4 counts at diagnosis were simultaneously studied in a multivariable quantile regression model. At each of the quantiles, the factors identified as negatively associated with CD4 count at diagnosis were older age, male sex , foreign patients, hepatitis B virus or hepatitis C virus co-infection, employment status, non-MSM transmission, heterosexual transmission, suburban and rural's place of residence and earlier period of diagnosis. Association with CD4 count was not uniformly significant, most factors being significant for some quantiles. The only significant determinant for all quantiles was being born in a foreign country. These results are particularly helpful in the context of human immunodeficiency virus clinical care, management and prevention.

Advanced HIV disease at presentation to care in Nairobi, Kenya: late diagnosis or delayed linkage to care?--a cross-sectional study

Background

Presenting to care with advanced HIV is common in sub-Saharan Africa and increases the risk of severe disease and death; however, it remains unclear whether this is a consequence of late diagnosis or a delay in seeking care after diagnosis. The objectives of this cross-sectional study were to determine factors associated with advanced HIV at presentation to care and whether this was due to late diagnosis or delays in accessing care.

Methods

Between 2013 and 2015, adults presenting to care were recruited at two clinics in low-income areas of Nairobi, Kenya. Participants were considered to have advanced HIV if their CD4 count was below 200 cells/μL, or they were in WHO stage 4. Information on previous HIV diagnoses was collected using interviewer-administered questionnaires. Logistic regression was used to determine the association between clinical and socio-demographic factors and advanced HIV.

Results

Of 753 participants presenting to HIV care, 248 (33 %) had advanced HIV. Almost 60 % (146/248) of those presenting with advanced HIV had been previously diagnosed, most of whom (102/145; 70 %) presented to care within three months of their initial diagnosis. The median time to presentation to HIV care after an initial diagnosis was 22 days (IQR 6-147) for those with advanced HIV, compared to 19 days (IQR 4-119) for those with non-advanced HIV (p = 0.716). Clinic (adjusted odds ratio [AOR] 1.55, 95 % CI 1.09–2.20) and age (AOR 1.72 per unit increase in age category, 95 % CI 1.45–2.03) were associated with presenting with advanced HIV.

Conclusions

Presentation to care with advanced HIV was primarily due to delayed diagnosis, rather than delayed linkage to care after diagnosis. Variation by clinic suggests that outreach and other community-based efforts may drive earlier testing and linkage to care. Our findings highlight the ongoing importance of implementing strategies to encourage earlier HIV diagnosis, particularly among adults 30 years and older.

Unmatched Case-Control Study on Late Presentation of HIV Infection in Santiago, Cape Verde (2004-2011)

Access to free antiretroviral therapy (ART) in Sub-Saharan Africa has been steadily increasing over the past decade. However, the success of large-scale ART programmes depends on timely diagnosis and early initiation of HIV care. This study characterizes late presenters to HIV care in Santiago (Cape Verde) between 2004 and 2011, and identifies factors associated with late presentation for care. We defined late presentation as persons presenting to HIV care with a CD4 count below 350 cells/mm³. An unmatched case-control study was conducted using socio-demographic and behavioural data of 368 individuals (191 cases and 177 controls) collected through an interviewer-administered questionnaire, comparing HIV patients late and early presented to care. Logistic regression was performed to estimate odds ratio and 95% confidence intervals. Results show that 51.9% were late presenters for HIV. No differences were found in gender distribution, marital status, or access to health services between cases and controls. Participants who undertook an HIV test by doctor indication were more likely to present late compared with those who tested for HIV by their own initiative. Also, individuals taking less time to initiate ART are more likely to present late. This study highlights the need to better understand reasons for late presentation to HIV care in Cape Verde. People in older age groups should be targeted in future approaches focused on late presenters to HIV care.

High proportion of HIV late presenters at an academic tertiary care center in northern Germany confirms the results of several cohorts in Germany: time to put better HIV screening efforts on the national agenda?

