Late HIV Presentation Research Articles

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.

To analyze the impact of late presentation (LP) on overall mortality and causes of death and describe LP trends and risk factors (2004-2013). 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<350cells/ml or AIDS. 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]). 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.

HIV Infection in Migrant Populations in the European Union and European Economic Area in 2007-2012: An Epidemic on the Move.

Migrants are considered a key group at risk for HIV infection. This study describes the epidemiology of HIV and the distribution of late HIV presentation among migrants within the European Union/European Economic Area during 2007-2012. HIV cases reported to European Surveillance System (TESSy) were analyzed. Migrants were defined as people whose geographical origin was different than the reporting country. Multiple logistic regression was used to model late HIV presentation. Overall, 156,817 HIV cases were reported, of which 60,446 (38%) were migrants. Of these, 53% were from Sub-Saharan Africa, 12% from Latin America, 9% from Western Europe, 7% from Central Europe, 5% from South and Southeast Asia, 4% from East Europe, 4% from Caribbean, and 3% from North Africa and Middle East. Male and female migrants from Sub-Saharan Africa and Latin America had higher odds of late HIV presentation than native men and women. Migrants accounted for 40% of all HIV notifications in 2007 versus 35% in 2012. HIV cases in women from Sub-Saharan Africa decreased from 3725 in 2007 to 2354 in 2012. The number of HIV cases from Latin America peaked in 2010 to decrease thereafter. HIV diagnoses in migrant men who have sex with men increased from 1927 in 2007 to 2459 in 2012. Migrants represent two-fifths of the HIV cases reported and had higher late HIV presentation. HIV epidemic in migrant populations in European Union/European Economic Area member states is changing, probably reflecting the global changes in the HIV pandemic, the impact of large-scale ART implementation, and migration fluctuations secondary to the economic crisis in Europe.

Gender difference in advanced HIV disease and late presentation according to European consensus definitions.

Effectiveness of highly active antiretroviral therapy is limited for a large proportion of individuals living with HIV presenting for medical care at an advanced stage. Controversial results of gender differences in risk of late HIV diagnosis were reported among existing literatures. Therefore, we conducted this meta-analysis to synthesize a summary of gender differences in risk of advanced HIV disease (AHD) and late presentation (LP) according to European consensus definitions. Totally, 32 studies were included based on predetermined selection criteria. The pooled adjusted odds ratios of males presenting with AHD and LP compared with females were 1.73 (95% confidence interval [CI], 1.59–1.89) and 1.38 (95% CI, 1.18–1.62) with significant heterogeneity observed (I2 = 78.50%, and I2 = 85.60%, respectively). Subgroup analysis revealed that time lag, study location, number of patients, proportion of females, study design, number of adjusted variables might be potential source of heterogeneity. Sensitivity analysis showed robustness of the results. No publication bias was observed in studies on AHD or LP. The current meta-analysis indicated that males are at higher risk of AHD or LP compared with females. More attention should be paid to males to make sure early testing, diagnosis, and treatment, and ultimately improve individual and population health.

Stage of HIV presentation at initial clinic visit following a community-based HIV testing campaign in rural Kenya.

BackgroundThe Kenyan Ministry of Health and partners implemented a community-based integrated prevention campaign (IPC) in Western Kenya in 2008. The aim of this study was to determine whether the IPC, compared to Voluntary Counselling and Testing (VCT) services, was able to identify HIV positive individuals earlier in the clinical course of HIV infection following testing.MethodsA total of 1,752 adults aged over 15 years who tested HIV positive through VCT services or the IPC, and subsequently registered at initial clinic visit between September 2008 and September 2010, were considered in the analysis. Multivariable logistic regression models were developed to assess the association of CD4 count and WHO clinical stage of HIV infection at first clinic appointment with age group, gender, marital status and HIV testing source.ResultsMale gender and marital status were independently associated with late HIV presentation (WHO clinical stage 3 or 4 or CD4 count ≤350 cells/μl) at initial clinic visit. Patients testing HIV positive during the IPC had significantly higher mean CD4 count at initial clinic visit compared to individuals who tested HIV positive via VCT services. Patients testing HIV positive during the IPC had more than two times higher odds of presenting early with CD4 count greater than 350 cells/μl (adjusted OR 2.15, 95% CI 1.28 – 3.61, p = 0.004) and presenting early with WHO clinical stage 1 or 2 of HIV infection (adjusted OR 2.39, 95% CI 1.24 – 4.60, p = 0.01) at initial clinic visit compared to individuals who tested HIV positive via VCT services.ConclusionThe community-based integrated prevention campaign identified HIV positive individuals earlier in the course of HIV infection, compared to Voluntary Counselling and Testing services. Community-based campaigns, such as the IPC, may be able to assist countries to achieve earlier testing and initiation of ART in the course of HIV infection. Improving referral mechanisms and strengthening linkages between HIV testing and treatment services remain a challenge and electronic medical record (EMR) systems may support monitoring of patients throughout the HIV care and treatment continuum.

