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Msukwa MT, MacLachlan EW, Gugsa ST, Theu J, Namakhoma I, Bangara F, Blair CL, Payne D, Curran KG, Arons M, Namachapa K, Wadonda N, Kabaghe AN, Dobbs T, Shanmugam V, Kim E, Auld A, Babaye Y, O'Malley G, Nyirenda R, Bello G. Characterising persons diagnosed with HIV as either recent or long-term using a cross-sectional analysis of recent infection surveillance data collected in Malawi from September 2019 to March 2020. BMJ Open 2022; 12:e064707. [PMID: 36153024 PMCID: PMC9511604 DOI: 10.1136/bmjopen-2022-064707] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVES In Malawi, a recent infection testing algorithm (RITA) is used to characterise infections of persons newly diagnosed with HIV as recent or long term. This paper shares results from recent HIV infection surveillance and describes distribution and predictors. SETTING Data from 155 health facilities in 11 districts in Malawi were pooled from September 2019 to March 2020. PARTICIPANTS Eligible participants were ≥13 years, and newly diagnosed with HIV. Clients had RITA recent infections if the rapid test for recent infection (RTRI) test result was recent and viral load (VL) ≥1000 copies/mL; if VL was <1000 copies/mL the RTRI result was reclassified as long-term. Results were stratified by age, sex, pregnancy/breastfeeding status and district. RESULTS 13 838 persons consented to RTRI testing and 12 703 had valid RTRI test results and VL results after excluding clients not newly HIV-positive, RTRI negative or missing data (n=1135). A total of 12 365 of the 12 703 were included in the analysis after excluding those whose RTRI results were reclassified as long term (n=338/784 or 43.1%). The remainder, 446/12 703 or 3.5%, met the definition of RITA recent infection. The highest percentage of recent infections was among breastfeeding women (crude OR (COR) 3.2; 95% CI 2.0 to 5.0), young people aged 15-24 years (COR 1.6; 95% CI 1.3 to 1.9) and persons who reported a negative HIV test within the past 12 months (COR 3.3; 95% CI 2.6 to 4.2). Factors associated with recent infection in multivariable analysis included being a non-pregnant female (adjusted OR (AOR) 1.4; 95% CI 1.2 to 1.8), a breastfeeding female (AOR 2.2; 95% CI 1.4 to 3.5), aged 15-24 years (AOR 1.6; 95% CI 1.3 to 1.9) and residents of Machinga (AOR 2.0; 95% CI 1.2 to 3.5) and Mzimba (AOR 2.4; 95% CI 1.3 to 4.5) districts. CONCLUSIONS Malawi's recent HIV infection surveillance system demonstrated high uptake and identified sub-populations of new HIV diagnoses with a higher percentage of recent infections.
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Affiliation(s)
- Malango T Msukwa
- Department of Global Health, I-TECH, University of Washington, Lilongwe, Malawi
| | - Ellen W MacLachlan
- Department of Global Health, I-TECH, University of Washington, Seattle, Washington, USA
| | - Salem T Gugsa
- Department of Global Health, University of Washington, Seattle, Washington, USA
| | - Joe Theu
- Department of Global Health, I-TECH, University of Washington, Lilongwe, Malawi
| | - Ireen Namakhoma
- Department of Global Health, I-TECH, University of Washington, Lilongwe, Malawi
| | - Fred Bangara
- Department of Global Health, I-TECH, University of Washington, Lilongwe, Malawi
| | - Christopher L Blair
- Department of Global Health, I-TECH, University of Washington, Lilongwe, Malawi
| | - Danielle Payne
- Centers for Disease Control and Prevention, Lilongwe, Malawi
| | - Kathryn G Curran
- Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Melissa Arons
- Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Khumbo Namachapa
- Department of HIV and AIDS, Ministry of Health, Lilongwe, Central Region, Malawi
| | - Nellie Wadonda
- Centers for Disease Control and Prevention, Lilongwe, Malawi
| | | | - Trudy Dobbs
- Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | | | - Evelyn Kim
- Centers for Disease Control and Prevention, Lilongwe, Malawi
| | - Andrew Auld
- Centers for Disease Control and Prevention, Lilongwe, Malawi
| | - Yusuf Babaye
- Department of Global Health, I-TECH, University of Washington, Lilongwe, Malawi
| | - Gabrielle O'Malley
- Department of Global Health, I-TECH, University of Washington, Seattle, Washington, USA
| | - Rose Nyirenda
- Department of HIV and AIDS, Ministry of Health, Lilongwe, Central Region, Malawi
| | - George Bello
- Department of Global Health, I-TECH, University of Washington, Lilongwe, Malawi
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Marukutira T, Gunaratnam P, Douglass C, Jamil MS, McGregor S, Guy R, Gray RT, Spelman T, Horyniak D, Higgins N, Giele C, Crowe SM, Stoove M, Hellard M. Trends in late and advanced HIV diagnoses among migrants in Australia; implications for progress on Fast-Track targets: A retrospective observational study. Medicine (Baltimore) 2020; 99:e19289. [PMID: 32080144 PMCID: PMC7034696 DOI: 10.1097/md.0000000000019289] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
Abstract
Achieving the Joint United Nations Program on human immunodeficiency virus (HIV)/AIDS Fast-Track targets requires additional strategies for mobile populations. We examined trends and socio-demographics of migrants (overseas-born) and Australian-born individuals presenting with late and advanced HIV diagnoses between 2008 and 2017 to help inform public health approaches for HIV testing coverage and linkage to care and treatment.We conducted a retrospective population-level observational study of individuals diagnosed with HIV in Australia and reported to the National HIV Registry. Annual proportional trends in late (CD4+ T-cell count <350 cells/μL) and advanced (CD4+ T-cell count <200 cells/μL). HIV diagnoses were determined using Poisson regression.Of 9926 new HIV diagnoses from 2008 to 2017, 84% (n = 8340) were included in analysis. Overall, 39% (n = 3267) of diagnoses were classified as late; 52% (n = 1688) of late diagnoses were advanced. Of 3317 diagnoses among migrants, 47% were late, versus 34% of Australian-born diagnoses (P < .001).The annual proportions of late (incidence rate ratio [IRR] 1.00; 95% confidence interval [CI] 0.99-1.01) and advanced HIV diagnoses (IRR 1.01; 95% CI 0.99-1.02) remained constant. Among migrants with late HIV diagnosis, the proportion reporting male-to-male sex exposure (IRR 1.05; 95% CI 1.03-1.08), non-English speaking (IRR 1.03; 95% CI 1.01-1.05), and individuals born in countries in low HIV-prevalence (IRR 1.02; 95% CI 1.00-1.04) increased. However, declines were noted among some migrants' categories such as females, heterosexual exposure, English speaking, and those born in high HIV-prevalence countries.Late HIV diagnosis remains a significant public health concern in Australia. Small declines in late diagnosis among some migrant categories are offset by increases among male-to-male exposures. Reaching the Fast-Track targets in Australia will require targeted testing and linkage to care strategies for all migrant populations, especially men who have sex with men.
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Affiliation(s)
- Tafireyi Marukutira
- Public Health, Burnet Institute
- School of Public Health and Preventive Medicine, Monash University, Melbourne
| | | | - Caitlin Douglass
- Public Health, Burnet Institute
- School of Population and Global Health, University of Melbourne, Melbourne
| | | | | | | | | | | | - Danielle Horyniak
- Public Health, Burnet Institute
- School of Public Health and Preventive Medicine, Monash University, Melbourne
| | | | - Carolien Giele
- Department of Health and Human Services, Public and Aboriginal Health Division, Western Australia
| | - Suzanne Mary Crowe
- Public Health, Burnet Institute
- Department of Infectious Diseases, Monash University, Melbourne, Australia
| | - Mark Stoove
- Public Health, Burnet Institute
- School of Public Health and Preventive Medicine, Monash University, Melbourne
| | - Margaret Hellard
- Public Health, Burnet Institute
- School of Public Health and Preventive Medicine, Monash University, Melbourne
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Schäfer G, Hoffmann C, Arasteh K, Schürmann D, Stephan C, Jensen B, Stoll M, Bogner JR, Faetkenheuer G, Rockstroh J, Klinker H, Härter G, Stöhr A, Degen O, Freiwald E, Hüfner A, Jordan S, Schulze Zur Wiesch J, Addo M, Lohse AW, van Lunzen J, Schmiedel S. Immediate versus deferred antiretroviral therapy in HIV-infected patients presenting with acute AIDS-defining events (toxoplasmosis, Pneumocystis jirovecii-pneumonia): a prospective, randomized, open-label multicenter study (IDEAL-study). AIDS Res Ther 2019; 16:34. [PMID: 31729999 PMCID: PMC6857475 DOI: 10.1186/s12981-019-0250-2] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2019] [Accepted: 10/26/2019] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND To evaluate clinical outcomes after either immediate or deferred initiation of antiretroviral therapy in HIV-1-infected patients, presenting late with pneumocystis pneumonia (PCP) or toxoplasma encephalitis (TE). METHODS Phase IV, multicenter, prospective, randomized open-label clinical trial. Patients were randomized into an immediate therapy arm (starting antiretroviral therapy (ART) within 7 days after initiation of OI treatment) versus a deferred arm (starting ART after completing the OI-therapy). All patients were followed for 24 weeks. The rates of clinical progression (death, new or relapsing opportunistic infections (OI) and other grade 4 clinical endpoints) were compared, using a combined primary endpoint. Secondary endpoints were hospitalization rates after completion of OI treatment, incidence of immune reconstitution inflammatory syndrome (IRIS), virologic and immunological outcome, adherence to proteinase-inhibitor based antiretroviral therapy (ART) protocol and quality of life. RESULTS 61 patients (11 patients suffering TE, 50 with PCP) were enrolled. No differences between the two therapy groups in all examined primary and secondary endpoints could be identified: immunological and virologic outcome was similar in both groups, there was no significant difference in the incidence of IRIS (11 and 10 cases), furthermore 9 events (combined endpoint of death, new/relapsing OI and grade 4 events) occurred in each group. CONCLUSIONS In summary, this study supports the notion that immediate initiation of ART with a ritonavir-boosted proteinase-inhibitor and two nucleoside reverse transcriptase inhibitors is safe and has no negative effects on incidence of disease progression or IRIS, nor on immunological and virologic outcomes or on quality of life.