165 treatment-naive patients who first presented at the infectious disease clinic of the University Medical Center Hamburg-Eppendorf from 2009 to 2011 were retrospectively analyzed with emphasis on patients with late presentation (LP). In line with other recent German reports, there was a large proportion of 105 of the 165 treatment-naïve patients (63.6 %) who presented late. Old age, heterosexual transmission risk and migrant background were associated risk factors for late presentation. Thus, further intensified national efforts like the HIV in Europe initiative are needed to identify such patients at high risk for HIV infection.

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

The aim of this study was to present a definition of late presentation according to different time periods between initial diagnosis of human immunodeficiency virus (HIV) infection and acquired immune deficiency syndrome (AIDS) diagnosis which would reliably identify individuals with high risk of mortality within 1 year of diagnosis, and could be used as a suggested common definition.Data of individuals diagnosed from 1994 to February 2012 in Wuhan, China were extracted retrospectively from the national HIV surveillance system. Four time periods (1, 3, 6, and 12 months) combined with the European consensus definition of advanced HIV disease (AHD) were compared. The predictive ability of each definition for identifying an individual who died within 1 year after HIV diagnosis was assessed.A total of 980 patients were included, of whom 289 (29.49%), 324 (33.06%), 353 (36.02%), and 387 (39.49%) were defined as AHD according to the definition of a CD4 count <200 cells/μL or AIDS-defining event (ADE) within 1, 3, 6, and 12 months of HIV diagnosis, respectively. One hundred twenty-seven (12.96%) patients died within 1 year of diagnosis. The highest Youden's index and largest area under the curve were presented in time period within 3 months. Time period within 1 month presented the highest consistency rate, positive likelihood ratio, and kappa value. Longer time periods increased the sensitivity but decreased the specificity.Given the European consensus definitions and the current results, we suggested that AHD could be defined as "a first-reported CD4 count <200 cells/μL or an ADE within 1 month after HIV diagnosis." "Late presentation" could be defined as "a first-reported CD4 count <350 cells/μL or an ADE within 1 month after HIV diagnosis."

Late presentation to HIV testing is overestimated when based on the consensus definition

Objectives

In 2011, a consensus was reached defining “late presenters” (LPs) as individuals presenting for care with a CD4 count < 350 cells/μL or with an AIDS‐defining event, regardless of CD4 count. However, a transient low CD4 count is not uncommon in recent infections. The objective of this study was to investigate how measurements of late presentation change if the clinical stage at the time of diagnosis is taken into account.

Methods

Case surveillance data for newly diagnosed patients in Belgium in 1998–2012 were analysed, including CD4 count at diagnosis, the presence of AIDS‐defining events, and recent infections (< 6 months) as reported by clinicians in the case of acute illness or a recent negative test. First, proportions of LPs were calculated according to the consensus definition. Secondly, LPs were reclassified as “nonlate” if infections were reported as recent.

Results

A total of 7949 HIV diagnoses were included in the study. Recent infections were increasingly reported over time, accounting for 8.2% of new infections in 1998 and 37.5% in 2012. The consideration of clinical stage significantly modified the proportion of LPs: 18.2% of men who have sex with men (MSM) diagnosed in 2012 would be classified as LPs instead of 30.9% using the consensus definition (P < 0.001). The proportion of patients misclassified as LPs increased significantly over time: 5% in MSM in 1998 vs. 41% in 2012.

Conclusions

This study suggests that low CD4 counts in recent infections may lead to overestimation of late presentation when applying the consensus definition. The impact of transient CD4 count on late presentation estimates should be assessed and, if relevant, the introduction of clinical stage in the definition of late presentation should be considered.

Lack of awareness in both patients and physicians contributes to a high rate of late presentation in a South West German HIV patient cohort

PURPOSE

To assess rate of late presentation with HIV in Southwestern Germany and to identify patient characteristics correlated with CD4 nadir.

METHODS

Patients with primary diagnosis who presented to one of ten participating clinics rated on knowledge and behavior towards HIV testing on a self-developed questionnaire, whereas clinical data was assessed by the physician.