Reasons for late presentation to HIV care in Switzerland.

IntroductionLate presentation to HIV care leads to increased morbidity and mortality. We explored risk factors and reasons for late HIV testing and presentation to care in the nationally representative Swiss HIV Cohort Study (SHCS).MethodsAdult patients enrolled in the SHCS between July 2009 and June 2012 were included. An initial CD4 count <350 cells/µl or an AIDS-defining illness defined late presentation. Demographic and behavioural characteristics of late presenters (LPs) were compared with those of non-late presenters (NLPs). Information on self-reported, individual barriers to HIV testing and care were obtained during face-to-face interviews.ResultsOf 1366 patients included, 680 (49.8%) were LPs. Seventy-two percent of eligible patients took part in the survey. LPs were more likely to be female (p<0.001) or from sub-Saharan Africa (p<0.001) and less likely to be highly educated (p=0.002) or men who have sex with men (p<0.001). LPs were more likely to have their first HIV test following a doctor's suggestion (p=0.01), and NLPs in the context of a regular check-up (p=0.02) or after a specific risk situation (p<0.001). The main reasons for late HIV testing were “did not feel at risk” (72%), “did not feel ill” (65%) and “did not know the symptoms of HIV” (51%). Seventy-one percent of the participants were symptomatic during the year preceding HIV diagnosis and the majority consulted a physician for these symptoms.ConclusionsIn Switzerland, late presentation to care is driven by late HIV testing due to low risk perception and lack of awareness about HIV. Tailored HIV testing strategies and enhanced provider-initiated testing are urgently needed.

Educational attainment and risk of HIV infection, response to antiretroviral treatment, and mortality in HIV-infected patients

To estimate association between educational attainment and risk of HIV diagnosis, response to HAART, all-cause, and cause-specific mortality in Denmark in 1998-2009. Prospective, population-based cohort study including 1277 incident HIV-infected patients without hepatitis C virus or intravenous drug abuse identified in the Danish HIV Cohort Study and 5108 individually matched population controls. Data on educational attainment, categorized as low, medium, or high, were identified in The Danish Attainment Register. Logistic and Poisson regression were used to estimate odds ratios (ORs) and mortality rate ratios (MRRs). OR of HIV diagnosis was 1.7 (95% confidence interval, CI 1.3-2.3) among heterosexual individuals with low educational attainments, but no associations between educational attainment and time to HAART initiation, CD4 cell count, or viral suppression were identified. All-cause MRRs were 1.8 (95% CI 1.0-3.2) and 1.8 (1.1-2.8) for HIV-infected patients and population controls with low educational attainment compared with medium and high educational attainment. MRRs for smoking and alcohol-related deaths were 3.6 (95% CI 1.5-8.9) for HIV-infected patients and 2.0 (95% CI 1.2-3.4) for population controls with low educational attainment compared with medium and high educational attainment. With free and equal access to healthcare, low educational attainment might increase risk of HIV infection among heterosexual individuals, but was not associated with late/very late presentation of HIV, time to HAART initiation, or HAART response. However, low educational attainment substantially increased lifestyle-related mortality, which indicates that increased mortality in HIV-infected patients with low educational attainments stems from risk factors unrelated to HIV.