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Affiliation(s)
- Guido Schäfer
- Infectious Diseases Clinic, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.
- 1st Medical Department, Section Infectious Diseases & Tropical Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.
| | | | - Keikawus Arasteh
- Department for Infectious Diseases, Vivantes Auguste-Viktoria-Klinikum, Berlin, Germany
| | - Dirk Schürmann
- Department for Pneumology and Infectious Diseases, Charité Universitätsmedizin, Berlin, Germany
| | - Christoph Stephan
- 2nd Medical Department, Section Infectious Diseases, University Medical Center, Frankfurt am Main, Germany
| | - Björn Jensen
- Department for Gastroenterology, Hepatology, Infectious Diseases, Universitätsklinikum Düsseldorf, Düsseldorf, Germany
| | - Matthias Stoll
- Department for Immunology and Rheumatology, Medizinische Hochschule Hannover, Hannover, Germany
| | - Johannes R Bogner
- Department for Infectious Diseases, Mediznische Klinik und Poliklinik IV der Universität München, Munich, Germany
| | - Gerd Faetkenheuer
- 1st Medical Department, Section Infectious Diseases, Universitätsklinikum Köln, Cologne, Germany
| | - Jürgen Rockstroh
- Medical Department, Section Infectious Diseases, Universitätsklinikum Bonn, Bonn, Germany
| | - Hartwig Klinker
- Department for Infectious Diseases, Julius Maximilians University, Würzburg, Germany
| | - Georg Härter
- Department for Infectious Diseases, University Hospital, Ulm, Germany
| | - Albrecht Stöhr
- ifi-Institute for Interdisciplinary Medicine, Hamburg, Germany
| | - Olaf Degen
- Infectious Diseases Clinic, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Eric Freiwald
- Institute for Medical Biometry and Epidemiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Anja Hüfner
- Infectious Diseases Clinic, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Sabine Jordan
- Infectious Diseases Clinic, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
- 1st Medical Department, Section Infectious Diseases & Tropical Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Julian Schulze Zur Wiesch
- Infectious Diseases Clinic, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
- 1st Medical Department, Section Infectious Diseases & Tropical Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Marylyn Addo
- 1st Medical Department, Section Infectious Diseases & Tropical Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Ansgar W Lohse
- 1st Medical Department, Section Infectious Diseases & Tropical Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | | | - Stefan Schmiedel
- Infectious Diseases Clinic, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
- 1st Medical Department, Section Infectious Diseases & Tropical Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
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Crabtree-Ramírez B, Caro-Vega Y, Shepherd BE, Grinsztejn B, Wolff M, Cortes CP, Padgett D, Carriquiry G, Fink V, Jayathilake K, Person AK, McGowan C, Sierra-Madero J. Time to HAART Initiation after Diagnosis and Treatment of Opportunistic Infections in Patients with AIDS in Latin America. PLoS One 2016; 11:e0153921. [PMID: 27271083 PMCID: PMC4896474 DOI: 10.1371/journal.pone.0153921] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2015] [Accepted: 04/06/2016] [Indexed: 12/02/2022] Open
Abstract
Background Since 2009, earlier initiation of highly active antiretroviral therapy (HAART) after an opportunistic infection (OI) has been recommended based on lower risks of death and AIDS-related progression found in clinical trials. Delay in HAART initiation after OIs may be an important barrier for successful outcomes in patients with advanced disease. Timing of HAART initiation after an OI in “real life” settings in Latin America has not been evaluated. Methods Patients in the Caribbean, Central and South America network for HIV Epidemiology (CCASAnet) ≥18 years of age at enrolment, from 2001–2012 who had an OI before HAART initiation were included. Patients were divided in an early HAART (EH) group (those initiating within 4 weeks of an OI) and a delayed HAART (DH) group (those initiating more than 4 weeks after an OI). All patients with an AIDS-defining OI were included. In patients with more than one OI the first event reported was considered. Calendar trends in the proportion of patients in the EH group (before and after 2009) were estimated by site and for the whole cohort. Factors associated with EH were estimated using multivariable logistic regression models. Results A total of 1457 patients had an OI before HAART initiation and were included in the analysis: 213 from Argentina, 686 from Brazil, 283 from Chile, 119 from Honduras and 156 from Mexico. Most prevalent OI were Tuberculosis (31%), followed by Pneumocystis pneumonia (24%), Invasive Candidiasis (16%) and Toxoplasmosis (9%). Median time from OI to HAART initiation decreased significantly from 5.7 (interquartile range [IQR] 2.8–12.1) weeks before 2009 to 4.3 (IQR 2.0–7.1) after 2009 (p<0.01). Factors associated with starting HAART within 4 weeks of OI diagnosis were lower CD4 count at enrolment (p-<0.001), having a non-tuberculosis OI (p<0.001), study site (p<0.001), and more recent years of OI diagnosis (p<0.001). Discussion The time from diagnosis of an OI to HAART initiation has decreased in Latin America coinciding with the publication of evidence of its benefit. We found important heterogeneity between sites which may reflect differences in clinical practices, local guidelines, and access to HAART. The impact of the timing of HAART initiation after OI on patient survival in this “real life” context needs further evaluation.
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Affiliation(s)
- Brenda Crabtree-Ramírez
- Instituto Nacional de Ciencias Médicas y Nutrición, Salvador Zubirán, Infectious Diseases Department. Mexico City, Mexico
- * E-mail:
| | - Yanink Caro-Vega
- Instituto Nacional de Ciencias Médicas y Nutrición, Salvador Zubirán, Infectious Diseases Department. Mexico City, Mexico
| | - Bryan E. Shepherd
- Vanderbilt University, Department of Biostatistics, Nashville, TN, United States of America
| | - Beatriz Grinsztejn
- Instituto Nacional de Infectologia Evandro Chagas-Fiocruz, Rio de Janeiro, Brazil
| | - Marcelo Wolff
- Universidad de Chile- Fundación Arriarán, Santiago, Chile
| | | | - Denis Padgett
- Instituto Hondureño de Seguro Social and Hospital Escuela Universitario, Tegucigalpa, Honduras
| | | | - Valeria Fink
- Fundación Huésped, Investigaciones Clínicas, Buenos Aires, Argentina
| | - Karu Jayathilake
- Vanderbilt University, Department of Medicine, Nashville, TN, United States of America
| | - Anna K. Person
- Vanderbilt University, Department of Medicine, Nashville, TN, United States of America
| | - Catherine McGowan
- Vanderbilt University, Department of Medicine, Nashville, TN, United States of America
| | - Juan Sierra-Madero
- Instituto Nacional de Ciencias Médicas y Nutrición, Salvador Zubirán, Infectious Diseases Department. Mexico City, Mexico
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Temporal trends of time to antiretroviral treatment initiation, interruption and modification: examination of patients diagnosed with advanced HIV in Australia. J Int AIDS Soc 2015; 18:19463. [PMID: 25865372 PMCID: PMC4394156 DOI: 10.7448/ias.18.1.19463] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2014] [Revised: 02/17/2015] [Accepted: 03/04/2015] [Indexed: 11/08/2022] Open
Abstract
Introduction HIV prevention strategies are moving towards reducing plasma HIV RNA viral load in all HIV-positive persons, including those undiagnosed, treatment naïve, on or off antiretroviral therapy. A proxy population for those undiagnosed are patients that present late to care with advanced HIV. The objectives of this analysis are to examine factors associated with patients presenting with advanced HIV, and establish rates of treatment interruption and modification after initiating ART. Methods We deterministically linked records from the Australian HIV Observational Database to the Australian National HIV Registry to obtain information related to HIV diagnosis. Logistic regression was used to identify factors associated with advanced HIV diagnosis. We used survival methods to evaluate rates of ART initiation by diagnosis CD4 count strata and by calendar year of HIV diagnosis. Cox models were used to determine hazard of first ART treatment interruption (duration >30 days) and time to first major ART modification. Results Factors associated (p<0.05) with increased odds of advanced HIV diagnosis were sex, older age, heterosexual mode of HIV exposure, born overseas and rural–regional care setting. Earlier initiation of ART occurred at higher rates in later periods (2007–2012) in all diagnosis CD4 count groups. We found an 83% (69, 91%) reduction in the hazard of first treatment interruption comparing 2007–2012 versus 1996–2001 (p<0.001), and no difference in ART modification for patients diagnosed with advanced HIV. Conclusions Recent HIV diagnoses are initiating therapy earlier in all diagnosis CD4 cell count groups, potentially lowering community viral load compared to earlier time periods. We found a marked reduction in the hazard of first treatment interruption, and found no difference in rates of major modification to ART by HIV presentation status in recent periods.
