Date Published: October 15, 2012
Publisher: Hindawi Publishing Corporation
Author(s): Paz Sobrino-Vegas, Santiago Pérez-Hoyos, Ronald Geskus, Belén Padilla, Ferrán Segura, Rafael Rubio, Jorge del Romero, Jesus Santos, Santiago Moreno, Julia del Amo.
Objectives. Since subjects may have been diagnosed before cohort entry, analysis of late HIV diagnosis (LD) is usually restricted to the newly diagnosed. We estimate the magnitude and risk factors of LD in a cohort of seroprevalent individuals by imputing seroconversion dates. Methods. Multicenter cohort of HIV-positive subjects who were treatment naive at entry, in Spain, 2004–2008. Multiple-imputation techniques were used. Subjects with times to HIV diagnosis longer than 4.19 years were considered LD. Results. Median time to HIV diagnosis was 2.8 years in the whole cohort of 3,667 subjects. Factors significantly associated with LD were: male sex; Sub-Saharan African, Latin-American origin compared to Spaniards; and older age. In 2,928 newly diagnosed subjects, median time to diagnosis was 3.3 years, and LD was more common in injecting drug users. Conclusions. Estimates of the magnitude and risk factors of LD for the whole cohort differ from those obtained for new HIV diagnoses.
The majority of clinical cohorts of HIV-infected people are made up of seroprevalent subjects whose dates of seroconversion are unknown [1–3]. Seroprevalent subjects have been used to quantify the magnitude and risk factors of late diagnosis of HIV infection, an important public health problem which, by definition, cannot be studied in seroconverter cohorts [4, 5]. Although there are multiple definitions of late diagnosis based on different biological markers [4, 6–8], most of them are based on the patient’s CD4 lymphocyte count close to the date of HIV diagnosis. For some persons, HIV may have been diagnosed before their inclusion in a clinical cohort; therefore, no CD4 counts close to HIV diagnosis are usually available. Consequently, these people are ignored, and estimates are obtained only from those with available CD4 counts—largely the new HIV diagnoses—rather than from the whole cohort. Most clinical cohorts include newly diagnosed people as well as people who have been diagnosed in the past, but the latter group is rendered invisible. The use of multiple imputation techniques to estimate the time between HIV seroconversion and HIV diagnosis could overcome the aforementioned problem. These techniques, which so far have not been applied to study late HIV diagnosis, are based on the correlation between certain biological markers like CD4 lymphocytes and the duration of infection [9–11].
CoRIS is an open, multicenter, and prospective cohort of adult patients with confirmed HIV infection who are naive to antiretroviral treatment (ART) at the first visit to any of the CoRIS centers and who agree to participate in the study by signing an informed consent form. A complete description has been published elsewhere . Briefly, CoRIS collects a minimum dataset which is subject to internal and external quality controls. Between January 2004 and October 2008, 4,057 subjects were recruited from 27 participating centers where the percentage of CD4 lymphocytes (hereinafter referred to as “CD4%”) was measured. A total of 231 subjects were excluded because they had recently been recruited, and no CD4% results were available, and 159 were excluded because their first CD4% values were recorded after ART initiation. Accordingly, 3,667 patients were available for analysis.
Of the 3,667 patients included in this analysis, most were men (77.8%), were infected by sexual transmission (43.1% MSM and 37.5% heterosexual), and were Spanish nationals (68.5%); 15.8% had been infected through injecting drug use. The mean age at HIV diagnosis was 34.8 years (SD = 10.2) and the median follow-up time was 1.38 years. At cohort entry, 442 patients (12%) had been diagnosed with AIDS, another 191 (5.2%) developed AIDS, and 86 persons (2.3%) died during followup.
This study illustrates the application of a multiple imputation method to estimate the date of HIV seroconversion in a cohort of seroprevalent patients who are not all newly diagnosed with HIV at entry. We defined as late diagnosis the subjects with times to HIV diagnosis longer than 4.19 years. The advantage of this definition is that it allows estimation of late diagnosis in the whole cohort and not just in patients with CD4 markers close to the time of HIV diagnosis.