Diagnosed late: missed opportunities for care and prevention

Buenos Aires: Despite the widespread availability of effective anti-HIV therapy in well-resourced nations, many HIV-positive people continue to experience ill health, and death, due to delayed diagnosis of their HIV infection. Following a recent report from the UK, available within the aidsmap news archive, new data on late diagnoses were reported by groups in New York City, USA, and Andalusia, Spain, at the First International AIDS Society Conference on HIV Pathogenesis and Treatment in a temperate Buenos Aires today.

A retrospective analysis of people diagnosed with HIV infection at the Columbia Presbyterian Medical Centre identified 142 individuals who were diagnosed while in hospital (Hogan). Ninety-five percent of these consented to HIV testing because of symptomatic illness. The median CD4 count amongst 111 patients for whom a record of their CD4 count at the time of diagnosis was available, was 57 cells. Forty-nine percent of male patients and 42% of females had a CD4 count below 50 cells. The median viral load in 106 patients at diagnosis was 106,000 copies. Current guidelines on initiation of antiretroviral therapy in the US advise that treatment begin before the CD4 count has fallen below 350 cells. Though the optimum point for intervention is not known, clinical response to therapy is inferior when begun at CD4 counts below 200 compared to higher levels.

Eighty-one people, more than half of the cohort, presented to medical services with an opportunistic infection. Another 44 (31%) had symptoms which were possibly HIV-related. Over a third also had thrush, and over half had weight loss at presentation. When medical histories were reviewed, 50% were found to have past experience of clinical illness which might have prompted consideration of HIV testing. Data from the UK supports this finding – whilst these cases clearly represent late diagnoses of HIV, it is less clear that they should be termed ‘late presentations’. Many of these individuals are presenting for medical care but the opportunity to diagnose their infection is being missed by health care professionals, and with it the provision of appropriate medical care, and opportunities for counselling on HIV prevention.

It is estimated that of some 650,000 to 900,000 people with HIV infection in the United States, around 500,000 are aware of their HIV status and far fewer, 335,000, are in receipt of healthcare services. Data from the Manhattan group indicates that the problems inherent in delayed access to care and treatment may disproportionately affect certain social groups – in this case older people, immigrant communities and people with heterosexual risk of HIV acquisition.

Clinicians from Southern Spain reviewed newly diagnosed HIV infections between the study period from January 1997 and December 2000 (Santos). Of 266 diagnoses, 93 occurred in people with CD4 counts below 50. Of these individuals, the average CD4 count was 23, and average viral load 5.31 log copies.

In this group, follow-up data on subsequent health is available, indicating a mixture of experience. Eighty percent of the cohort began HAART, within an average of 1.8 months after diagnosis. One year later, 56% had viral load suppressed below the limit of detection, by intent to treat analysis.

However, within a median follow-up period of 14 months, 21 people were lost to follow-up and 20 people died. Fifty-five percent of these deaths occurred within one month of diagnosis of HIV infection. Pneumocystis pneumonia was both the most common cause of death and the most common presenting opportunistic infection.