Heterosexual men and women with HIV test positive at a later stage of infection than homo- or bisexual men

Duration of delayed diagnosis in HIV/AIDS patients in Iran: a CD4 depletion model analysis

Objective

Delayed diagnosis of HIV can lead to an inappropriate response to antiretroviral therapy (ART), rapid progression of the disease, and death. It can also carry harmful effects on public health due to the increment of transmission. This study aimed to estimate the duration of delayed diagnosis (DDD) in HIV patients in Iran.

Methods

This hybrid cross-sectional cohort study was conducted on the national HIV surveillance system database (HSSD). Linear mixed effect models with random intercept, random slope, and both were used to estimate the parameters required for the CD4 depletion model to determine the best-fitted model for DDD, stratified by the route of transmission, gender, and age group.

Results

The DDD was estimated in 11,373 patients including 4,762 (41.87%) injection drug users (IDUs), 512 (4.5%) men who had sexual contact with men (MSM), 3,762 (33.08%) patients with heterosexual contacts, and 2,337 (20.55%) patients who were infected through other routes of HIV transmission. The total mean DDD was 8.41 ± 5.97 years. The mean DDD was 7.24 ± 0.08 and 9.43 ± 6.83 years in male and female IDUs, respectively. In the heterosexual contact group, DDD was obtained as 8.60 ± 6.43 years in male patients and 9.49 ± 7.17 years in female patients. It was also estimated as 9.37 ± 7.30 years in the MSM group. Furthermore, patients infected through other transmission routes were found with a DDD of 7.90 ± 6.74 years for male patients and a DDD of 7.87 ± 5.87 years for female patients.

Conclusion

A simple CD4 depletion model analysis is represented, which incorporates a pre-estimation step to determine the best-fitted linear mixed model for calculating the parameters required for the CD4 depletion model. Considering such a noticeably high HIV diagnostic delay, especially in older adults, MSM, and heterosexual contact groups, regular periodic screening is required to reduce the DDD.

Late Presenters of HIV Infection in an HIV Unit of a Tertiary University Hospital in a Rural Region of Greece

A significant progress has been made over the years in the prognosis and treatment of patients with early diagnosis of HIV infection. However, late presentation of a large number of patients remains a serious public health problem. The aim of our study is to highlight the dimensions of the problem by evaluating the data from the HIV Unit of Alexandroupolis, a rural region with population heterogeneity and a strategic position between West and East, Europe, and Asia. This was a retrospective study, including 107 patients diagnosed with HIV infection in our unit from 2010 to 2018. Late presenters (LP) were defined as patients diagnosed with a CD4 cell count <350/mm³ or an AIDS-defining condition regardless of CD4 cell count. The proportion of patients diagnosed late was 49.5%. The majority were males in the age group 31-40 years (41.5%). Men who had sex with men were 37.8%. Among LP, 34% were at Center for Disease Prevention and Control stage C3. The most common AIDS-defining condition observed was Pneumocystis jirovecii Pneumonia (15.1%), followed by esophageal candidiasis (7.5%) and cryptococcal meningitis (3.8%). In addition, immune reconstitution inflammatory syndrome was documented (3.8%). A high percentage of patients were also coinfected with hepatitis B (22.6%) virus. The notably high percentage of LP in our unit demonstrates that late presentation remains a challenge for public health. Further efforts must be made to ensure an early diagnosis of HIV infection. The early initiation of antiretroviral therapy is vital to reduce viral load to undetectable levels and the risk of HIV transmission.

HIV Testing, Access to HIV-Related Services, and Late-Stage HIV Diagnoses Across US States, 2013-2016

Objectives. To examine state-level factors associated with late-stage HIV diagnoses in the United States.Methods. We examined state-level factors associated with late-stage diagnoses by estimating negative binomial regression models. We used 2013 to 2016 data from the National HIV Surveillance System (late-stage diagnoses), the Behavioral Risk Factor Surveillance System (HIV testing), and the American Community Survey (sociodemographics).Results. Among individuals 25 to 44 years old, a 5% increase in the percentage of the state population tested for HIV in the preceding 12 months was associated with a 3% decrease in late-stage diagnoses. Among both individuals 25 to 44 years of age and those aged 45 years and older, a 5% increase in the percentage of the population living in a rural area was associated with a 2% to 3% increase in late-stage diagnoses.Conclusions. Increasing HIV testing may lower late-stage HIV diagnoses among younger individuals. Increasing HIV-related services may benefit both younger and older people in rural areas.

Late Presentation and Missed Opportunities for HIV Diagnosis in Guatemala

Early HIV diagnosis remains a challenge in many regions with delayed diagnosis resulting in increased morbidity and mortality. We conducted a retrospective cohort study of people living with HIV receiving outpatient care at a large tertiary referral center in Guatemala to describe the proportion of late presenters (LP) and missed opportunities for HIV diagnosis. Of 3686 patients, 2990 (81.1%) were LP who were more likely to be male (60.2% vs. 48.0%, p < 0.0001), heterosexual (88.0% vs. 78.0%, p < 0.0001) and rural dwellers (43.7% vs. 33.8%. p < 0.0001). The proportions of patients who presented late or with AIDS at diagnosis decreased over time. Only 665 patients (18.2%) sought care in the 2 years prior to HIV diagnosis. This study, the first of its kind in Central America to focus on late presenters and missed opportunities for HIV diagnosis, demonstrates extremely high rates of LP in Guatemala. Although in recent years rates of LP have improved somewhat, the need for screening outside of traditional healthcare settings is apparent.

