Time trends and correlates of late presentation for HIV care in Northern Greece during the decade 2000 to 2010

Estimation of the determinants for HIV late presentation using the traditional definition and molecular clock-inferred dates: Evidence that older age, heterosexual risk group and more recent diagnosis are prognostic factors

OBJECTIVES

HIV late presentation (LP) has been increasing in recent years in Europe. Our aim was to investigate the characteristics of LP in Greece using in addition to the traditional definition for LP, the time interval between HIV infection and diagnosis.

METHODS

Our nationwide sample included HIV-1 sequences generated from 6166 people living with HIV (PLWH) in Greece during the period 1999-2015. Our analysis was based on the molecularly inferred HIV-1 infection dates for PLWH infected within local molecular transmission clusters of subtypes A1 and B.

RESULTS

Analysis of the determinants of LP was conducted using either CD4 counts or AIDS-defining condition at diagnosis or the time from infection to diagnosis. Older age, heterosexual transmission risk group and more recent diagnosis were associated with increased risk for LP. In contrast to previous studies, people who inject drugs (PWID) had a shorter median time to diagnosis (0.63 years) compared to men who have sex with men (MSM) (1.72 years) and heterosexuals (2.43 years). Using HIV infection dates that provide an unbiased marker for LP compared to CD4 counts at diagnosis, which are age-dependent, we estimated that the time to diagnosis increased gradually with age. Migrants infected regionally do not differ with respect to LP status compared to native Greeks.

CONCLUSIONS

We demonstrate that older people and heterosexuals are among those at higher risk for LP; and given the growing number of older people among newly diagnosed cases, tailored interventions are needed in these populations.

The prevalence of people who inject drugs among those with HIV late presentation: a meta-analysis

Background

One of the most important routes of HIV transmission is through injections of drugs, and this group, due to unawareness of their infection, causes the spread of HIV. The coexistence of other opportunistic infections and diseases with HIV among people who inject drugs (PWID) imposes healthcare costs and is associated with high morbidity/mortality rates. Early detection of HIV among PWID is essential to prevent and control the spread of the disease.

Objectives

This study aimed to determine the prevalence of PWID among those with late presentation (LP).

Methods

Three electronic databases of PubMed, Scopus, and Web of science were searched using appropriate keywords. Besides the prevalence data reported for PWID among LP, the other outcomes of interest were LP defined as having CD4 count < 350 cells/μL or HIV or advanced disease defined with CD4 count < 200 cells/μL or HIV at the time of diagnosis.

Results

Of the 160 studies found, only eight met the inclusion criteria. Among those presented late, 36.5% were PWID (95% CI = 24.88–48.17). Compared with men who have sex with men (MSM), HIV-infected PWID had a higher risk of LP [OR = 1.51; 95% CI = 0.96–2.06].

Conclusion

The results of this study show that HIV is diagnosed late in the majority of PWID when CD4 is less than 350 cells/μL. Targeted interventions/strategies are highly required to reduce LP among HIV-infected PWID.

Temporal trend of the proportion of patients presenting with advanced HIV in French Guiana: stuck on the asymptote?

Objective

In French Guiana, the French territory with the most preoccupying HIV epidemic, there have been great efforts to intensify and diversify HIV testing strategies. The aim of the present study was to review the temporal trends of patients diagnosed with advanced HIV disease in French Guiana. Data trends from the HIV cohort of French Guiana between 1996 and 2016 were thus analyzed.

Results

The proportion of patients diagnosed with advanced disease did not decline over time. Males had lower CD4 counts at the time of diagnosis and there was a plateau for both males (around 40%) and females (around 25%) with no apparent reduction of the proportion of advanced disease. Older age groups and migrants presented more often with advanced disease. By contrast, the proportion of patients diagnosed with stage B and C disease declined over time and the CD4 count at antiretroviral initiation and the CD4 nadir increased over time. Despite some progress, the group of patients with advanced disease reached a plateau around 30% suggesting this particular group still has epidemiological importance in driving the epidemic and in fueling morbidity and mortality, and thus remains a challenge for testing strategies.