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Stricker SM, Fox KA, Baggaley R, Negussie E, de Pee S, Grede N, Bloem MW. Retention in care and adherence to ART are critical elements of HIV care interventions. AIDS Behav 2014; 18 Suppl 5:S465-75. [PMID: 24292251 DOI: 10.1007/s10461-013-0598-6] [Citation(s) in RCA: 50] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
Retention in care and adherence to antiretroviral treatment (ART) are critical elements of HIV care interventions and are closely associated with optimal individual and public health outcomes and cost effectiveness. This literature review was conducted to analyse how the roles of clients in HIV care and treatment are discussed, from terminology used to measurement methods to consequences of a wide range of patient-related factors impacting client adherence to ART and retention in care. Unfortunately, data suggests that clients find it hard to follow recommended behaviour. For HIV, the greatest loss to follow-up occurs before starting treatment, though each step of the continuum of care is affected. Measurement approaches can be divided into 'direct' and 'indirect' methods; in practice, a combination is often considered the best strategy. Inadequate retention and adherence lead to decreased health outcomes (morbidity, mortality, drug resistances, risk of transmission) and cost effectiveness (increased costs and lower productivity).
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Affiliation(s)
- Sebastian M Stricker
- HIV/AIDS and Nutrition Policy Division, United Nations World Food Programme, Via C.G.Viola 68, Parco dei Medici, 00148, Rome, Italy,
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Determinants of progression to AIDS and death following HIV diagnosis: a retrospective cohort study in Wuhan, China. PLoS One 2013; 8:e83078. [PMID: 24376638 PMCID: PMC3871665 DOI: 10.1371/journal.pone.0083078] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2013] [Accepted: 11/07/2013] [Indexed: 01/22/2023] Open
Abstract
OBJECTIVE To identify determinants associated with disease progression and death following human immunodeficiency virus (HIV) diagnosis. METHODS Disease progression data from the diagnosis of HIV infection or acquiring immunodeficiency syndrome (AIDS) to February 29, 2012 were retrospectively collected from the national surveillance system databases and the national treatment database in Wuhan, China. Kaplan-Meier method, Logistic regression and Cox proportional hazards model were applied to identify the related factors of progression to AIDS or death following HIV diagnosis. RESULTS By the end of February 2012, 181 of 691 HIV infectors developed to AIDS, and 129 of 470 AIDS patients died among whom 289 cases received concurrent HIV/AIDS diagnosis. Compared with men infected through homosexual behavior, injection drug users possessed sharply decreased hazard ratio (HR) for progression to AIDS following HIV diagnosis [HR = 0.31, 95% confidence interval (CI), 0.18-0.54, P = 4.01×10(-5)]. HIV infectors at least 60 years presented 1.15-fold (HR = 2.15, 95% CI, 1.15-4.03, P = 0.017) increased risk to develop AIDS when compared with those aged 17-29 years. Similarly, AIDS patients with diagnosis ages between 50 and 59 years were at a 1.60-fold higher risk of death (HR = 2.60, 95% CI, 1.18-5.72, P = 0.017) compared to those aged 19-29 years. AIDS patients with more CD4(+) T-cells within 6 months at diagnosis (cell/µL) presented lower risk of death (HR = 0.29 for 50- vs <50, 95% CI, 0.15-0.59, P = 0.001). The highly active antiretroviral therapy (HAART) delayed progression to AIDS from HIV diagnosis (HR = 0.15, 95% CI, 0.07-0.34, P = 6.46×10(-6)) and reduced the risk of death after AIDS diagnosis (HR = 0.02, 95% CI, 0.01-0.04, P = 7.25×10(-25)). CONCLUSIONS Progression to AIDS and death following HIV diagnosis differed in age at diagnosis, transmission categories, CD4(+) T-cell counts and HAART. Effective interventions should target those at higher risk for morbidity or mortality, ensuring early diagnosis and timely treatment to slow down the disease progression.
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MacCarthy S, Bangsberg DR, Fink G, Reich M, Gruskin S. Late presentation to HIV/AIDS testing, treatment or continued care: clarifying the use of CD4 evaluation in the consensus definition. HIV Med 2013; 15:130-4. [PMID: 24024559 DOI: 10.1111/hiv.12088] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/16/2013] [Indexed: 11/26/2022]
Abstract
OBJECTIVES Late presentation to HIV/AIDS services compromises treatment outcomes and misses opportunities for biomedical and behavioural prevention. There has been significant heterogeneity in how the term 'late presentation' (LP) has been used in the literature. In 2011, a consensus definition was reached using CD4 counts to define and measure late presenters and, while it is useful for clinical care, the consensus definition has several important limitations that we discuss in this article. METHODS Using the spectrum of engagement in HIV care presented by Gardner and colleagues, this article highlights issues and opportunities associated with use of the consensus definition. RESULTS The consensus definition is limited by three principal factors: (1) the CD4 count threshold of 350 cells/μL is being increasingly questioned as the biomedical justification grows for earlier initiation of treatment; (2) CD4 evaluations are conducted at multiple services providing HIV care; thus it remains unclear to which service the patient is presenting late; and (3) the limited availability of CD4 evaluation restricts its use in determining the prevalence of LP in many settings. CONCLUSIONS The consensus definition is useful because it describes the level of disease progression and allows for consistent evaluation of the prevalence and determinants of LP. Suggestions are provided for improving the application of the consensus definition in future research.
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Affiliation(s)
- S MacCarthy
- Alpert Medical School of Brown University and The Miriam Hospital, Providence, RI, USA
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Estimation of HIV-testing rates to maximize early diagnosis-derived benefits at the individual and population level. PLoS One 2013; 8:e53193. [PMID: 23308161 PMCID: PMC3538781 DOI: 10.1371/journal.pone.0053193] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2012] [Accepted: 11/29/2012] [Indexed: 11/19/2022] Open
Abstract
Background In HIV infection, initiation of treatment is associated with improved clinical outcom and reduced rate of sexual transmission. However, difficulty in detecting infection in early stages impairs those benefits. We determined the minimum testing rate that maximizes benefits derived from early diagnosis. Methods We developed a mathematical model of HIV infection, diagnosis and treatment that allows studying both diagnosed and undiagnosed populations, as well as determining the impact of modifying time to diagnosis and testing rates. The model’s external consistency was assessed by estimating time to AIDS and death in absence of treatment as well as by estimating age-dependent mortality rates during treatment, and comparing them with data previously reported from CASCADE and DHCS cohorts. Results In our model, life expectancy of patients diagnosed before 8 years post infection is the same as HIV-negative population. After this time point, age at death is significantly dependent on diagnosis delay but initiation of treatment increases life expectancy to similar levels as HIV-negative population. Early mortality during HAART is dependent on treatment CD4 threshold until 6 years post infection and becomes dependent on diagnosis delay after 6 years post infection. By modifying testing rates, we estimate that an annual testing rate of 20% leads to diagnosis of 90% of infected individuals within the first 8.2 years of infection and that current testing rate in middle-high income settings stands close to 10%. In addition, many differences between low-income and middle-high incomes can be predicted by solely modifying the diagnosis delay. Conclusions To increase testing rate of undiagnosed HIV population by two-fold in middle-high income settings will minimize early mortality during initiation of treatment and global mortality rate as well as maximize life expectancy. Our results highlight the impact of achieving early diagnosis and the importance of strongly work on improving HIV testing rates.