The high incidence of late presenters for HIV/AIDS infection in the Lodz province, Poland in the years 2009-2016: we are still far from the UNAIDS 90% target

The present study retrospectively analyses the prevalence of late diagnosis in patients with newly-diagnosed HIV infection in Lodz, Poland from January 2009 to December 2016, and assesses the predictive factors associated with late presenters. Late presentation is defined as a diagnosis of HIV with a CD4 count<350 cells/μL, or the occurrence of an AIDS- defining event, regardless of the CD4 cell count. Two hundred and fifty-nine (62.86%) patients were late presenters, 178 of whom (68.72%) were advanced late presenters (CD4 cell count below 200 cells/μL). Multivariate factors associated with late HIV presentation included referral from physician for HIV testing (OR: 3.95, 95% CI 2.42-6.46), older age (OR: 1.81, 95% CI: 1.38-2.38) and route of HIV transmission. Heterosexual patients (OR 1.98, 95% CI: 1.01-3.90), active drug users (OR: 3.49, 95% CI: 1.63-7.48) and patients who did not report the route of transmission (OR: 4.29, 95%: CI 1.45-12.62) were more likely to present late than MSM subjects. In conclusion, the majority of HIV-infected patients are still diagnosed late. There is a need for expanded testing not only in MSM group, in which HIV prevalence is the highest, but also in intravenous drug users, or among subjects who are heterosexual or from a higher age group.

AIDS-Defining Illnesses at Initial Diagnosis of HIV in a Large Guatemalan Cohort

Background

Anecdotal evidence suggests that a high proportion of patients diagnosed with HIV in Guatemala present with AIDS. There remain limited data on the epidemiology of AIDS-defining illnesses (ADIs) in Central America.

Methods

We conducted a retrospective cohort study of all patients living with HIV at the largest HIV clinic in Guatemala. Charts were analyzed for clinical and demographic data. Presence of an ADI was assessed by US Centers for Disease Control definitions; patients who presented with an ADI were compared with those without ADI using descriptive statistics.

Results

Of 3686 patients living with HIV, 931 (25.3%) had an ADI at HIV diagnosis, 748 (80.3%) of whom had CD4 counts lower than 200 cells/mm³. Those with ADIs were more likely to be male (67.5% vs 54.6%; P < .0001) and heterosexual (89.4% vs 85.0%; P = .005). The most common ADIs were Mycobacterium tuberculosis (55.0%), Pneumocystis jirovecii pneumonia (13.7%), esophageal candidiasis (13.4%), and histoplasmosis (11.4%). Histoplasmosis and HIV wasting syndrome were both more common among rural patients.

Conclusions

In this large Guatemalan cohort of patients currently living with HIV, a significant portion presented with an ADI. These data inform the most common ADIs diagnosed among survivors, show that histoplasmosis is more commonly diagnosed in rural patients, and suggest that HIV wasting syndrome may reflect missed histoplasmosis diagnoses.

Cascade of care among HIV patients diagnosed in 2013 in Georgia: Risk factors for late diagnosis and attrition from HIV care

INTRODUCTION

The major challenge in the HIV epidemic in Georgia is a high proportion of undiagnosed people living with HIV (estimated 48%) as well as a very high proportion of late presentations for care, with 66% presenting for HIV care with CD4 count <350 and 40% with <200 cells/mm3, in 2013. The objectives of this study was to evaluate patient engagement in the continuum of HIV care for HIV patients diagnosed in 2013 and, within this cohort, to evaluate factors associated with late diagnosis and attrition from care.

METHODS

Factors associated with late diagnosis were analyzed through binary logistic regression. Exposure variables were the mode of HIV transmission (injecting drug use, male-to-male contact, and heterosexual contact), gender (male vs female), and age (categorized by median value ≤36 vs >36). In addition, CD4 count at diagnosis (cells/mm3) (≤350 or >350) together with all above factors were tested for the association with attrition through Poisson regression.

RESULTS

Overall, 317 patients retained in care, representing 65% of those diagnosed (n = 488). Out of eligible 295 patients, 89.5% were on treatment and 84% of those viral load count was measured after 6 months of antiretroviral treatment initiation had HIV-1 viral load <1000 copies/mL. Patients reporting injecting drug use as a route-of HIV transmission had two times the odds (95% confidence interval = 1.34-3.49) to be diagnosed late and patients reporting male-to-male contact as a way of HIV transmission had half the odds (odds ratio = 0.46 (95% confidence interval = 0.26-0.81)) of late diagnosis compared to patients acquiring HIV through heterosexual contact. Patients older than 36 years were more likely to being diagnosed late.

CONCLUSION

More attention should be given to injecting drug users as they represent the most at-risk population for late diagnosis together with older age and attrition.

Examining the health and health service utilization of heterosexual men with HIV: a community-informed scoping review

The prevalence of HIV infection among heterosexual men has increased. Consequently, the need for health and support services for this group is likely to increase. We conducted a scoping review of studies regarding the health and health service use of heterosexual men with HIV that was informed by research priorities identified by this community. We searched six databases from inception to August 2014. We included all English-language qualitative and quantitative studies examining the health and health service use of heterosexual men with HIV. Our search strategy yielded 2665 references, of which 70 were included in the scoping review. We summarized the research into the following domains identified by summit participants: treatment of HIV and its complications (n = 9), health and social support services utilization (n = 27), social determinants of health (n = 20), prevention (n = 11), family planning (n = 4) and psychosocial research (n = 33). Key findings from the review included poor mental health-related well-being, over-representation among "late presenters" to care and greater fear of disclosure of HIV status relative to men who have sex with men. In general, research conducted to date was not well aligned with the priorities identified by the community.

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.