RESULTS

161 patients were included. Risk factors were homosexual (59.5 %) or heterosexual contacts (26.8 %), drug use (2.0 %), migration (3.9 %), or others (7.8 %). 63.5 % had a CD4 T cell count < 350/µl. 52.5, 17.4, and 31.1 % were diagnosed in CDC stadium A, B or C, respectively. 209 disease episodes were reported, from whom 83.7 % had led to the diagnosis of HIV. 75.2 and 68.3 % said to have been well-informed about ways of transmission and testing offerings, respectively, and 20.4 % admitted to have psychologically repressed the possibility of being infected. 48 patients rated their personal behavioral risk as "high" or "very high". Of these, however, only ten had performed at test in the precedent year. Performing a regression analysis, younger age and previous testing were correlated with a higher CD4 T cell nadir (p = 0.005, and 0.018, resp.).

CONCLUSION

The rate of late presentation in this region was even higher compared to national or European surveys. Most infected patients perceived to have had only a low risk. Several disease episodes did not lead to the initiation of HIV testing by the physician.

Making the invisible, visible: a cross-sectional study of late presentation to HIV/AIDS services among men who have sex with men from a large urban center of Brazil

Background

Late presentation to testing, treatment and continued care has detrimental impacts on the health of HIV-positive individuals as well as their sexual partners’ health. Men who have sex with men (MSM) experience disproportionately high rates of HIV both globally and in Brazil. However, the factors that inhibit linkage to care among MSM remain unclear.

Methods

We conducted a cross-sectional study of HIV-positive MSM (n = 740) enrolled in HIV/AIDS services in a large urban center of Brazil from August 2010 to June 2011. Descriptive, bivariate and multivariate statistics were conducted using STATA 12 to examine the relationship between a range of variables and late presentation, defined as having a first CD4 count <350 cells/mm³.

Results

Within the sample, the prevalence of LP was 63.1%. Men who self-identified as heterosexual (AOR 1.54 and 95% CI 1.08 - 2.20) compared to men who self-identified as homosexual and bisexual were at increased odds of late presentation. Additionally, men age 30 and older (AOR 1.56, 95% CI 1.01 – 2.43) compared to individuals age 18–29 experienced increased odds of late presentation among MSM.

Conclusions

The prevalence of LP in this population was higher than noted in the global literature on LP among MSM. Heterosexual men and older age individuals experienced substantial barriers to HIV care. The stigma around same-sex behaviors and the current focus of HIV prevention and treatment campaigns on younger age individuals may limit patients’ and providers’ awareness of the risk for HIV and access to available services. In addition to addressing HIV-specific barriers to care, developing effective strategies to reduce late presentation in Brazil will require addressing social factors - such as stigma against diverse sexualities - to concretely identify and eliminate barriers to available services. Only in so doing can we make currently invisible people, visible.

What's pregnancy got to do with it? Late presentation to HIV/AIDS services in Northeastern Brazil

Despite the known benefits of early treatment initiation for individual morbidity and mortality, as well as for reducing the risk of transmission, late presentation (LP) to HIV/AIDS services remains a major concern in many countries. There is little information on LP from middle- and low-income countries and studies that do evaluate LP commonly disaggregate data by sex. It is rare, however, for researchers to further disaggregate the data by pregnancy status so it remains unclear if pregnancy status modifies the effects associated with sex. The study was conducted at the only State Reference Center for HIV/AIDS in Salvador, Brazil's third largest city. LP was defined as a patient accessing services with a CD4 < 350 cells/mm(3). Data were abstracted from the electronic medical records of 1421 patients presenting between 2007 and 2009. CD4 counts and viral load (VL) information was validated with data from the National CD4/VL Database. Descriptive and bivariate statistics were conducted to inform the multivariate analysis. Adjusted prevalence ratios (APR) were estimated using generalized linear models due to the high frequency of the outcome. Half of the sample (52.5%; n = 621) was classified as LP. Compared to the prevalence among pregnant women (21.1%), the prevalence of LP was more than twice as high among non-pregnant women (56.0%) and among men (55.4%). The multivariate analysis demonstrated no statistical difference between men and nonpregnant women (APR 1.04; 95%CI 0.92-1.19), but the APR of LP for nonpregnant women was 53% less than men (APR 0.47; 95%CI 0.33-0.68). These results highlight the importance of analyzing data disaggregated not only by sex but also by pregnancy status to accurately identify the risk factors associated with LP so that programs and policies can effectively and efficiently address LP in Brazil and beyond.