Predictors of advanced disease and late presentation in new HIV diagnoses reported to the surveillance system in Spain

ObjectiveTo present surveillance data on advanced disease (AD) and late presentation (LP) of HIV in Spain and their determinants. MethodsWe included all new HIV diagnoses notified by the autonomous regions that consistently reported such cases throughout the period 2007–2011. Coverage was 54% of the total Spanish population. Data sources consisted of clinicians, laboratories and medical records. AD was defined as the presence of a CD4 cell count <200cells/μL in the first test after HIV diagnosis, while LP was defined as the presence of a CD4 cell count <350cells/μL after HIV diagnosis. Odds ratios and their 95% confidence intervals (OR, 95% CI) were used as the measure of association. Logistic regressions were fit to identify predictors of AD and LP. ResultsA total of 13,021 new HIV diagnoses were included. Among these, data on the outcome variable were available in 87.7%. The median CD4 count at presentation was 363 (interquartile range, 161–565). Overall, 3356 (29.4%) patients met the definition of AD and 5494 (48.1%) were classified as LP. Both AD and LP increased with age and were associated with male sex and infection through drug use or heterosexual contact. All immigrants except western Europeans were more prone to AD and LP. Multivariate models disaggregated by sex showed that the effect of age and region of origin was weaker in women than in men. ConclusionsDespite universal health care coverage in Spain, men, immigrants and people infected through drug use or heterosexual contact seem to be experiencing difficulties in gaining timely access to HIV care.

The potential impact of routine testing of individuals with HIV indicator diseases in order to prevent late HIV diagnosis

BackgroundThe aim of our work was to evaluate the potential impact of the European policy of testing for HIV all individuals presenting with an indicator disease, to prevent late diagnosis of HIV. We report on a retrospective analysis among individuals diagnosed with HIV to assess whether a history of certain diseases prior to HIV diagnosis was associated with the chance of presenting late for care, and to estimate the proportion of individuals presenting late who could have been diagnosed earlier if tested when the indicator disease was diagnosed.MethodsWe studied a large cohort of individuals newly diagnosed with HIV infection in 13 counselling and testing sites in the Lazio Region, Italy (01/01/2004-30/04/2009). Considered indicator diseases were: viral hepatitis infection (HBV/HCV), sexually transmitted infections, seborrhoeic dermatitis and tuberculosis. Logistic regression analysis was performed to estimate association of occurrence of at least one indicator disease with late HIV diagnosis.ResultsIn our analysis, the prevalence of late HIV diagnosis was 51.3% (890/1735). Individuals reporting at least one indicator disease before HIV diagnosis (29% of the study population) had a lower risk of late diagnosis (OR = 0.7; 95%CI: 0.5-0.8) compared to those who did not report a previous indicator disease. 52/890 (5.8%) late presenters were probably already infected at the time the indicator disease was diagnosed, a median of 22.6 months before HIV diagnosis.ConclusionsOur data suggest that testing for HIV following diagnosis of an indicator disease significantly decreases the probability of late HIV diagnosis. Moreover, for 5.5% of late HIV presenters, diagnosis could have been anticipated if they had been tested when an HIV indicator disease was diagnosed.However, this strategy for enhancing early HIV diagnosis needs to be complemented by client-centred interventions that aim to increase awareness in people who do not perceive themselves as being at risk for HIV.

Analysis of risk factors for late presentation in a cohort of HIV-infected patients in Dresden: positive serology for syphilis in MSM is a determinant for earlier HIV diagnosis

Late HIV presentation is still a health concern, even in industrialised countries. Data concerning this problem in Eastern Germany are scarce. We investigated associated factors in a cohort of HIV-infected patients in Dresden, Germany, including syphilis serology as a proxy for sexual risk behaviour. A retrospective cohort study on 348 patients presenting for the first time in our treatment centre from 1986 to 2010 was undertaken. Risk factors of late (CD4 cells <350/μl) and very late (CD4 cells <200/μl) presentation either to care or to diagnosis were identified by means of logistic regression analyses. Of 348 classifiable patients, 54% were late and 33.9% were very late presenters to care. In a subgroup of 260 patients with recent HIV diagnosis, 50.4% were late and 31.2% were very late presenters to diagnosis. Age >24years was a significant independent factor associated with late or very late presentation, but not male gender, originating from high-prevalence countries (HPC) or years of presentation. Being MSM alone was not associated with early or late HIV presentation, but MSM with positive TPHA or TPPA showed a lower risk of late presentation, predominantly in those presenting late to diagnosis [odds ratio (OR) 0.42, p=0.048]. A positive syphilis screening test seems to be a determinant for lower risk of late presentation to HIV care and diagnosis in MSM. The presence and awareness of sexually transmitted infections (STIs) such as syphilis may lead to earlier utilisation of HIV health care and, thus, promote earlier HIV diagnosis. HIV prevention strategies should focus more on STIs and not only on HIV.