Late HIV diagnosis: Differences by rural/urban residence, Florida, 2007-2011

The purpose of this retrospective cohort study was to identify individual-level demographic and community-level socioeconomic and health care resource factors associated with late diagnosis of HIV in rural and urban areas of Florida. Multilevel modeling was conducted with linked 2007-2011 Florida HIV surveillance, American Community Survey, Area Health Resource File, and state counseling and testing data. Late diagnosis (defined as AIDS diagnosis within 3 months of HIV diagnosis) was more common in rural than urban areas (35.8% vs. 27.4%) (p<0.0001). This difference persisted after controlling for age, sex, race/ethnicity, HIV transmission mode, country of birth, and diagnosis year (adjusted OR 1.39; 95% CI 1.17-1.66). In rural areas, older age and male sex were associated with late HIV diagnosis; zip code-level socioeconomic and county level health care resource variables were not associated with late diagnosis in rural areas. In urban areas only, Hispanic and non-Hispanic black race/ethnicity, foreign birth, and heterosexual mode of transmission were additionally associated with late HIV diagnosis. These findings suggest that, in rural areas, enhanced efforts are needed to target older individuals and men in screening programs and that studies of psychosocial and structural barriers to HIV testing in rural and urban areas be pursued.

Patients who present late to HIV care and associated risk factors in Nigeria

OBJECTIVES

Our objectives were to assess trends in late presentation and advanced HIV disease (AHD) and determine associated risk factors.

METHODS

We conducted a retrospective cohort analysis of patients who had received care and treatment at the AIDS Prevention Initiative Nigeria Plus (APIN)/Harvard School of Public Health-President's Emergency Plan for AIDS Relief (PEPFAR) programme at the Jos University Teaching Hospital, Jos, Nigeria from 2005 to 2010. We used the European Consensus Definition to assess trends in late presentation (CD4 count < 350 cells/μL or AIDS-defining illness) and AHD (CD4 count < 200 cells/μL or AIDS-defining illness) and evaluated associated risk factors using logistic regression methods.

RESULTS

Among 14,487 eligible patients, 12,401 (85.6%) were late presenters and 9127 (63.0%) presented with AHD. Late presentation decreased from 88.9% in 2005 to 80.1% in 2010 (P < 0.001). Similarly, AHD decreased from 67.8% in 2005 to 53.6% in 2010 (P < 0.001). In logistic regression models adjusting for sociodemographic and biological variables, male sex [adjusted odds ratio (aOR) = 1.80; 95% confidence interval (CI) 1.60-2.04], older age (aOR = 1.37; 95% CI 1.22-1.54), civil service employment (aOR = 1.48; 95% CI 1.00-2.21), referral from out-patient (aOR = 2.18; 95% CI 1.53-3.08) and in-patient (aOR = 1.55; 95% CI 1.11-2.17) services, and hepatitis B virus (aOR = 1.43; 95% CI 1.26-1.63) and hepatitis C virus (aOR = 1.18; 95% CI 1.02-1.37) coinfections were associated with late presentation. Predictors of AHD were male sex (aOR = 1.67; 95% CI 1.54-1.82), older age (aOR = 1.26; 95% CI 1.16-1.36), unemployment (aOR = 1.34; 95% CI 1.00-1.79), referral from out-patient (aOR = 2.40; 95% CI 1.84-3.14) and in-patient (aOR = 1.97; 95% CI 1.51-2.57) services and hepatitis B virus coinfection (aOR = 1.30; 95% CI 1.19-1.42).

CONCLUSIONS

Efforts to reduce the proportion of patients who first seek care at late stages of disease are needed. The identified risk factors should be utilized in formulating targeted public health interventions to improve early diagnosis and presentation for HIV care.

Analysis of the immunologic status of a newly diagnosed HIV positive population in China

Background

The immunologic status of a newly diagnosed HIV positive population in the era of antiretroviral therapy in China has not been extensively evaluated. We conducted a cross-sectional survey to evaluate the CD4 counts of newly diagnosed HIV-infected persons and determine the factors influencing these counts in China.

Methods

Two thousand eight hundred and sixty-six newly diagnosed HIV-infected patients from 10 provinces in China were selected during 2009 to 2010. Serum samples were collected to measure CD4 counts by flow cytometry. Demographics and medical histories were recorded. Multivariate logistic regression models were used to analyze factors associated with low CD4 count (<100 cells/mm³) at HIV diagnosis.

Results

Among the 2866 patients, 2159 (75.33%) were male. Mean age was 40 years (range: 18–86 years). The median CD4 count at HIV diagnosis was 83 cells/mm³, 72.02% of the patients had a CD4 count that was ≤200 cells/mm³, 53.98% had CD4 counts <100 cells/mm³. The difference in CD4 counts between males and females was not statistically significant (P=0.469). The median CD4 count differed significantly according to age (P=0.002), province (P<0.001), ethnicity (P<0.001) and HIV transmission route (P<0.001). In multivariate logistic analysis, factors associated with greater odds of low CD4 count at HIV diagnosis included male sex, younger age, HIV transmission route classified as unknown transmission risk, having been diagnosed in provinces Guangxi, Henan, Heilongjiang, Jiangxi, Shanghai and Yunnan.

Conclusions

At the time of HIV diagnosis, a large proportion of HIV-infected patients in China had an initial CD4 count that was consistent with relatively advanced disease. Low CD4 count was associated with male gender, younger age, route of HIV transmission and geographical areas. HIV testing policy that promotes routine testing for HIV infection is needed to facilitate earlier HIV diagnosis.

Missed opportunities for HIV testing in newly-HIV-diagnosed patients, a cross sectional study

BACKGROUND

In France, 1/3 HIV-infected patients is diagnosed at an advanced stage of the disease. We describe missed opportunities for earlier HIV testing in newly-HIV-diagnosed patients.

METHODS

Cross sectional study. Adults living in France for ≥1 year, diagnosed with HIV-infection ≤6 months earlier, were included from 06/2009 to 10/2010. We collected information on patient characteristics at diagnosis, history of HIV testing, contacts with healthcare settings, and occurrence of HIV-related events 3 years prior to HIV diagnosis. During these 3 years, we assessed whether or not HIV testing had been proposed by the healthcare provider upon first contact in patients notifying that they were MSM or had HIV-related conditions.

