Over the past five years there have been numerous advances in the management of HIV disease in the UK. Antiretroviral therapy has become widely available and year on year, the overall number of HIV-positive individuals accessing care is increasing.
However, estimates from anonymous testing suggest that one third of individuals living with HIV remain unaware of their status. Among heterosexuals the proportion remaining undiagnosed is closer to 50%. In the UK the overwhelming majority of heterosexually acquired HIV infections occur amongst people who are from or who have spent time in sub-Saharan Africa.
Research published in 1996 highlighted that black African individuals were more likely to present later with HIV disease than their non-African counterparts. Late presentation means that advances in HIV care are denied those who do not present.
Until now it has been unclear whether the more widespread availability of HAART since 1996 and the introduction of routine antenatal HIV testing for pregnant women in 1999 would provide both incentive and opportunity for those people who have traditionally avoided HIV testing and treatment to access testing and treatment and care.
Researchers from two London HIV clinics, the Bloomsbury Clinic at the Mortimer Market Centre and the Greenway Clinic at Newham General Hospital have retrospectively reviewed all adults diagnosed with HIV infection between January 1998 and December 1999 at one of these clinics and have compared these data with a retrospective study of all HIV-positive black Africans and non-Africans diagnosed at the same centres between 1982 and 1995.
Their findings suggest that the wider availability of HAART has not facilitated HIV-positive heterosexuals (specifically black Africans) to access testing and treatment.
In the period 1998-1999 the median CD4 cell count at diagnosis was 188 cells for black Africans and 380 cells for non-Africans. This compares with 277 cells for black Africans and 440 cells for non-Africans diagnosed with HIV between 1982 and 1998.
The decline in CD4 count at time of HIV diagnosis is most significant and worrying among black Africans. Indeed, illustrating this point, thirty -five per cent of black African patients had an AIDS –defining illness within one month of their HIV diagnosis, compared to 13% of non-Africans.
Individuals can only benefit from advances in HIV care, if they are aware of their HIV status and improved survival after an AIDS diagnosis has been associated with a longer awareness of HIV status before an AIDS diagnosis.
Black Africans and non-Africans have different patterns of health service utilisation. Black Africans were more likely to be diagnosed via antenatal testing, and take an HIV test when a preceding event suggests the likelihood of HIV infection, whereas non-Africans were more likely to have had a previous HIV test and to have been diagnosed with a sexually transmitted infection prior to their HIV diagnosis.
The continuation of late presentation of black Africans in the UK is extremely worrisome; the authors suggest that this might relate to a lack of a perceived risk of HIV or a lack of perceived benefit in the knowledge of their HIV status and potential interventions.
Most importantly, recent evidence suggests individuals with a CD4 count below 200 cells before the initiation of HAART have a poorer prognosis. Promoting awareness of HIV status and the availability of effective treatments among African communities must be a priority.
Burns F et al. Research Letter. AIDS, 2001 7;15 (18):2453-2455.