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

BackgroundInitiating 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.MethodsPatients 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.ResultsOf 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).ConclusionsOlder 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.

Erratum to: Late presentation of HIV despite earlier opportunities for detection, experience from an Irish Tertiary Referral Institution

Erratum to: Late presentation of HIV despite earlier opportunities for detection, experience from an Irish Tertiary Referral Institution

Late presentation of HIV despite earlier opportunities for detection, experience from an Irish Tertiary Referral Institution

Late presentation of HIV continues to undermine advances in the management of HIV. Opportunities to detect HIV at an earlier stage are often missed. Current estimates suggest that undiagnosed individuals comprise approximately one quarter of all people in the western world living with HIV. 'Testing-and-treating' this group has been proposed as a means to curb the HIV epidemic. In this study we assessed the characteristics of individuals newly diagnosed with HIV, and their utilisation of healthcare services in Ireland prior to their diagnosis. A retrospective review was undertaken of all patients newly diagnosed with HIV over a 27-month period. Patient demographics were recorded, as were details of healthcare contacts in the year preceding diagnosis. Individuals detected via screening of recent immigrants/asylum seekers were excluded. In the period studied 114 patients received a new diagnosis of HIV, 59 met inclusion criteria. The majority (54%) fulfilled the European consensus definition for late presenters (CD4<350 cells/µl). 'Late presenters' were significantly more likely to be symptomatic at diagnosis (OR=4.62; 95% CI 1.45-14.67; p=0.015), diagnosed by acute tertiary hospital services (p=0.015), and 56% reported heterosexual mode of acquisition (OR=2.12; 95% CI 0.73-6.16; p=0.19). Patients detected via screening had significantly higher CD4 counts at diagnosis compared with those diagnosed due to symptoms (Median CD4 422 cells/µl; IQR 285-594 vs. 142 cells/µl; IQR 62-333; p=0.0007). 'Symptomatic' patients were significantly more likely to report prior healthcare contacts (OR 4.71; 95 % CI 1.32-16.79; p=0.013). Current screening activities are inadequate. Unfortunately newly diagnosed HIV patients continue to be symptomatic, at advanced stages of disease, to acute hospital services. Heterosexual groups in particular are at risk for late detection.

Morbidität und Mortalität der HIV-Infektion

Combination antiretroviral therapy (cART) has dramatically improved the prognosis of HIV-infected individuals, with a close to a normal life expectancy in a significant proportion of treated individuals. Upon start of cART, HIV-induced immune deficiency can be prevented or, if already present, reconstituted. Remaining morbidity and mortality is partly due to the late diagnosis of HIV infection or late presentation of patients, when CD4-T-cells have already fallen below 200 cells/µl and/or AIDS-defining conditions have manifested. Further reasons for remaining morbidity and mortality are related to co-morbidities such as viral hepatitis and tumors, particularly in older patients. As HIV-infected patients become older, increasing co-morbidities and socio-economic costs may become a challenge in the future.

Reconsidering Cryptococcal Antigen Screening in the U.S. Among Persons With CD4 &lt;100 cells/mcL