RESULTS

1,008 newly HIV-diagnosed patients (mean age: 39 years; male: 79%; MSM: 53%; diagnosed with an AIDS-defining event: 16%). During the 3-year period prior to HIV diagnosis, 99% of participants had frequented a healthcare setting and 89% had seen a general practitioner at least once a year. During a contact with a healthcare setting, 91/191 MSM (48%) with no HIV-related conditions, said being MSM; 50 of these (55%) did not have any HIV test proposal. Only 21% (41/191) of overall MSM who visited a healthcare provider received a test proposal. Likewise, 299/364 patients (82%) who sought care for s had a missed opportunity for HIV testing.

CONCLUSIONS

Under current screening policies, missed opportunities for HIV testing remain unacceptably high. This argues in favor of improving risk assessment, and HIV-related conditions recognition in all healthcare facilities.

Older HIV-infected individuals present late and have a higher mortality: Brighton, UK cohort study

Background

Initiating therapy with a low CD4 cell count is associated with a substantially greater risk of disease progression and death than earlier initiation. We examined factors associated with late presentation of HIV using the new European consensus definition (CD4 cell count <350 cells/mm³) and mortality.

Methods

Patients newly diagnosed with HIV infection at a UK clinic were recruited from January 1996 to May 2010. Factors associated with late presentation were assessed using logistic regression. Factors associated with mortality rates were analysed using Poisson regression.

Results

Of the 1536 included in the analysis, 86% were male and 10% were aged 50 years and older. Half the cohort (49%) had a CD4 cell count below 350 cells/mm³ at presentation (“late presentation”). The frequency of late presentation was highest in those aged 50 years or older and remained unchanged over time (64.3% in 1996-1998 and 65.4% in 2008-2010). In contrast, among those aged less than 50 years, the proportion with late presentation decreased over time (57.1% in 1996-1998 and 38.5% in 2008-2010). Other factors associated with late presentation were African ethnicity and being a male heterosexual.

The mortality rate was 15.47/1000 person-years (pyrs) (95%-CI: 13.00-18.41). When compared with younger adults, older individuals had a higher mortality, after adjusting for confounders (rate ratio (RR) = 2.87; 95%-CI: 1.88-4.40).

Conclusions

Older adults were more likely to present late and had a higher mortality. Initiatives to expand HIV testing in clinical and community setting should not neglect individuals aged over 50.

Estimation of HIV-testing rates to maximize early diagnosis-derived benefits at the individual and population level

Background

In HIV infection, initiation of treatment is associated with improved clinical outcom and reduced rate of sexual transmission. However, difficulty in detecting infection in early stages impairs those benefits. We determined the minimum testing rate that maximizes benefits derived from early diagnosis.

Methods

We developed a mathematical model of HIV infection, diagnosis and treatment that allows studying both diagnosed and undiagnosed populations, as well as determining the impact of modifying time to diagnosis and testing rates. The model’s external consistency was assessed by estimating time to AIDS and death in absence of treatment as well as by estimating age-dependent mortality rates during treatment, and comparing them with data previously reported from CASCADE and DHCS cohorts.

Results

In our model, life expectancy of patients diagnosed before 8 years post infection is the same as HIV-negative population. After this time point, age at death is significantly dependent on diagnosis delay but initiation of treatment increases life expectancy to similar levels as HIV-negative population. Early mortality during HAART is dependent on treatment CD4 threshold until 6 years post infection and becomes dependent on diagnosis delay after 6 years post infection. By modifying testing rates, we estimate that an annual testing rate of 20% leads to diagnosis of 90% of infected individuals within the first 8.2 years of infection and that current testing rate in middle-high income settings stands close to 10%. In addition, many differences between low-income and middle-high incomes can be predicted by solely modifying the diagnosis delay.

Conclusions

To increase testing rate of undiagnosed HIV population by two-fold in middle-high income settings will minimize early mortality during initiation of treatment and global mortality rate as well as maximize life expectancy. Our results highlight the impact of achieving early diagnosis and the importance of strongly work on improving HIV testing rates.

The impact of living with HIV: differences in experiences of stigma for heterosexual and homosexual people living with HIV in Australia

Background HIV in Australia has been closely aligned with the gay community and continues to disproportionately affect members of this community. Although heterosexual transmission remains low, recently there has been an increase in new HIV diagnoses attributable to heterosexual sex. This highlights the need to address the health and social consequences for heterosexual people living with HIV (PLHIV). This subanalysis of a larger study compared the experiences of stigma, health and wellbeing of a sample of gay and heterosexual PLHIV. Methods: Data were drawn from a study of experiences of stigma among PLHIV in Australia. All 49 participants who reported being heterosexual were included, as were 49 participants randomly selected from the 611 gay participants. The samples were compared on perceived HIV stigma, HIV treatment-related stigma, perceived negative reactions of others, HIV status disclosure, and health and wellbeing measures. Results: The findings illustrate that heterosexual PLHIV have more negative experiences in terms of both general HIV stigma and treatment-related stigma than gay PLHIV. The heterosexual PLHIV also perceived greater negative reactions in relation to their HIV status by different people in their social environment and were less likely to access treatment than the gay PLHIV. There were no differences between the two groups in any of the health and wellbeing measures. Conclusions: This study shows that in the Australian context, heterosexual PLHIV may feel more stigmatised than gay PLHIV. In view of lower HIV treatment uptake in heterosexual PLHIV, addressing HIV-related stigma could contribute to increasing access to HIV treatment.

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.

Late presenters in new HIV diagnoses from an Italian cohort of HIV-infected patients: prevalence and clinical outcome

BACKGROUND

To study the prevalence, predictors and outcome of late HIV diagnosis in the Icona cohort, according to the new European consensus definition of late diagnosis.