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Predictors of late presentation for HIV diagnosis: a literature review and suggested way forward. AIDS Behav 2013; 17:5-30. [PMID: 22218723 DOI: 10.1007/s10461-011-0097-6] [Citation(s) in RCA: 71] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Early commencement of antiretroviral treatment can be beneficial and economical in the long run. Despite global advances in access to care, a significant proportion of adults presenting at HIV/AIDS care facilities present with advanced HIV disease. Understanding factors associated with late presentation for HIV/AIDS services is critical to the development of effective programs and treatment strategies. Literature on factors associated with late presentation for an HIV diagnosis is reviewed. Highlighted is the current emphasis on socio-demographic factors, the limited exploration of psychosocial correlates, and inconsistencies in the definition of late presentation that make it difficult to compare findings across different studies. Perspectives based on experiences from resource limited settings are underreported. Greater exploration of psychosocial predictors of late HIV diagnosis is advocated for, to guide future intervention research and to inform public policy and practice targeted at 'difficult to reach' populations.
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McMahon T, Ward PR. HIV among immigrants living in high-income countries: a realist review of evidence to guide targeted approaches to behavioural HIV prevention. Syst Rev 2012; 1:56. [PMID: 23168134 PMCID: PMC3534573 DOI: 10.1186/2046-4053-1-56] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2012] [Accepted: 10/29/2012] [Indexed: 11/10/2022] Open
Abstract
UNLABELLED BACKGROUND Immigrants from developing and middle-income countries are an emerging priority in HIV prevention in high-income countries. This may be explained in part by accelerating international migration and population mobility. However, it may also be due to the vulnerabilities of immigrants including social exclusion along with socioeconomic, cultural and language barriers to HIV prevention. Contemporary thinking on effective HIV prevention stresses the need for targeted approaches that adapt HIV prevention interventions according to the cultural context and population being addressed. This review of evidence sought to generate insights into targeted approaches in this emerging area of HIV prevention. METHODS We undertook a realist review to answer the research question: 'How are HIV prevention interventions in high-income countries adapted to suit immigrants' needs?' A key goal was to uncover underlying theories or mechanisms operating in behavioural HIV prevention interventions with immigrants, to uncover explanations as how and why they work (or not) for particular groups in particular contexts, and thus to refine the underlying theories. The realist review mapped seven initial mechanisms underlying culturally appropriate HIV prevention with immigrants. Evidence from intervention studies and qualitative studies found in systematic searches was then used to test and refine these seven mechanisms. RESULTS Thirty-four intervention studies and 40 qualitative studies contributed to the analysis and synthesis of evidence. The strongest evidence supported the role of 'consonance' mechanisms, indicating the pivotal need to incorporate cultural values into the intervention content. Moderate evidence was found to support the role of three other mechanisms - 'understanding', 'specificity' and 'embeddedness' - which indicated that using the language of immigrants, usually the 'mother tongue', targeting (in terms of ethnicity) and the use of settings were also critical elements in culturally appropriate HIV prevention. There was mixed evidence for the roles of 'authenticity' and 'framing' mechanisms and only partial evidence to support role of 'endorsement' mechanisms. CONCLUSIONS This realist review contributes to the explanatory framework of behavioural HIV prevention among immigrants living in high-income countries and, in particular, builds a greater understanding of the suite of mechanisms that underpin adaptations of interventions by the cultural context and population being targeted.
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Affiliation(s)
- Tadgh McMahon
- Multicultural HIV and Hepatitis Service, PO Box M139, MISSENDEN ROAD, Camperdown, NSW, 2050, Australia
- Discipline of Public Health, School of Medicine, Flinders University, GPO Box 2100, Flinders, SA, 5001, Australia
| | - Paul R Ward
- Discipline of Public Health, School of Medicine, Flinders University, GPO Box 2100, Flinders, SA, 5001, Australia
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Manzardo C, Esteve A, Ortega N, Podzamczer D, Murillas J, Segura F, Force L, Tural C, Vilaró J, Masabeu A, Garcia I, Guadarrama M, Ferrer E, Riera M, Navarro G, Clotet B, Gatell JM, Casabona J, Miró JM. Optimal timing for initiation of highly active antiretroviral therapy in treatment-naïve human immunodeficiency virus-1-infected individuals presenting with AIDS-defining diseases: the experience of the PISCIS Cohort. Clin Microbiol Infect 2012; 19:646-53. [PMID: 22967234 DOI: 10.1111/j.1469-0691.2012.03991.x] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
In this prospective, multicentre cohort study, we analysed specific prognostic factors and the impact of timing of highly active antiretroviral therapy (HAART) on disease progression and death among 625 human immunodeficiency virus (HIV)-1-infected, treatment-naïve patients diagnosed with an AIDS-defining disease. HAART was classified as early (<30 days) or late (30-270 days). Deferring HAART was significantly associated with faster progression to a new AIDS-defining event/death overall (p 0.009) and in patients with Pneumocystis jiroveci pneumonia (p 0.017). In the multivariate analysis, deferring HAART was associated with a higher risk of a new AIDS-defining event/death (p 0.002; hazard ratio 1.83; 95% CI 1.25-2.68). Other independent risk factors for poorer outcome were baseline diagnosis of AIDS-defining lymphoma, age >35 years, and low CD4(+) count (<50 cells/μL).
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Affiliation(s)
- C Manzardo
- Hospital Clínic-IDIBAPS, University of Barcelona, Barcelona, Spain
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McGrath JW, Kaawa-Mafigiri D, Bridges S, Kakande N. 'Slipping through the cracks': policy implications of delays in HIV treatment seeking. Glob Public Health 2012; 7:1095-108. [PMID: 22813066 PMCID: PMC3505559 DOI: 10.1080/17441692.2012.701318] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
Public health initiatives to 'test and treat' HIV-infected persons require understanding HIV care seeking. A study of 101 HIV-infected women receiving anti-retroviral medications in Kampala, Uganda, examined barriers to HIV care. Participants entered HIV/AIDS care late, despite knowing their risk and having sought care for symptoms. Over half of the participants (51%) reported delays of up to 5 years from when they suspected they were infected to seeking an HIV test. Some women reported that they did not perceive a need to be tested because they 'knew' they had HIV due to their partner's death from AIDS. Once tested, delays in entering HIV specific care ranged from less than 6 months to over 5 years. The most common reason reported for entering HIV care was the occurrence of serious or persistent symptoms. Late presentation for HIV care in this cohort is due to the inability of the medical system to link women to appropriate care. Women 'slip through the cracks' of this system, despite their care seeking behaviours. The inability to provide linkage to care is a challenge at the health system level that threatens the success of 'test and treat' protocols.
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Affiliation(s)
- Janet W McGrath
- Department of Anthropology, Center for Social Sciences Research on AIDS, Case Western Reserve University, Cleveland, OH, USA.
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Miro JM, Manzardo C, Mussini C, Johnson M, d'Arminio Monforte A, Antinori A, Gill MJ, Sighinolfi L, Uberti-Foppa C, Borghi V, Sabin C. Survival outcomes and effect of early vs. deferred cART among HIV-infected patients diagnosed at the time of an AIDS-defining event: a cohort analysis. PLoS One 2011; 6:e26009. [PMID: 22043301 PMCID: PMC3197144 DOI: 10.1371/journal.pone.0026009] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2011] [Accepted: 09/15/2011] [Indexed: 11/18/2022] Open
Abstract
Objectives We analyzed clinical progression among persons diagnosed with HIV at the time of an AIDS-defining event, and assessed the impact on outcome of timing of combined antiretroviral treatment (cART). Methods Retrospective, European and Canadian multicohort study.. Patients were diagnosed with HIV from 1997–2004 and had clinical AIDS from 30 days before to 14 days after diagnosis. Clinical progression (new AIDS event, death) was described using Kaplan-Meier analysis stratifying by type of AIDS event. Factors associated with progression were identified with multivariable Cox regression. Progression rates were compared between those starting early (<30 days after AIDS event) or deferred (30–270 days after AIDS event) cART. Results The median (interquartile range) CD4 count and viral load (VL) at diagnosis of the 584 patients were 42 (16, 119) cells/µL and 5.2 (4.5, 5.7) log10 copies/mL. Clinical progression was observed in 165 (28.3%) patients. Older age, a higher VL at diagnosis, and a diagnosis of non-Hodgkin lymphoma (NHL) (vs. other AIDS events) were independently associated with disease progression. Of 366 patients with an opportunistic infection, 178 (48.6%) received early cART. There was no significant difference in clinical progression between those initiating cART early and those deferring treatment (adjusted hazard ratio 1.32 [95% confidence interval 0.87, 2.00], p = 0.20). Conclusions Older patients and patients with high VL or NHL at diagnosis had a worse outcome. Our data suggest that earlier initiation of cART may be beneficial among HIV-infected patients diagnosed with clinical AIDS in our setting.