To the Editor—The 2012 International AIDS Conference was themed around the need for an “AIDS free generation.” The concept is that the HIV virus is not yet curable, but with medications, we can prevent those who are HIV-infected from developing complications of AIDS and opportunistic infections. Cryptococcal meningitis is one such opportunistic infection that causes 20%–25% of AIDS-related mortality in Africa [1]. Cryptococcal antigen (CrAg) can be detected in a subclinical phase, weeks prior to onset of symptomatic infection, and can be screened and preemptively treated with fluconazole to prevent overt cryptococcal meningitis. The new Food and Drug Administration–approved point-of-care CrAg lateral flow assay (LFA; Immy, Inc., Norman, OK) has fundamentally changed the cost-effectiveness of CrAg screening to prevent cryptococcal meningitis from occurring in those with subclinical infection. The CrAg LFA assay cost is $2.00 in resource limited regions and $5.00 in high-income countries, which translates to a probable real world cost of approximately $2.50–$5.00 in resource limited settings and $10 in high-income countries when including labor, shipping, and overhead costs. This screen and preemptive treatment strategy has the potential to vastly diminish and eliminate cryptococcal meningitis from occurring after antiretroviral therapy (ART) initiation and reduce the 20%–25% of early ART mortality caused by cryptococcosis [2–4]. Previously Meya et al showed the value of CrAg screening in a prospective cohort, using the CrAg latex agglutination at a cost of $16.75 in Uganda [3]. Now with a real world cost of the CrAg LFA at $2.50, the cost per life saved with CrAg screening and pre-emptive fluconazole therapy is $39.73 in Uganda among persons with CD4<100 cells/μL, and $2.21 per quality adjusted life year saved [5]. In contrast to the cost of cryptococcal meningitis hospitalization, CrAg screening and targeted preemptive treatment of those CrAg+ is cost saving to healthcare systems at ≥1% CrAg+ prevalence (Figure 1). But is this program only relevant to Africa? While early HIV testing is key, the US reality is that 38% of newly HIV diagnosed Americans received an AIDS diagnosis concurrently or within 1 year of their HIV diagnosis between 1996–2005 [6]. In North America, our opinion is CrAg screening should also be considered among those who do present with advanced AIDS and CD4<100. The US cost of cryptococcal meningitis hospitalization is extraordinarily high, in contrast to CrAg screening (approximately $10) followed by pre-emptive treatment with 10 weeks of fluconazole per World Health Organization guidelines ($30.24) at 800 mg daily for 2 weeks followed by 8 weeks of 400 mg daily [7]. The approximate cost of hospitalization for cryptococcosis from one Boston hospital including room and board ($700/day), liposomal amphotericin (approximately $350/day), and flucytosine (approximately $500/day) for 14 days is on average $50 000. For this cost, assuming that the LFA would cost $10 in high-income settings, one could screen approximately 5000 persons for asymptomatic antigenemia. Thus while the prevalence of cryptococcal antigenemia among those with CD4 0.1%. Thus, US CrAg prevalence data are needed. Given the improved cost considerations, the US Department of Health and Human Services Opportunistic Infection guidelines should reexamine the benefit of routine pre-ART CrAg screening for those with CD4 < 100 or among persons hospitalized shortly after ART initiation [8]. While ideally in the future this population of late HIV presenters will be eliminated, among those who do present late, CrAg screening in the U.S. may not only be cost saving, but life saving.​saving.Figure 1.Cost Figure 1. Cost of serum cryptococcal antigen screening using the latex agglutination versus the lateral flow assay based on asymptomatic prevalence. The figure displays the relative cost-effectiveness of cryptococcal antigen (CrAg) screening and preemptive fluconazole ...

Delay in diagnosis of HIV infection

Late presentation of HIV is common. It has been associated with greater risk of AIDS, death, lower immunological response, greater toxicity and a higher probability of transmission. In this study we review the impact of different definitions in terms of mortality and morbidity, associated factors, economic implications, as well as strategies for increasing diagnosis.

Factors Associated with Late Presentation of HIV and Estimation of Antiretroviral Treatment Need according to CD4 Lymphocyte Count in a Resource-Limited Setting: Data from an HIV Cohort Study in India

We describe the CD4 lymphocyte count at HIV presentation in an HIV cohort from a rural district of India. The majority of patients were diagnosed for their HIV-related symptoms, although a sizeable proportion of women were diagnosed because of antenatal screening or for having an HIV-positive partner. Patients diagnosed of HIV for antenatal screening or having an HIV-positive sexual partner had higher CD4 lymphocyte count than patients having tuberculosis or HIV-related symptoms. The proportion of patients diagnosed with CD4 count <200 and <350 cells/mm3 were 46% and 68.7%, respectively, and these figures did not change during the five years of the study. Factors associated with late presentations were male sex, older age, not having a permanent house, and, in women, lower education and being a widow or separated. With the implementation of 2010 WHO guidelines, the number of newly diagnosed patients who will require HIV treatment will increase 13.8%. If the CD4 count threshold for initiating HIV treatment is increased from 350 to 500 cells/mm3, the number of patients in need of treatment would increase 15.7%. Therefore, new strategies for avoiding HIV late presentation are urgently needed in developing countries.