METHODS

In this observational cohort study we investigated patients diagnosed with HIV over 3 months preceding enrolment who were defined as diagnosed late if they presented with AIDS or a CD4(+) T-cell count ≤ 350/mm³ (European consensus definition). We estimated the prevalence of late diagnosis, identified factors associated with being diagnosed late and looked at the prognostic value of the European consensus definition of late presentation to predict subsequent clinical progression (new AIDS events or death).

RESULTS

In total, 1,438/2,276 patients (63%) were defined as diagnosed late using the new European Consensus definition. Of these, 387 (16%) were AIDS-presenters. Predictors of being diagnosed late were older age, non-Italian origin, high HIV RNA and unemployment (versus retirement). A total of 293 patients showed clinical progression (3 events/100 person-years of follow-up, 95% CI: 2.7-3.4). Presenting late was strongly associated with a >5-fold increased risk of disease progression.

CONCLUSIONS

In our observational setting with free access to care, more than 60% of new HIV diagnoses occurred below the recommended threshold for initiating antiretroviral treatment. Presenting late for care was associated with a high risk of clinical progression.

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.

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.

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.

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.

Late presenters to HIV care and treatment, identification of associated risk factors in HIV-1 infected Indian population

Background

Timely access to antiretroviral therapy is a key to controlling HIV infection. Late diagnosis and presentation to care diminish the benefits of antiretrovirals and increase risk of transmission. We aimed to identify late presenters in patients sent for first CD4 T cell count after HIV diagnosis, for therapy initiation evaluation. Further we aimed at identifying patient factors associated with higher risk of late presentation.

Methods

Retrospective data collection and analysis was done for 3680 subjects visiting the laboratory for CD4 T cell counts between 2001 and 2007. We segregated the patients on basis of their CD4 T cell counts after first HIV diagnosis. Factors associated with risk of late presentation to CD4 T cell counts after HIV diagnosis were identified using univariate analysis, and the strength of association of individual factor was assessed by calculation of odds ratios.

Results

Of 3680 subjects, 2936 (83.37%) were defined as late presenters. Late testing varied among age groups, transmission categories, and gender. Males were twice as likely to present late as compared to females. We found significant positive association of heterosexual transmission route (p < 0.001), and older age groups of 45 years and above (p = 0.0004) to late presentation. Female sex, children below 14 years of age and sexual contact with HIV positive spouse were associated with significantly lower risks to presenting late. Intravenous drug users were also associated with lower risks of late presentation, in comparison to heterosexual transmission route.

Conclusions

The study identifies HIV infected population groups at a higher risk of late presentation to care and treatment. The risk factors identified to be associated with late presentation should be utilised in formulating targeted public health interventions in order to improve early HIV diagnosis.

[Delayed diagnosis of HIV infection in Spain]

OBJECTIVES

To analyse the prevalence of delayed diagnosis (DD) of human immunodeficiency virus (HIV) infection, the trends over time and its determining factors from the Newly Diagnosed HIV-infected individuals Information System (SINIVIH) data, in process of being implemented in Spain.

METHODS

Cross-sectional study of newly diagnosed HIV-infected individuals between 2003 and 2007 in the 8 currently participating Spanish autonomous regions (AR). DD was defined as a CD4 count <200cells/μL at diagnosis. Adjusted odds ratios with 95% confidence interval were calculated using logistic regression (OR; 95%CI).

RESULTS

Among the 5785 newly diagnosed HIV cases reported, 4798 had a CD4 cell count at diagnosis. Of these, 37.3% met the DD definition. An additional 19% had between 200 and 350cells/μL. The proportion of DD was lower for women than for men (32.9% versus 38.6%). According to exposure category, it was higher in heterosexuals (42.4%) and injecting drug users (IDUs) (40.1%) than in men who have sex with men (MSM) (26.7%). In the Spanish patient group, in multivariate logistic regression analyses, adjusting for AR and year of diagnosis, men were more likely to have a DD (OR=1.49; 95%CI:1.21-1.85). Compared to younger patients (20-29 years), LD was more frequent in older: 30-39 years (OR=2.08; 95% CI:1.63-2.67), 40-49 years (OR=3.98; 95% CI:3.07-5.16) and >49 years (OR=6.77; 95% CI:5.10-9.00); and compared to MSM, was more frequent in heterosexuals (OR=1.75; 95% CI:1.43-2.15) and IDUs (OR=1.75; 95% CI:1.38-2.22). DD decreased from 2003 to 2007 (OR=1.38; 95% CI:1.08-1.76). The same associated factors were found in immigrants, but with different magnitude: stronger association with men, heterosexuals and IDUs, and weaker association with older age.

CONCLUSIONS

DD affects almost four in every ten newly diagnosed HIV-infected individuals, and is significantly more common among men, age group over 30 years, IDUs and heterosexuals. These are associated factors both in Spanish and immigrants, but in the last group the association is stronger. Strategies to increase the perception of risk among these groups are needed, as well as the implementation of the SINIVIH in the whole country to improve and to extend the information on DD.

Heterosexual HIV and sexual partnerships between injection drug users and noninjection drug users

Sex partnerships with injection drug users (IDU) are an understudied network-level risk factor for heterosexual HIV infection. Heterosexuals with no history of injection were recruited from high-risk areas in New York City through respondent-driven sampling. We examined the prevalence of IDU sex partnerships among these non-IDU, the factors associated with having a past year IDU partner, and the independent association of HIV infection and IDU sex partnerships in multiple logistic regression. Of the 601 non-IDU in this analysis, 13.8% had a sex partner in the past year with a history of injection. IDU partnerships were significantly more common among women and those with higher levels of unprotected sex and drug and alcohol use. Overall, 7.0% tested positive for HIV. HIV prevalence was higher (p = 0.07) for participants with IDU partners (9.6%) compared to those with no IDU partners (4.6%). In multiple logistic regression, participants with IDU partners were over twice as likely to be HIV-infected (p = 0.08). Sex partnerships with IDU were common and may play an important role in heterosexual HIV transmission in areas with large IDU populations. Prevention interventions to encourage the disclosure of injection history and risk reduction specifically for those with IDU partners are indicated.