Electronic supplementary material

The online version of this article (10.1186/s13104-018-3944-y) contains supplementary material, which is available to authorized users.

Factors associated with late Human Immunodeficiency Virus (HIV) diagnosis among peoples living with it, Northwest Ethiopia: hospital based unmatched case-control study

Background

Early HIV diagnosis and access to treatment is one of the most effective ways to prevent its further spread and to protect the health of those living with the virus. However, delay in diagnosis is the major risk factor for uptake of and response to antiretroviral therapy.

Methods

Institution-based unmatched case-control study design was used in the study. The study was conducted in Debre-Markos and Finote-Selam Hospitals, Northwest Ethiopia. Cases were people living with HIV who had CD4 count <350cells/mm³ or WHO clinical stage III and IV regardless of the CD4 count at first presentation and controls were those who had CD4 count ≥350cells/mm³ or WHO clinical stage I and II. If both criteria were available, the CD4 count was used in the study as World Health Organization recommended. A total of 392 respondents (196 cases and 196 controls) were recruited and selected systematically. The data were collected by trained nurses using chart review and interviewer administered structured questionnaire. Binary Logistic Regression Model was used to identify the factors associated with late HIV diagnosis.

Results

About 95.9 % of study participants provided complete response. Having no understanding, compared to having understanding, about HIV/AIDS (AOR = 1.7, 95 %CI = 1.08–2.79) and ART (AOR = 2.1, 95 %CI: 1.25–3.72), being tested as a result of symptoms/ illness, compared to being tested for risk exposure (inverted AOR =2.5, 95 %CI: 1.64–4.76), and acquiring HIV through sexual contact, compared to acquiring it through other modes (AOR = 2.5, 95 %CI = 1.52–4.76) were positively and independently associated with late HIV diagnosis.

Conclusions

Unlike perceived HIV stigma, having no understanding about HIV and ART, being tested for presence of symptoms/illness, and acquiring HIV through sexual contact were independent and significant factors for late HIV diagnosis.

Syphilis on the rise: A prolonged syphilis outbreak among HIV-infected patients in Northern Greece

INTRODUCTION

Sexually transmitted diseases (STDs) are a major public health issue in Europe. Numerous outbreaks of syphilis have been described recently and an increased prevalence of high-risk sexual practices has raised concern about the transmission of HIV and other STDs. Similarly, an increase in sexually transmitted infections has been recorded in Northern Greece.

METHODS

This report describes a recent outbreak of syphilis in people living with HIV. The demographic, clinical, and serologic data of HIV patients diagnosed with syphilis were recorded and analyzed. Data on syphilis incidence from the general population was also compared to HIV patients' data.

RESULTS

Fifty-eight HIV-patients of the Infectious Diseases Unit of a tertiary hospital (5.2%) were diagnosed with syphilis during a three-year period (2008-2010). Highly active antiretroviral therapy (HAART) and coexistence of other STDs were independent predictors of syphilis (OR: 2.4, 95CI%: 1.26, 4.63, p=0.008; OR: 9.4, 95%CI: 4.49, 19.64, p<0.001, respectively). Origin from a country other than Greece (p=0.005), and homosexual contact (p=0.003), were separate risk factors for syphilis in the general population in the same area.

CONCLUSION

Diagnosis of a sexually transmitted disease in an HIV patient is a crucial clinical event that should trigger the clinician's suspicion for high-risk sexual behavior. Sexual health assessments should be a routine process for HIV patients.

Late presentation to HIV/AIDS care in Brazil among men who self-identify as heterosexual

OBJECTIVE

To analyze the factors associated with late presentation to HIV/AIDS services among heterosexual men.

METHODS

Men infected by HIV who self-identified as heterosexual (n = 543) were included in the study. Descriptive, biivariate and logistic regression analyses were performed to evaluate the factors associated with late presentation (defined as individuals whose first CD4 count was <350 cells/mm³) in the study population.