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Affiliation(s)
- Jose M. Miro
- Hospital Cliníc-IDIBAPS, University of Barcelona, Barcelona, Spain
- * E-mail:
| | | | - Cristina Mussini
- Clinic of Infectious and Tropical Diseases, University of Modena and Reggio Emilia, Modena, and Azienda Policlinico, Modena, Italy
| | - Margaret Johnson
- Ian Charleson Centre, Royal Free Hospital, London, United Kingdom
| | | | - Andrea Antinori
- National Institute for Infectious Diseases ‘L. Spallanzani’, IRCCS, Rome, Italy
| | | | - Laura Sighinolfi
- Department of Infectious Diseases, S. Anna Hospital, Ferrara, Italy
| | | | - Vanni Borghi
- Clinic of Infectious and Tropical Diseases, University of Modena and Reggio Emilia, Modena, and Azienda Policlinico, Modena, Italy
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CD4 Cell Counts at HIV Diagnosis among HIV Outpatient Study Participants, 2000-2009. AIDS Res Treat 2011; 2012:869841. [PMID: 21941640 PMCID: PMC3176626 DOI: 10.1155/2012/869841] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2011] [Revised: 06/27/2011] [Accepted: 06/28/2011] [Indexed: 11/21/2022] Open
Abstract
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.
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Crabtree-Ramírez B, Caro-Vega Y, Shepherd BE, Wehbe F, Cesar C, Cortés C, Padgett D, Koenig S, Gotuzzo E, Cahn P, McGowan C, Masys D, Sierra-Madero J. Cross-sectional analysis of late HAART initiation in Latin America and the Caribbean: late testers and late presenters. PLoS One 2011; 6:e20272. [PMID: 21637802 PMCID: PMC3102699 DOI: 10.1371/journal.pone.0020272] [Citation(s) in RCA: 52] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2011] [Accepted: 04/17/2011] [Indexed: 01/28/2023] Open
Abstract
BACKGROUND Starting HAART in a very advanced stage of disease is assumed to be the most prevalent form of initiation in HIV-infected subjects in developing countries. Data from Latin America and the Caribbean is still lacking. Our main objective was to determine the frequency, risk factors and trends in time for being late HAART initiator (LHI) in this region. METHODOLOGY Cross-sectional analysis from 9817 HIV-infected treatment-naïve patients initiating HAART at 6 sites (Argentina, Chile, Haiti, Honduras, Peru and Mexico) from October 1999 to July 2010. LHI had CD4(+) count ≤200 cells/mm(3) prior to HAART. Late testers (LT) were those LHI who initiated HAART within 6 months of HIV diagnosis. Late presenters (LP) initiated after 6 months of diagnosis. Prevalence, risk factors and trends over time were analyzed. PRINCIPAL FINDINGS Among subjects starting HAART (n = 9817) who had baseline CD4(+) available (n = 8515), 76% were LHI: Argentina (56%[95%CI:52-59]), Chile (80%[95%CI:77-82]), Haiti (76%[95%CI:74-77]), Honduras (91%[95%CI:87-94]), Mexico (79%[95%CI:75-83]), Peru (86%[95%CI:84-88]). The proportion of LHI statistically changed over time (except in Honduras) (p≤0.02; Honduras p = 0.7), with a tendency towards lower rates in recent years. Males had increased risk of LHI in Chile, Haiti, Peru, and in the combined site analyses (CSA). Older patients were more likely LHI in Argentina and Peru (OR 1.21 per +10-year of age, 95%CI:1.02-1.45; OR 1.20, 95%CI:1.02-1.43; respectively), but not in CSA (OR 1.07, 95%CI:0.94-1.21). Higher education was associated with decreased risk for LHI in Chile (OR 0.92 per +1-year of education, 95%CI:0.87-0.98) (similar trends in Mexico, Peru, and CSA). LHI with date of HIV-diagnosis available, 55% were LT and 45% LP. CONCLUSION LHI was highly prevalent in CCASAnet sites, mostly due to LT; the main risk factors associated were being male and older age. Earlier HIV-diagnosis and earlier treatment initiation are needed to maximize benefits from HAART in the region.
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Affiliation(s)
| | - Yanink Caro-Vega
- Instituto Nacional de Ciencias Médicas y Nutrición, Salvador Zubiran, Mexico City, Mexico
| | - Bryan E. Shepherd
- Biostatistics, Vanderbilt University, Nashville, Tennessee, United States of America
| | - Firas Wehbe
- Biomedical Informatics, Vanderbilt University, Nashville, Tennessee, United States of America
| | - Carina Cesar
- Investigaciones Clínicas, Fundación Huésped, Buenos Aires, Argentina
| | - Claudia Cortés
- Fundación Arriarán, Universidad de Chile, Santiago, Chile
| | - Denis Padgett
- Instituto Hondureño de Seguro Social y Hospital Escuela, Tegucigalpa, Honduras
| | - Serena Koenig
- GHESKIO/Weill Medical College of Cornell University, Port au Prince, Haiti
- Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, United States of America
| | - Eduardo Gotuzzo
- Instituto de Medicina Tropical Alexander von Humboldt, Lima, Peru
| | - Pedro Cahn
- Investigaciones Clínicas, Fundación Huésped, Buenos Aires, Argentina
| | - Catherine McGowan
- Infectious Diseases, Vanderbilt University, Nashville, Tennessee, United States of America
| | - Daniel Masys
- Biomedical Informatics, Vanderbilt University, Nashville, Tennessee, United States of America
| | - Juan Sierra-Madero
- Instituto Nacional de Ciencias Médicas y Nutrición, Salvador Zubiran, Mexico City, Mexico
- * E-mail:
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Colucci A, Balzano R, Camoni L, Regine V, Longo B, Pezzotti P, Starace F, Cafaro L, Aloisi MS, Suligoi B, Rezza G, Girardi E. Characteristics and behaviors in a sample of patients unaware of their infection until AIDS diagnosis in Italy: a cross-sectional study. AIDS Care 2011; 23:1067-75. [DOI: 10.1080/09540121.2011.554525] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Affiliation(s)
- Anna Colucci
- a Department of Infectious Parasitic and Immune-Mediated Diseases , Istituto Superiore di Sanità , Rome , Italy
| | - Roberta Balzano
- b National Institute for Infectious Diseases, “Lazzaro Spallanzani” IRCCS , Rome , Italy
| | - Laura Camoni
- a Department of Infectious Parasitic and Immune-Mediated Diseases , Istituto Superiore di Sanità , Rome , Italy
| | - Vincenza Regine
- a Department of Infectious Parasitic and Immune-Mediated Diseases , Istituto Superiore di Sanità , Rome , Italy
| | | | - Patrizio Pezzotti
- a Department of Infectious Parasitic and Immune-Mediated Diseases , Istituto Superiore di Sanità , Rome , Italy
| | - Fabrizio Starace
- d Department of Consultation Psychiatry and Behavioral Epidemiology , “Cotugno” Hospital , Naples , Italy
| | - Loredana Cafaro
- d Department of Consultation Psychiatry and Behavioral Epidemiology , “Cotugno” Hospital , Naples , Italy
| | | | - Barbara Suligoi
- a Department of Infectious Parasitic and Immune-Mediated Diseases , Istituto Superiore di Sanità , Rome , Italy
| | - Giovanni Rezza
- a Department of Infectious Parasitic and Immune-Mediated Diseases , Istituto Superiore di Sanità , Rome , Italy
| | - Enrico Girardi
- b National Institute for Infectious Diseases, “Lazzaro Spallanzani” IRCCS , Rome , Italy
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Late-disease stage at presentation to an HIV clinic in the era of free antiretroviral therapy in Sub-Saharan Africa. J Acquir Immune Defic Syndr 2010; 52:280-9. [PMID: 19521248 DOI: 10.1097/qai.0b013e3181ab6eab] [Citation(s) in RCA: 132] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Access to free antiretroviral therapy in sub-Saharan Africa has been steadily increasing, and the success of large-scale antiretroviral therapy programs depends on early initiation of HIV care. However, little is known about the stage at which those infected with HIV present for treatment in sub-Saharan Africa. METHODS We conducted a cross-sectional analysis of initial visits to the Immune Suppression Syndrome Clinic of the Mbarara University Teaching Hospital, including patients who had their initial visit between February 2007 and February 2008 (N = 2311). RESULTS The median age of the patients was 33 years (range 16-81 years), and 64% were female. More than one third (40%) were categorized as late presenters, that is, World Health Organization disease stage 3 or 4. Male gender, age 46-60 years (vs. younger), lower education level, being unemployed, living in a household with others, being unmarried, and lack of spousal HIV status disclosure were independently associated with late presentation, whereas being pregnant, having young children, and consuming alcohol in the prior year were associated with early presentation. CONCLUSIONS Targeted public health interventions to facilitate earlier entry into HIV care are needed, as well as additional study to determine whether late presentation is due to delays in testing vs. delays in accessing care.