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.

Determinants of late HIV diagnosis among different transmission groups in Finland from 1985 to 2005

OBJECTIVES

To study determinants of late HIV diagnosis in a low-HIV-prevalence (<0.1%) country where HIV spread among men who have sex with men (MSM) and heterosexuals in the 1980s, and among injecting drug users (IDUs) in the late 1990s.

METHODS

Newly diagnosed HIV cases referred to the Helsinki University Central Hospital between 1985 and 2005 were reviewed to identify determinants of late HIV diagnosis, defined as diagnosis when the first CD4 count was <200 cells/microL, or when AIDS occurred within 3 months of HIV diagnosis. Determinants of late diagnosis were analysed using multivariate logistic regression.

RESULTS

Among 934 HIV cases, 211 (23%) were diagnosed late. In the first 4-year interval of each sub-epidemic (1985-1989 for MSM and heterosexuals, 1998-2001 for IDUs), rates of late HIV diagnosis were 13%, 18% and 6%, respectively, but increased thereafter to 29%, 27% and 37%. Late diagnosis was associated with non-Finnish ethnicity, older age, male gender, lack of earlier HIV testing, diagnosis at health care settings and later stage of the sub-epidemic.

CONCLUSIONS

The lower rate of late diagnosis in the first 4-year interval of each HIV sub-epidemic suggests that the early stages of the HIV epidemic in Finland were detected early. This factor may have contributed to the low prevalence of HIV infection in Finland. The stage and age of the epidemic should be taken into account when interpreting the data on late HIV diagnosis, especially in cross-country comparisons.

Causes of death in HIV-infected women: persistent role of AIDS. The 'Mortalité 2000 & 2005' Surveys (ANRS EN19)

BACKGROUND

Little is known about the causes of death in human immunodeficiency virus (HIV)-infected women in the era of combination antiretroviral therapy (ART).

METHODS

In the French nationwide Mortalité 2000 and 2005 surveys, physicians reported causes of deaths in HIV-infected adults in 2000 and 2005, using a standardized questionnaire. We used multivariate logistic regression models to study the association between gender and AIDS-defining causes of death, adjusting for other characteristics.

RESULTS

Of the 1013 HIV-infected adults who died in 2005, 247 (24%) were women. Half of women were infected through heterosexual contacts, compared with 25% men. In 2005, the proportion of AIDS-defining causes of death was higher in women than in men (43 vs 34%; P = 0.01), whereas it had been the same in 2000 (47% in women and men). In 2005, women died less frequently than men from respiratory malignancies (lung, ear/nose/throat) and cardiovascular disease (9% of all causes of death in women compared with 16% in men; P = 0.004), and suicides or accidents (4 vs 9%; P = 0.02). Socio-economic precariousness, younger age, less alcohol and tobacco consumption and lack of prior ART explained the higher proportion of deaths from AIDS in women compared with men.

CONCLUSIONS

The higher proportion of AIDS-related deaths in women is probably explained by two factors: (i) some HIV-infected women, especially migrants in poor socio-economic conditions, may not have access to optimal care; and (ii) a lower prevalence of risk factors for respiratory, cardiovascular and violent deaths means that the risk of dying from non-AIDS causes may be lower in women.

Time to testing and accessing care among a population of newly diagnosed patients with HIV with a high proportion of Canadian Aboriginals, 1998-2003

Early HIV diagnosis and treatment are important for decreasing HIV transmission and morbidity. By using initial CD4 counts and time to first viral load test, we examined the stage of disease at the time of diagnosis and the time to accessing medical care after diagnosis, respectively. Initial CD4 count, first HIV viral load test, demographics and exposure risks were obtained for all newly diagnosed HIV cases in Northern Alberta from 1998-2003. Time to accessing care was determined as the time between diagnosis and the first viral load test. Correlates were determined using simple descriptive statistics and survival analysis methods. Of 526 HIV cases, median age was 36 years (interquartile range [IQR]: 31-43), 69% were males and 41% were Aboriginal. At diagnosis, 28% of the population had CD4 counts less than 200 cells=mm3. After diagnosis, 92.2% accessed care and median time to care for the entire population was 29 days. In multivariate analysis, age at diagnosis less than 45 years was independently associated with longer median time to care (versus age 45 years or more; adjusted hazard ratio [AHR]: 0.69; 95% confidence interval [CI] 0.55-0.88), while Aboriginal ethnicity (versus Caucasian; AHR: 0.82; 95% CI 0.68-1.01), and nonmetropolitan residence (versus metropolitan; AHR: 0.81; 95% CI 0.65-1.00) were marginally significant correlates for longer times to care. Although more than one quarter of cases were diagnosed at relatively advanced stages of infection, the majority of new HIV cases in Northern Alberta accessed care within 2 months of diagnosis. We need to explore new strategies to facilitate and promote earlier access to testing among individuals at risk.

Optimal HIV testing and earlier care: the way forward in Europe

The articles in this supplement were developed from a recent pan-European conference entitled 'HIV in Europe 2007: Working together for optimal testing and earlier care', which took place on 26-27 November in Brussels, Belgium. The conference, organized by a multidisciplinary group of experts representing advocacy, clinical and policy areas of the HIV field, was convened in an effort to gain a common understanding on the role of HIV testing and counselling in optimizing diagnosis and the need for earlier care. Key topics discussed at the conference and described in the following articles include: current barriers to HIV testing across Europe, trends in the epidemiology of HIV in the region, problems associated with undiagnosed infection and the psychosocial barriers impacting on testing. The supplement also provides a summary of the World Health Organization's recommendations for HIV testing in Europe and an outline of an indicator disease-guided approach to HIV testing proposed by a committee of experts from the European AIDS Clinical Society (EACS). We hope that consideration of the issues discussed in this supplement will help to shift the HIV field closer towards our ultimate goal: provision of optimal HIV testing and earlier care across the whole of the European region.