RESULTS

The prevalence of late presentation was 69.8%. The multivariate logistic analysis showed testing initiated by the provider (OR_adjusted 3.75; 95%CI 2.45–5.63) increased the odds of late presentation. History of drug use (OR_adjusted 0.59; 95%CI 0.38–0.91), history of having sexually transmitted infections (OR_adjusted 0.64; 95%CI 0.42–0.97), and having less education (OR_adjusted 0.63; 95%CI 0.41–0.97) were associated with a decreased odds of LP.

CONCLUSIONS

Provider initiated testing was the only variable to increase the odds of late presentation. Since the patients in this sample all self-identified as heterosexual, it appears that providers are not requesting they be tested for HIV until the patients are already presenting symptoms of AIDS. The high prevalence of late presentation provides additional evidence to shift towards routine testing and linkage to care, rather than risk-based strategies that may not effectively or efficiently engage individuals infected with HIV.

Factors associated with late HIV diagnosis in North-East Scotland: a six-year retrospective study

OBJECTIVES

Late HIV diagnosis is associated with increased morbidity and mortality, increased risk of transmission, impaired response to antiretroviral therapy and increased health care costs. The aim of this study was to determine the factors associated with late HIV diagnosis in Grampian, North-East Scotland.

STUDY DESIGN

A population based retrospective database analysis.

METHODS

All newly diagnosed HIV positive individuals in Grampian, North-East Scotland between 2009 and 2014 were included in the study. Participants were classified as having a late diagnosis if the CD4 cell count at presentation was less than 350 cells/mm³. Socio-economic and demographic factors were investigated in relation to outcome (late diagnosis) using Chi-squared and Mann-Whitney tests.

RESULTS

CD4 cell count results were available for 111 (89.5%) of the 124 newly diagnosed individuals during the study period. The prevalence of late diagnosis was 53.2% (n = 59). Those infected via heterosexual mode of transmission had a 2.83 times higher odds of late diagnosis (OR 2.83 [95% CI: 1.10-7.32]) than men who have sex with men (MSM) and those with no previous HIV testing had a 5.46 increased odds of late diagnosis (OR 5.46 [95% CI: 1.89-15.81]) compared to those who had previously been tested. Missed opportunities for HIV diagnosis were identified in 16.3% (n = 15) of participants.

CONCLUSION

Heterosexual individuals and those with no previous HIV testing were more likely to be diagnosed late. Targeted initiatives to increase perception of HIV risk and uptake of testing in these risk groups are recommended.

Impact of late presentation of HIV infection on short-, mid- and long-term mortality and causes of death in a multicenter national cohort: 2004-2013

OBJECTIVES

To analyze the impact of late presentation (LP) on overall mortality and causes of death and describe LP trends and risk factors (2004-2013).

METHODS

Cox models and logistic regression were used to analyze data from a nation-wide cohort in Spain. LP is defined as being diagnosed when CD4 < 350 cells/ml or AIDS.

RESULTS

Of 7165 new HIV diagnoses, 46.9% (CI95%:45.7-48.0) were LP, 240 patients died. First-year mortality was the highest (aHRLP.vs.nLP = 10.3[CI95%:5.5-19.3]); between 1 and 4 years post-diagnosis, aHRLP.vs.nLP = 1.9(1.2-3.0); and >4 years, aHRLP.vs.nLP = 1.5(0.7-3.1). First-year's main cause of death was HIV/AIDS (73%); and malignancies among those surviving >4 years (32%). HIV/AIDS-related deaths were more likely in LP (59.2% vs. 25.0%; p < 0.001). LP declined from 55.9% (2004-05) to 39.4% (2012-13), and reduced in 46.1% in men who have sex with men (MSM) and 37.6% in heterosexual men, but increased in 22.6% in heterosexual women. Factors associated with LP: sex (ORMEN.vs.WOMEN = 1.4[1.2-1.7]); age (OR31-40.vs.<30 = 1.6[1.4-1.8], OR41-50.vs.<30 = 2.2[1.8-2.6], OR>50.vs.<30 = 3.6[2.9-4.4]); behavior (ORInjectedDrugUse.vs.MSM = 2.8[2.0-3.8]; ORHeterosexual.vs.MSM = 2.2[1.7-3.0]); education (ORPrimaryEducation.vs.University = 1.5[1.1-2.0], ORLowerSecondary.vs.University = 1.3[1.1-1.5]); and geographical origin (ORSub-Saharan.vs.Spain = 1.6[1.3-2.0], ORLatin-American.vs.Spain = 1.4[1.2-1.8]).