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Adler A, Mounier-Jack S, Coker R. Late diagnosis of HIV in Europe: definitional and public health challenges. AIDS Care 2009; 21:284-93. [DOI: 10.1080/09540120802183537] [Citation(s) in RCA: 69] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Affiliation(s)
- A. Adler
- a Department of Public Health and Policy , London School of Hygiene and Tropical Medicine , London , UK
| | - S. Mounier-Jack
- a Department of Public Health and Policy , London School of Hygiene and Tropical Medicine , London , UK
| | - R.J. Coker
- a Department of Public Health and Policy , London School of Hygiene and Tropical Medicine , London , UK
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Late diagnosis and subsequent survival among HIV-infected truck drivers in the northwest of France: a retrospective study. AIDS 2009; 23:1440-2. [PMID: 19448527 DOI: 10.1097/qad.0b013e32832d40c4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Late diagnosis of HIV infection is associated with a lower survival rate. Because of several consecutive cases of late diagnosis of AIDS occurring in truck drivers, a retrospective study was carried out in the northwest of France. Truck drivers were significantly associated with a late diagnosis of HIV infection (P = 0.009) and an increased risk of death (P = 0.03). Consequently, prevention and HIV-testing campaigns targeting this profession appear necessary.
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Coenen T, Lundgren J, Lazarus JV, Matic S. Optimal HIV testing and earlier care: the way forward in Europe. HIV Med 2008; 9 Suppl 2:1-5. [PMID: 18557862 DOI: 10.1111/j.1468-1293.2008.00583.x] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
The articles in this supplement were developed from a recent pan-European conference entitled 'HIV in Europe 2007: Working together for optimal testing and earlier care', which took place on 26-27 November in Brussels, Belgium. The conference, organized by a multidisciplinary group of experts representing advocacy, clinical and policy areas of the HIV field, was convened in an effort to gain a common understanding on the role of HIV testing and counselling in optimizing diagnosis and the need for earlier care. Key topics discussed at the conference and described in the following articles include: current barriers to HIV testing across Europe, trends in the epidemiology of HIV in the region, problems associated with undiagnosed infection and the psychosocial barriers impacting on testing. The supplement also provides a summary of the World Health Organization's recommendations for HIV testing in Europe and an outline of an indicator disease-guided approach to HIV testing proposed by a committee of experts from the European AIDS Clinical Society (EACS). We hope that consideration of the issues discussed in this supplement will help to shift the HIV field closer towards our ultimate goal: provision of optimal HIV testing and earlier care across the whole of the European region.
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Affiliation(s)
- T Coenen
- AIDS Fonds and STI AIDS Netherlands, Amsterdam, the Netherlands
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Abstract
OBJECTIVE Many patients infected with HIV still present with an AIDS diagnosis. The aim of this study was to evaluate the virological, immunological and clinical outcomes of HAART in these patients. DESIGN The present study was a multi-cohort study. All patients with an AIDS diagnosis between 30 days before and 14 days after HIV diagnosis, recruited between 1997 and 2004 from eight hospital cohorts, were evaluated. RESULTS A total of 760 patients were included [268 (35.3%) had pneumocystis and 168 (22.1%) tuberculosis]. Six hundred and twenty-four patients (82.1%) started HAART a median of 31 days after HIV diagnosis. One hundred and fifty-three patients started a nonnucleoside transcriptase inhibitor-based regimen (20.1%), 409 a protease inhibitor-based regimen (53.8%) and 62 other regimens (8.2%). In adjusted analyses, HAART was started sooner in more recent years, in patients with lower CD4 cell count and in those with Kaposi's sarcoma, whereas it was started later in those with tuberculosis. Five hundred and five patients (89%) attained a viral load of less than 500 copies/ml. The factors associated with a better virological response were later calendar year, lower initial viral load and cytomegalovirus disease. Virological rebound was more common in those receiving nucleoside reverse transcriptase inhibitor-based regimens, in those with tuberculosis and in earlier calendar years. One hundred and twenty-five (16%) patients died; 61 had received HAART (48.6%). Mortality was more likely in those who were older, those with a higher viral load at diagnosis, those with nonsexual HIV risks and those with lower CD4 cell count and haemoglobin levels over follow-up. CONCLUSION Virological suppression was achieved in most AIDS patients, though mortality remains high in these individuals.
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Guy RJ, McDonald AM, Bartlett MJ, Murray JC, Giele CM, Davey TM, Appuhamy RD, Knibbs P, Coleman D, Hellard ME, Grulich AE, Kaldor JM. Characteristics of HIV diagnoses in Australia, 1993-2006. Sex Health 2008; 5:91-6. [DOI: 10.1071/sh07070] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Objective: To describe recent trends in the diagnosis of HIV infection in Australia. Methods: National HIV surveillance data from 1993 to 2006 were analysed with a focus on geographic differences by HIV exposure route and late presentation (HIV within 3 months of a first AIDS-defining illness or a CD4 count of less than 200 cells μL–1). Results: In 1993–99, the number of HIV diagnoses declined by 32%, and then increased by 39% from 1999 to 2006. From 2000 onwards, rates increased significantly in Victoria, Queensland, South Australia and Western Australia. The most frequently reported routes of HIV exposure were male to male sex (71%) and heterosexual contact (18%), and the population rate of diagnoses have increased in both categories. Among the cases reported as heterosexually acquired (n = 2199), 33% were in people born in a high-prevalence country and 19% in those with partners from a high-prevalence country. Late presentation was most frequent in heterosexually acquired infections in persons who had a partner from a high-prevalence country: 32% compared with 20% overall. Conclusions: Recent increases in annual numbers of HIV diagnoses in Australia underline the continuing need for HIV-prevention programs, particularly among men having male to male sex. Early diagnosis and access to care and treatment should also be emphasised, as a substantial proportion of people with HIV infection are unaware of their status until late in the course of disease.
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McDonald AM, Li Y, Dore GJ, Ree H, Kaldor JM. Late HIV presentation among AIDS cases in Australia, 1992-2001. Aust N Z J Public Health 2007; 27:608-13. [PMID: 14723408 DOI: 10.1111/j.1467-842x.2003.tb00607.x] [Citation(s) in RCA: 33] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
OBJECTIVE To describe time trends and demographic, exposure and clinical factors associated with late HIV presentation among notified AIDS cases diagnosed in Australia in 1992-2001. METHODS AIDS cases, diagnosed in Australia and notified to the National AIDS Registry, were included in the analysis. AIDS cases newly diagnosed with HIV infection within three months of AIDS diagnosis were defined as cases of late HIV presentation. RESULTS The percentage of AIDS cases with late HIV presentation increased significantly from 18% in 1992-96 to 33.1% in 1997 (adjusted odds ratio (AOR)=1.79, p<0.005) and to 49.6% in 2001 (AOR=3.01, p<0.005). Older age, having been born in Asia, a HIV exposure history of heterosexual contact or an 'other/undetermined' exposure and a diagnosis of PCP only or of multiple AIDS illnesses, were associated with late HIV presentation among AIDS cases diagnosed in 1992-96 and in 1997-2001, and among overseas-born cases diagnosed in 1992-2001. In 1997-2001, a low CD4+ cell count was also associated with late HIV presentation. Among homosexually active men diagnosed with AIDS in 1997-2001, older age, a diagnosis of PCP or multiple AIDS illnesses and a low CD4+ cell count were associated with late HIV presentation. CONCLUSION Predictors of late HIV presentation have remained substantially unchanged over time and among population subgroups, suggesting a need for innovation in HIV/AIDS testing and counselling strategies.
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Affiliation(s)
- Ann M McDonald
- National Centre in HIV Epidemiology and Clinical Research, University of New South Wales, for the National HIV Surveillance Committee, Darlinghurst.