Late presentation to care for HIV infection in Croatia and the effect of interventions during the Croatian Global Fund Project

There are limited data on how HIV prevention interventions affect individuals presenting to care in settings with a low-level HIV epidemic. We examined whether interventions undertaken during the Croatian Global Fund Project in 2004-2006 had an influence on patients entering care. The number of men who have sex with men (MSM) presenting in 2004-2006 (n = 86) was 59% higher than in 2001-2003 (n = 54); in heterosexual patients the increase was 14% (n = 51 in 2001-2003; n = 58 in 2004-2006). MSM presented at a younger age (median 32 years) in 2004-2006 than in 2001-2003 (median 36 years). Late presentation to care was found in 28% of MSM and in 59% of heterosexual patients in 2004-2006. MSM were less frequently late presenters in 2004-2006 compared with 2001-2003 (odds ratio, 0.48; 95% confidence interval, 0.24 to 0.99; P = 0.046). Additional strategies for earlier initiation of care must be developed for MSM and particularly for heterosexual patients.

Concurrent HIV/AIDS diagnosis increases the risk of short-term HIV-related death among persons newly diagnosed with AIDS, 2002-2005

Despite the overall effectiveness and availability of highly active antiretroviral therapy (HAART), 1500 HIV-related deaths still occur annually in New York City. In considering ways to further reduce deaths, we assessed the contribution of concurrent HIV/AIDS diagnosis to HIV-related mortality in New York City among persons newly diagnosed with AIDS. We used Cox regression to conduct a retrospective cohort analysis of HIV-related mortality among 15,211 residents age 13+ reported with AIDS to the population-based HIV/AIDS registry between January 2002 and June 2005. Concurrent HIV/AIDS diagnosis was defined as a diagnosis of AIDS occurring within 1 month of initial diagnosis of HIV. HIV-related mortality was 20.2% among persons diagnosed concurrently and 12.2% among those diagnosed nonconcurrently (p < 0.0001). Concurrent HIV/AIDS was associated with more than twice the risk of HIV-related death within the 4 months after diagnosis (hazard ratio [HR] 2.27, 95% confidence interval [CI] 1.94-2.65) but no increased risk thereafter (HR 1.12, 95% CI 0.77-1.61). Other significant predictors of death included injection drug use and birth in the Caribbean or Latin America. After 4 years 11.9% of all HIV-related deaths were attributable to a concurrent HIV/AIDS diagnosis. Public health initiatives that facilitate early diagnosis of HIV may reduce HIV-related mortality by giving people the opportunity to initiate care and begin treatment with HAART before immunosuppression places them at risk for opportunistic illness and death.

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.

Optimal Timing and Best Antiretroviral Regimen in Treatment-naive HIV-Infected Individuals with Advanced Disease

The introduction of highly active antiretroviral therapy (HAART) in developed countries has achieved a good control of HIV infection. Despite this, a delayed HIV diagnosis makes it necessary to start antiretroviral treatment in individuals with severe impairment of their immunological function. Very often, this is accompanied by an opportunistic infection that needs to be treated, with a consequent complication of management because of overlapping toxicities and pharmacokinetic interactions with antiretroviral drugs, and a greater pill burden. All this could impair adherence and reconstitution of the immune function with a paradoxical clinical worsening in some patients, especially if the CD4 cell count is below 50 cells/microl. The best antiretroviral regimen and the best timing for starting antiretroviral therapy in treatment-naive patients with advanced infection have not yet been established. Recommendations for the clinical management of advanced HIV disease come from panels of experts in the therapy of opportunistic infections and antiretroviral treatment, and they advise starting combined antiretroviral therapy 2-4 weeks after initiating treatment of the opportunistic infection. Many patients have been successfully treated with a pharmacologically enhanced (boosted) protease inhibitor (mainly lopinavir/ritonavir)-based regimens. The efficacy of non-nucleoside reverse transcriptase inhibitor-based regimens for the treatment of very immunosuppressed patients has been tested in few clinical trials during the HAART era. Some cohort studies and randomized clinical trials support the use of efavirenz-based antiretroviral therapy for the treatment of advanced HIV-1-infected patients; however, recent randomized controlled data suggest, in a moderately advanced HIV population, a better CD4 cell recovery for lopinavir-ritonavir than for efavirenz-treated patients, but a greater virological suppression in the efavirenz arm. Further randomized clinical trials are needed in order to determine whether the efficacy, tolerability and the immunological reconstitution of efavirenz-based therapy can match that achieved with lopinavir/ritonavir or other current boosted protease inhibitor regimens in advanced patients.

Late Presentation of HIV-Infected Individuals

Late presentation remains a major concern despite the dramatically improved prognosis realized by ART. We define a first presentation for HIV care during the course of HIV infection as ‘late’ if an AIDS-defining opportunistic disease is apparent, or if CD4+ T-cells are <200/μl. In the Western world, approximately 10 and 30% of HIV-infected individuals still present with CD4+ T-cells <50 and <200/μl, respectively; estimates are substantially higher for developing countries. Diagnosis and treatment of opportunistic diseases and intense supportive in-hospital care take precedence over ART. Benefits of starting ART without delay, that is, when opportunistic diseases are still active, include faster resolution of opportunistic diseases and a decreased risk of recurrence. The downside of starting ART without delay could include toxicity, drug interactions and immune reconstitution inflammatory syndrome (IRIS). Among asymptomatic or oligosymptomatic individuals presenting late, where ART and primary prophylaxis are initiated, ∼10–20% will become symptomatic from drug toxicity or undiagnosed opportunistic complications, including IRIS, which require appropriate therapies. In this review we describe late presentation to HIV care, the scale of the problem, the evaluation of a late-presenting patient and challenges associated with initiation of potent anti-retroviral therapy (ART) in the setting of acute opportunistic infections and other comorbidities.