Efficacy of 1998 Vs 2006 First-Line Antiretroviral Regimens for HIV Infection: An Ordinary Clinics Retrospective Investigation

Purpose: The evidence suggesting increased HAART efficacy over time comes from randomized trials or cohort studies. This retrospective multicenter survey aimed to assess the variation over time in the efficacy and tolerability of first-line HAART regimens in unselected patients treated in ordinary clinical settings. Methods: Retrospective analysis of data of all patients starting first-line HAART regimens in 1998 and 2006 at adhering centers in the Italian CISAI group. Results: For the 543 patients included, mean age was 39.1 ± 9.8y in 1998 and 41.0 ± 10.7y in 2006 (p=0.03), with a similar proportion of males. Baseline mean log10 HIV-RNA was 4.56 ± 0.97 copies/mL in 1998 vs 4.91 ± 0.96 copies/mL in 2006 (p<0.001); baseline mean CD4 T-cell counts were 343 ± 314/mm3 in 1998 vs 244 ± 174/mm3 in 2006 (p<0.001). The following outcomes were significantly improved at 48w in 2006: proportion with undetectable HIV-RNA (86.3% vs 58.0%; p<0.001); mean increase in CD4 T-cells count (252 ± 225 vs 173 ± 246; p<0.001); HAART modification (20.1% vs 29.2%; p=0.02); HAART interruption (7.3% vs 14.6%; p=0.01); proportion reporting optimal adherence (92.2% vs 82.7%, p=0.03). No differences were observed in the prevalence of grade 3-4 WHO toxicities (26.4% vs 26.6%; p=0.9). Multivariate logistic regression showed that being treated in 1998 remained an independent predictor of virological failure after several adjustments, including adherence. Conclusions: Our data from patients not included in clinical trials or cohort studies provide an additional line of evidence that the effectiveness of HAART significantly improved in 2006. Treated patients, however, were significantly older and more frequently late HIV presenters in 2006 than in 1998.

HIV-Infected Late Presenter Patients

HIV-Infected Late Presenter Patients

Characteristics of HIV/AIDS Patients Presenting Late at a Teaching Hospital in Nigeria

Background: The introduction of highly active antiretroviral therapy (HAART) has significantly reduced the morbidity and mortality associated with HIV/AIDS. This benefit that HAART confers can only be maximized if patients present early. This study was embarked upon to describe the characteristics of patients presenting late at a teaching hospital in north central Nigeria. Methodology: This was a cross sectional study of patients who presented late with HIV/AIDS admitted into the medical wards of the Jos University Teaching Hospital over a one year period. Late presentation was defined as patients presenting in CDC class B or C Results: 56.7% of patients who were admitted with HIV /AIDS presented late with the majority (79%) being in CDC class C. The median CD4+ cell count was 88 cells/mm3 with a range of 12 -552 cells/mm3. Reasons for late presentation included fear of stigma 35 (46.7%), financial constraints 23 (30.7%), faith in herbal / spiritual healing 8 (10.7%) and not believing in HIV treatment 5 (6.7%). No one came to hospital in late stage because of distance from hospital. Similarly HCT services were not accessed early because of fear of stigma 37 (50.7 %), not wanting to know about status 29 (39.2 %), absence of symptoms 51(68%) and seeing partner as faithful 28 (38.9%). Tuberculosis was the commonest reason for hospitalization Conclusions: Stigma was the major reason for delayed HIV testing and late presentation.. Public education and enlightenment on the need for routine HCT and early presentation for care and treatment is advocated.Key Words HIV/AIDS, Late presentation, Stigma, Tuberculosis

Late HIV presentation: epidemiology, clinical implications and management

Late presentation of HIV is common and is associated with several adverse outcomes including an increased risk of clinical progression, blunted immune recovery on highly active antiretroviral therapy and a greater risk of drug toxicity. Late presenters may have higher rates of poor adherence, exacerbated by the same factors that contribute to their late diagnosis, such as lack of knowledge about HIV and the benefits of highly active antiretroviral therapy. We review the definitions of, risk factors for and subsequent impact of late presentation. Evidence regarding how and when to start antiretroviral therapy, and with which agents, will be discussed, as well as issues surrounding vaccination and opportunistic infection prophylaxis for individuals with a low CD4 count. Finally, strategies to increase HIV testing uptake to reduce late presentation will be summarized.