Date Published: September 20, 2012
Publisher: Hindawi Publishing Corporation
Author(s): Kate Buchacz, Carl Armon, Frank J. Palella, Rose K. Baker, Ellen Tedaldi, Marcus D. Durham, John T. Brooks.
Background. It is unclear if CD4 cell counts at HIV diagnosis have improved over a 10-year period of expanded HIV testing in the USA. Methods. We studied HOPS participants diagnosed with HIV infection ≤6 months prior to entry into care during 2000–2009. We assessed the correlates of CD4 count <200 cells/mm3 at HIV diagnosis (late HIV diagnosis) by logistic regression. Results. Of 1,203 eligible patients, 936 (78%) had a CD4 count within 3 months after HIV diagnosis. Median CD4 count at HIV diagnosis was 299 cells/mm3 and did not significantly improve over time (P = 0.13). Comparing periods 2000-2001 versus 2008-2009, respectively, 39% and 35% of patients had a late HIV diagnosis (P = 0.34). Independent correlates of late HIV diagnosis were having an HIV risk other than being MSM, age ≥35 years at diagnosis, and being of nonwhite race/ethnicity. Conclusions. There is need for routine universal HIV testing to reduce the frequency of late HIV diagnosis and increase opportunity for patient- and potentially population-level benefits associated with early antiretroviral treatment.
Recent HIV surveillance data suggest that approximately 33% of HIV-infected persons in the United States present for HIV testing late and have AIDS (CD4+ cell count <200 cells/mL or an AIDS-defining illness) within one year after HIV diagnosis [1, 2]. Patients are less likely to experience the full benefits of highly active combination antiretroviral (cART) therapy if they enter HIV care and initiate treatment at a CD4 count <350 cells/mm3 [3, 4]; the clinical cost is even more profound when the CD4 count is <200 cells/mm3 or the patient has already developed clinical AIDS [5–8]. In addition, persons who remain unaware of their HIV-positive status (estimated 21% to 25% of infected persons in the USA in recent years) [9, 10] may not only miss the benefits of earlier cART treatment, but are also more likely to remain chronically viremic and are thereby more likely to transmit HIV to their sexual and needle-sharing partners . Of 3,670 new HOPS participants seen at 10 HIV clinics during 2000–2009, 1,223 (33%) had a recent HIV diagnosis (≤6 months before entry into care at a HOPS site). Compared with the 2,447 patients who were diagnosed with HIV infection >6 months prior to entry into care at a HOPS site (and may have been in care elsewhere), recently diagnosed patients were significantly (P < 0.05) more likely to be ARV naïve (86% versus 16%), younger (median age of 38 versus 40 years), to have heterosexual activity as their sole risk for HIV infection (37% versus 25%), to be privately insured (61% versus 51%), less likely to be male (75% versus 80%), less likely to be of white race (40% versus 47%), and less likely to have injection drug use (IDU) activity as their sole risk for HIV infection (6% versus 11%). Among HOPS patients recently diagnosed with HIV infection, we found no statistically significant improvement in the median CD4 count at diagnosis during 2000–2009. Overall, 36% of patients were diagnosed with a CD4 count <200 cells/mm3 and 58% with a CD4 count <350 cells/mm3. Persons whose risk for HIV infection was other than being MSM, persons aged ≥35 years, and persons of nonwhite race/ethnicity were more likely to be diagnosed with a CD4 count <200 cells/mm3 and thus more likely to have missed an opportunity for timely access to HIV care and initiation of ARV therapy; the correlates of HIV diagnosis with CD4 <350 cells/mm3 were largely similar. Our finding that MSM were less likely to be diagnosed with advanced HIV infection than some other risk groups (e.g., IDUs) is consistent with the findings from US HIV surveillance [1, 2] and data from other HIV cohorts reporting on late HIV diagnosis  and presentation for care . The association of younger age (<35 years) with a lower likelihood of late HIV diagnosis may be partially explained by the fact that younger persons de facto have had less lifetime opportunity, if they became HIV-infected, to progress to CD4 <200 cells/mm3; older age has been associated with late HIV diagnosis previously [2, 15]. The findings and conclusions in this report are those of the authors and do not necessarily represent the views of the Centers for Disease Control and Prevention. None of the authors have conflict of interests. Source: http://doi.org/10.1155/2012/869841