CONCLUSIONS

LP is associated with higher mortality, especially short-term- and HIV/AIDS-related mortality. Mid-term-, but not long-term mortality, remained also higher in LP than nLP. LP decreased in MSM and heterosexual men, not in heterosexual women. The groups most affected by LP are low educated, non-Spanish and heterosexual women.

Risk Factors for Advanced HIV Disease and Late Entry to HIV Care: National 1994-2012 HIV Surveillance Data for Wuhan, China

Few studies in China have focused on advanced human immunodeficiency virus (HIV) disease (AHD) and late entry to HIV care, which are associated with increased morbidity and mortality. A population-based retrospective study was conducted using 980 national HIV surveillance reports from 1994 to February 2012 in Wuhan, China. AHD was defined as presence of a first-reported CD4 count<200 cells/μL or an acquired immune deficiency syndrome (AIDS)-defining event within 1 month of HIV diagnosis. Late entry to HIV care was defined as patients with a first-reported CD4 cell count>6 months after diagnosis. Non-conditional logistic regression analysis was used to identify factors associated with AHD, late entry to HIV care, and AIDS within 1 year of HIV diagnosis. The proportions of AHD, AIDS within 1 year of HIV diagnosis, and late entry to HIV care were 29.49%, 39.39%, and 20.84%, respectively. Most of the deaths (74.27%, 127/171) occurred within 1 year of diagnosis. Short-term mortality, proportion of AHD, and late entry to HIV care showed a similar downward trend from pre-2003 to 2011 (p<0.001). Age, transmission category, sample source, and occupation were associated with AHD, late entry to HIV care, and AIDS within 1 year of HIV diagnosis in the multivariate logistic regression analysis. These findings indicate that AHD and late entry to HIV care were associated with an increased incidence of AIDS or death, particularly within 1 year of diagnosis. More effort should be made to assure early diagnosis and timely entry to care.

Drug use as a driver of HIV risks: re-emerging and emerging issues

PURPOSE OF REVIEW

We reviewed the studies published in 2012-2013 that focused on re-emerging and emerging injection and noninjection drug use trends driving HIV risk behaviors and transmission in some parts of the world.

RECENT FINDINGS

Although HIV incidence has declined in many countries, HIV epidemics remain at troubling levels among key drug-using populations, including females who inject drugs (FWIDs), FWIDs who trade sex, sex partners of people who inject drugs, young people who inject drugs, and people who use noninjection drugs in a number of low-income and middle-income countries such as in Central Asia, Eastern Europe, Southeast Asia, and parts of Africa.

SUMMARY

HIV epidemics occur within the contexts of global economic and political forces, including poverty, human rights violations, discrimination, drug policies, trafficking, and other multilevel risk environments. Trends of injection and noninjection drug use and risk environments driving HIV epidemics in Central Asia, Eastern Europe, Southeast Asia, and parts of Africa call for political will to improve HIV and substance use service delivery, access to combination HIV prevention, and harm reduction programs.

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.

High rates of transmitted drug resistance among newly-diagnosed antiretroviral naïve HIV patients in Northern Greece, data from 2009-2011

We conducted a retrospective study on the prevalence and correlates of transmitted drug resistance among newly-diagnosed antiretroviral naive human immunodeficiency virus (HIV) patients in Northern Greece, during the period 2009-11. Transmitted drug resistance was documented in 21.8% of patients enrolled, affecting approximately 40% of subtype A HIV-1-infected individuals. Overcoming challenges due to the ongoing financial crisis, effective preventive measures should be implemented to control further dissemination of resistant HIV strains.