Frequency, determinants and consequences of delayed access to care for HIV infection in France

BACKGROUND AND OBJECTIVES

We analysed the frequency and predictors of delayed access to care (DAC) for HIV infection, and its influence on survival.

METHODS

We studied predictors of DAC among 18,721 patients enrolled between 1997 and 2002 in the French Hospital Database on HIV (FHDH), DAC being defined by a CD4* T-cell count below 200 copies/mm3 and/or AIDS at FHDH enrollment. The association of DAC with the initiation of combined antiretroviral therapy (cART) and of DAC with survival were analysed with Cox multivariable models.

RESULTS

The overall prevalence of DAC was 35.7%. Compared with patients under 30 years of age, patients over 60 were 3.5 times more likely to have DAC (P < 10(-4)). Compared with non-migrant women, odds ratios (OR) of DAC were higher among migrant women (1.5), non-migrant men (1.6) and migrant men (1.9; all P < 10(-4)). Compared with men who have sex with men, other transmission groups had an estimated OR for DAC of 1.6 (P < 10(-4)). DAC was more frequent among patients with a recent diagnosis of HIV infection [OR = 1.3, 95% confidence intervals (CI) = (1.2;1.4)]. Patients with DAC received cART earlier than other patients [hazard ratio (HR) = 2.2, 95% CI = (2.1;2.3)]. The DAC/mortality HR was 13.9 in the first 6 months after enrollment in the FHDH, and remained significantly higher than 1 during the subsequent 4 years.

CONCLUSION

DAC is common in France and was associated with a higher mortality, despite early initiation of cART. Earlier access to care and specific clinical management of patients with DAC should be considered.

Detecting Unsuspected HIV Infection With a Rapid Whole-Blood HIV Test in an Urban Emergency Department

OBJECTIVE

To evaluate and compare HIV screening and provider-referred diagnostic testing as strategies for detecting undiagnosed HIV infection in an urban emergency department (ED).

METHODS

From January 2003 through April 2004, study staff offered HIV screening with rapid tests to ED patients regardless of risks or symptoms. ED providers could also refer patients for diagnostic testing. Patients aged 18 to 54 years without known HIV infection were eligible.

RESULTS

Of 4849 eligible patients approached for screening, 2824 (58%) accepted and were tested; 414 (95%) of 436 provider-referred patients accepted and were tested. Thirty-five (1.2%) screened patients and 48 (11.6%) provider-referred patients were infected with HIV (P < 0.001). Of these, 18 (51%) screened patients and 24 (50%) referred patients reported no traditional risk factors; 27 (77%) screened patients and 38 (79%) referred patients entered HIV care. Of HIV-infected patients with CD4 cell counts available, 14 (45%) of 31 screened patients and 37 (82%) of 45 provider-referred patients had <200 cells/microL (P < 0.001).

CONCLUSIONS

ED screening detects HIV infection and links to care patients who may not be tested through risk- or symptom-based strategies. The diagnostic yield was higher among provider-referred patients, but screening detected patients earlier in the course of disease.

Late Diagnosis of HIV Infection

BACKGROUND

Persons diagnosed late in the course of HIV infection may be unknowingly transmitting infection and once diagnosed may have worse outcomes and greater medical expenses.

METHODS

Persons diagnosed with AIDS in San Francisco between 2001 and 2005 were included. Late testers were persons diagnosed with HIV 12 months or less before their AIDS diagnosis. Prevalence trends, demographic and risk correlates, and predictors of late testing were measured.

RESULTS

Among 2139 persons included, 830 (38.8%) were late testers. The prevalence of late testing was stable between 2001 and 2005. Late testing was more likely among persons <30 years old (Odds ratio [OR]: 1.99, 95% confidence interval [CI]: 1.4, 2.8), heterosexuals (OR: 1.88, 95% CI: 1.1, 3.1), persons without a reported risk (OR: 2.88, 95% CI: 1.7, 5.0), persons with private insurance (OR: 1.82, 95% CI: 1.4, 2.4), no insurance (OR: 1.83, 95% CI: 1.4, 2.4), born outside of the United States (OR: 1.64, 95% CI: 1.2, 2.2), and whose initial AIDS diagnosis was an opportunistic infection (OR: 2.24, 95% CI: 1.8, 2.8).

CONCLUSIONS

A large proportion of persons with AIDS have tested late in the course of HIV infection and this proportion has not declined in recent years. Routine testing in medical settings, and use of rapid oral-fluid testing in traditional and nontraditional settings may increase early HIV diagnosis.

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.

Reconsidering HIV testing--consent is still the key

The high quality and easy accessibility of HIV testing in Australia has been one of the reasons for Australia's effective response to the epidemic. However there have been a number of changes in the epidemiology of HIV and new technologies and treatments have emerged since the last Australian HIV policy was released in 1998. Antenatal testing to prevent vertical transmission, the licensing of rapid, point-of-care test kits in the United States and the problem of late diagnosis of infection in some populations are important issues to consider in the context of the drafting of a new HIV testing policy. The terms 'pre- and post-test counselling' are seen, by some, as barriers to HIV testing in the broader community. Reframing the process with a focus on the desired result (i.e. informed consent for voluntary testing) rather than on the process (i.e. pre-test counselling) could be one way to increase the rate of appropriate testing.