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Girardi E, Sabin CA, Monforte AD. Late Diagnosis of HIV Infection: Epidemiological Features, Consequences and Strategies to Encourage Earlier Testing. J Acquir Immune Defic Syndr 2007; 46 Suppl 1:S3-8. [PMID: 17713423 DOI: 10.1097/01.qai.0000286597.57066.2b] [Citation(s) in RCA: 228] [Impact Index Per Article: 13.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
A substantial proportion of HIV-infected individuals do not present for HIV testing until late in infection; these individuals are often ill, have a high mortality risk, and are less likely to respond to treatment when initiated. Furthermore, late presentation means that opportunities to reduce onward transmission, either by reducing high-risk behaviours or by reducing an individual's infectivity, are missed. The proportion of HIV-infected individuals who present late has remained relatively stable over the past decade, despite several attempts to encourage earlier diagnosis. Late presenters tend to be those at lower perceived risk of infection, those who are not routinely offered HIV testing, and are often from marginalized groups. Strategies that encourage earlier testing, including routine HIV testing in healthcare settings where high-risk individuals attend frequently, the availability of HIV testing services in non-medical settings, and partner notification schemes or peer-led projects to encourage high-risk individuals to attend for testing, may all increase the proportion of HIV-infected individuals who are aware of their HIV status, thus helping to control the spread of the epidemic. This review summarizes recent evidence on the epidemiology of late presentation and its impact on clinical progression, and describes several key strategies that may encourage earlier diagnosis.
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Affiliation(s)
- Enrico Girardi
- UOC Epidemiologia Clinica, Istituto Nazionale per le Malattie Infettive L. Spallanzani - IRCCS, Rome, Italy.
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Manzardo C, Zaccarelli M, Agüero F, Antinori A, Miró JM. Optimal Timing and Best Antiretroviral Regimen in Treatment-naive HIV-Infected Individuals with Advanced Disease. J Acquir Immune Defic Syndr 2007; 46 Suppl 1:S9-18. [PMID: 17713424 DOI: 10.1097/01.qai.0000286599.38431.ef] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
The introduction of highly active antiretroviral therapy (HAART) in developed countries has achieved a good control of HIV infection. Despite this, a delayed HIV diagnosis makes it necessary to start antiretroviral treatment in individuals with severe impairment of their immunological function. Very often, this is accompanied by an opportunistic infection that needs to be treated, with a consequent complication of management because of overlapping toxicities and pharmacokinetic interactions with antiretroviral drugs, and a greater pill burden. All this could impair adherence and reconstitution of the immune function with a paradoxical clinical worsening in some patients, especially if the CD4 cell count is below 50 cells/microl. The best antiretroviral regimen and the best timing for starting antiretroviral therapy in treatment-naive patients with advanced infection have not yet been established. Recommendations for the clinical management of advanced HIV disease come from panels of experts in the therapy of opportunistic infections and antiretroviral treatment, and they advise starting combined antiretroviral therapy 2-4 weeks after initiating treatment of the opportunistic infection. Many patients have been successfully treated with a pharmacologically enhanced (boosted) protease inhibitor (mainly lopinavir/ritonavir)-based regimens. The efficacy of non-nucleoside reverse transcriptase inhibitor-based regimens for the treatment of very immunosuppressed patients has been tested in few clinical trials during the HAART era. Some cohort studies and randomized clinical trials support the use of efavirenz-based antiretroviral therapy for the treatment of advanced HIV-1-infected patients; however, recent randomized controlled data suggest, in a moderately advanced HIV population, a better CD4 cell recovery for lopinavir-ritonavir than for efavirenz-treated patients, but a greater virological suppression in the efavirenz arm. Further randomized clinical trials are needed in order to determine whether the efficacy, tolerability and the immunological reconstitution of efavirenz-based therapy can match that achieved with lopinavir/ritonavir or other current boosted protease inhibitor regimens in advanced patients.
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Losina E, Figueroa P, Duncan J, Divi N, Wolf LL, Hirschhorn LR, Robertson M, Harvey K, Whorms S, Freedberg KA, Gebre Y. HIV morbidity and mortality in Jamaica: analysis of national surveillance data, 1993--2005. Int J Infect Dis 2007; 12:132-8. [PMID: 17706448 PMCID: PMC2365735 DOI: 10.1016/j.ijid.2007.05.002] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2007] [Accepted: 05/25/2007] [Indexed: 11/21/2022] Open
Abstract
OBJECTIVES Pre-antiretroviral therapy (ART) HIV-related survival and timing of HIV identification have not been reported from the Caribbean. Using Jamaican national surveillance data, we estimated overall, AIDS-free, and AIDS survival, identified factors influencing HIV-related mortality, and examined factors associated with late HIV/AIDS identification. METHODS The Jamaican HIV/AIDS tracking system (HATS) national surveillance data included timing of first positive HIV test, stage at identification, date of AIDS diagnosis, and death. We estimated overall and AIDS-free survival by initial stage, using a proportional hazard model to identify factors associated with worse survival, and logistic regression to examine factors related to later case identification. RESULTS Of 10674 reported HIV cases, 48% were asymptomatic, 14% symptomatic, and 38% first reported with AIDS. Five-year AIDS-free survival was 77% for asymptomatic persons and 63% for symptomatic. Median survival after AIDS diagnosis was 1.02 years. Age, number of opportunistic diseases, and initial stage were strongly associated with mortality. Older age, drug use, and sex with a commercial sex worker were associated with later identification. CONCLUSIONS In the pre-ART era, over one-third of HIV-infected persons in Jamaica were first identified with advanced disease. This highlights the need for earlier diagnosis as ART programs roll out in the Caribbean.
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Affiliation(s)
- Elena Losina
- Division of General Medicine and Infectious Diseases, Massachusetts General Hospital, 50 Staniford St, 9th Floor, Boston, Massachusetts 02114, USA.
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Abstract
Late presentation remains a major concern despite the dramatically improved prognosis realized by ART. We define a first presentation for HIV care during the course of HIV infection as ‘late’ if an AIDS-defining opportunistic disease is apparent, or if CD4+ T-cells are <200/μl. In the Western world, approximately 10 and 30% of HIV-infected individuals still present with CD4+ T-cells <50 and <200/μl, respectively; estimates are substantially higher for developing countries. Diagnosis and treatment of opportunistic diseases and intense supportive in-hospital care take precedence over ART. Benefits of starting ART without delay, that is, when opportunistic diseases are still active, include faster resolution of opportunistic diseases and a decreased risk of recurrence. The downside of starting ART without delay could include toxicity, drug interactions and immune reconstitution inflammatory syndrome (IRIS). Among asymptomatic or oligosymptomatic individuals presenting late, where ART and primary prophylaxis are initiated, ∼10–20% will become symptomatic from drug toxicity or undiagnosed opportunistic complications, including IRIS, which require appropriate therapies. In this review we describe late presentation to HIV care, the scale of the problem, the evaluation of a late-presenting patient and challenges associated with initiation of potent anti-retroviral therapy (ART) in the setting of acute opportunistic infections and other comorbidities.
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Affiliation(s)
- Manuel Battegay
- Division of Infectious Diseases & Hospital Epidemiology, University Hospital Basel, Switzerland
| | - Ursula Fluckiger
- Division of Infectious Diseases & Hospital Epidemiology, University Hospital Basel, Switzerland
| | - Bernard Hirschel
- Division of Infectious Diseases, Geneva University Hospital, Geneva, Switzerland
| | - Hansjakob Furrer
- Division of Infectious Diseases, University Hospital Berne, Switzerland
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Louis C, Ivers LC, Smith Fawzi MC, Freedberg KA, Castro A. Late presentation for HIV care in central Haiti: factors limiting access to care. AIDS Care 2007; 19:487-91. [PMID: 17453588 DOI: 10.1080/09540120701203246] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
OBJECTIVE Many patients with HIV infection present for care late in the course of their disease, a factor which is associated with poor prognosis. Our objective was to identify factors associated with late presentation for HIV care among patients in central Haiti. METHODS/DESIGN Thirty-one HIV-positive adults, approximately 10% of the HIV-infected population followed at a central Haiti hospital, participated in this research study. A two-part research tool that included a structured questionnaire and an ethnographic life history interview was used to collect quantitative as well as qualitative data about demographic factors related to presentation for HIV care. RESULTS Sixty-five percent of the patients in this study presented late for HIV care, as defined by CD4 cell count below 350 cells/mm3. Factors associated with late presentation included male sex, older age, patient belief that symptoms are not caused by a medical condition, greater distance from the medical clinic, lack of prior access to effective medical care, previous requirement to pay for medical care, and prior negative experience at local hospitals. Harsh poverty was a striking theme among all patients interviewed. CONCLUSIONS Delays in presentation for HIV care in rural Haiti are linked to demographic, socioeconomic and structural factors, many of which are rooted in poverty. These data suggest that a multifaceted approach is needed to overcome barriers to early presentation for care. This approach might include poverty alleviation strategies; provision of effective, reliable and free medical care; patient outreach through community health workers and collaboration with traditional healers.
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Affiliation(s)
- C Louis
- Yale University School of Medicine, New Haven, USA
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30
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Körner H. Late HIV diagnosis of people from culturally and linguistically diverse backgrounds in Sydney: The role of culture and community. AIDS Care 2007; 19:168-78. [PMID: 17364395 DOI: 10.1080/09540120600944692] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
In Australia more than 85% of newly diagnosed HIV infections in 1999-2003 were homosexually acquired. In contrast, among people from culturally and linguistically diverse backgrounds, there is a much higher proportion of heterosexual exposure and many of the heterosexually acquired infections are diagnosed 'late', with people sometimes presenting with symptoms of AIDS. This paper reports on circumstances of late HIV diagnosis, meaning of an HIV-positive diagnosis and perceptions of risk among HIV-positive people from a variety of cultural and ethnic backgrounds in Sydney. The focus was on commonalities across cultures and ethnicities. Data were collected through semi-structured in-depth interviews with clients of the Multicultural HIV/AIDS and Hepatitis C Service and a sexual health clinic. Regular HIV tests were the exception in this group. Testing was usually motivated by a serious health crisis. Participants interpreted their diagnosis in the context of their knowledge and experiences with HIV/AIDS in their country of birth and the perceptions of HIV/AIDS in their ethnic communities in Australia. Many were not aware of the relationship between HIV and AIDS. Risk was perceived in terms of 'risk group' membership not in terms of practices and behaviours. Late diagnosis cannot be explained solely by association with country of birth, race or ethnicity. Rather, it is located within complex sets of social and cultural relations: the values attributed to HIV/AIDS and those infected and the social and cultural relations of ethnic communities in Australia and the dominant culture. These are enacted in healthcare seeking behaviour, perceptions of people with HIV and perceptions of being 'at risk'.
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Affiliation(s)
- H Körner
- National Centre in HIV Social Research, Sydney, Australia.
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31
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Ayton DR, Guy RJ, Woolley IJ, Hellard ME. Cambodian-born individuals diagnosed with HIV in Victoria: epidemiological findings and health service implications. Sex Health 2007; 4:209. [DOI: 10.1071/sh07016] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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Hall HI, McDavid K, Ling Q, Sloggett A. Determinants of progression to AIDS or death after HIV diagnosis, United States, 1996 to 2001. Ann Epidemiol 2006; 16:824-33. [PMID: 17067817 DOI: 10.1016/j.annepidem.2006.01.009] [Citation(s) in RCA: 63] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2005] [Revised: 12/20/2005] [Accepted: 01/23/2006] [Indexed: 11/22/2022]
Abstract
PURPOSE The aim of the study is to determine factors associated with disease progression after human immunodeficiency virus (HIV) infection diagnosis. METHODS We applied generalized linear models with Poisson errors to obtain adjusted relative excess risk for death for persons diagnosed with acquired immunodeficiency syndrome (AIDS) or HIV infection (with or without concurrent AIDS) during 1996 to 2001. We examined differences in time between HIV diagnosis and AIDS by using standardized Kaplan-Meier survival methods. RESULTS Relative excess risk for death within 3 years after AIDS diagnosis was significantly greater for non-Hispanic blacks (1.15; 95% confidence interval [CI], 1.12-1.18), American Indians (1.33; 95% CI, 1.16-1.52), and Hispanics (1.16; 95% CI, 1.13-1.20) compared with whites. Risk for death also was greater among injection drug users (men, 1.50; 95% CI, 1.46-1.54; women, 1.57; 95% CI, 1.51-1.62) compared with men who have sex with men and among those diagnosed at older ages compared with younger persons. Similar disparities between groups in risk for death were observed from HIV diagnosis. Risk for progression from HIV to AIDS was greater for nonwhites, men, and older persons compared with whites, women, and younger persons, respectively. CONCLUSIONS Interventions should target those at excess risk for death or morbidity to ensure access to quality care and adherence to treatment to slow disease progression.
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Affiliation(s)
- H Irene Hall
- Division of HIV/AIDS Prevention, National Center for HIV, STD, and TB Prevention, Centers for Disease Control and Prevention, Atlanta, GA 30333, USA.
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Gay CL, Napravnik S, Eron JJ. Advanced immunosuppression at entry to HIV care in the southeastern United States and associated risk factors. AIDS 2006; 20:775-8. [PMID: 16514310 DOI: 10.1097/01.aids.0000216380.30055.4a] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
In this study we characterized factors associated with the late initiation of HIV care in the southeastern United States. At initiation of care, antiretroviral therapy was indicated for 75% of patients, 50% had a CD4 cell count of less than 200 cells/mul, and 27% presented with an AIDS-defining illness. Male sex was an independent predictor in multivariable analysis. These results indicate an urgent need to increase HIV testing for earlier diagnosis in the southeastern USA.
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Affiliation(s)
- Cynthia L Gay
- The University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
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McMahon T, Fairley CK, Donovan B, Wan L, Quin J. Evaluation of an ethnic media campaign on patterns of HIV testing among people from culturally and linguistically diverse backgrounds in Australia. Sex Health 2006; 1:91-4. [PMID: 16334990 DOI: 10.1071/sh03001] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
OBJECTIVE To evaluate a 2-week pilot ethnic media campaign that was implemented in 14 languages to promote awareness of HIV/AIDS and HIV testing among selected non-English speaking populations in Australia in November/December 2000. METHODS The main outcome measure was clinic attendances for the purpose of HIV testing by individuals from the target populations at one ofthree public sexual health clinics in Sydney and Melbourne prior to and immediately after the campaign. RESULTS The number of HIV tests on members of the 14 target language communities attending the clinics almost doubled from 66 to 122 tests. However, as a proportion of the total number of HIV tests performed at the three clinics this increase was not significant (16.3-18.8%; P = 0.31). For both periods in 2000 the proportion of HIV tests that were performed on members of the target language group were higher than during a 1999 comparison period (10.5%, both P < 0.01). CONCLUSIONS AND IMPLICATIONS This study did not demonstrate a significant increase in testing attributable to the pilot intervention. A larger campaign, with a more extensive evaluation, would probably be needed to demonstrate a measurable effect.
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Affiliation(s)
- Tadgh McMahon
- Multicultural HIV/AIDS and Hepatitis C Service, PO Box M139, Missenden Road, NSW 2050, Australia.
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Rudy ET, Mahoney-Anderson PJ, Loughlin AM, Metsch LR, Kerndt PR, Gaul Z, Del Rio C. Perceptions of Human Immunodeficiency Virus (HIV) Testing Services Among HIV-Positive Persons Not in Medical Care. Sex Transm Dis 2005; 32:207-13. [PMID: 15788917 DOI: 10.1097/01.olq.0000156132.19021.ba] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND AND OBJECTIVES Human immunodeficiency virus (HIV) counseling, testing, and referral (CTR) are provided in a wide variety of settings. GOAL To compare, by test setting, the perceptions of the testing experience among HIV-positive persons who were not receiving medical care. DESIGN A baseline questionnaire was administered at enrollment into the Antiretroviral Treatment Access Study by the use of audio computer-assisted self-interview. RESULTS Of 316 respondents, 27% reported that the counselor did not spend enough time with them and 22% that the counselor did not answer all questions. The odds were higher that persons in the following settings, compared with those at HIV test sites, would report that the counselor did not spend enough time with them: office of private physician or health maintenance organization (HMO) (adjusted odds ratio [AOR], 5.24; 95% confidence interval, 1.26-21.7), jail (AOR, 5.10; 95% CI, 1.06-24.6), and emergency room (ER) or hospital overnight visit (AOR, 2.93; 95% CI, 1.15-7.44). Similarly, the odds were higher that persons in the following settings compared with those at HIV test sites would report that the counselor did not answer all questions: office of private physician or HMO (AOR, 9.62; 95% CI, 2.22-41.7), jail (AOR, 7.87; 95% CI, 1.50-41.4), and ER or hospital overnight visit (AOR, 3.32; 95% CI, 1.11-9.90). CONCLUSION Further training and quality assurance in HIV CTR may be needed in some test settings.
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Affiliation(s)
- Ellen T Rudy
- Sexually Transmitted Diseases Program, Los Angeles Health Department, Los Angeles, California 90007, USA.
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Sabin CA, Smith CJ, Gumley H, Murphy G, Lampe FC, Phillips AN, Prinz B, Youle M, Johnson MA. Late presenters in the era of highly active antiretroviral therapy: uptake of and responses to antiretroviral therapy. AIDS 2004; 18:2145-51. [PMID: 15577647 DOI: 10.1097/00002030-200411050-00006] [Citation(s) in RCA: 171] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES To investigate the characteristics and clinical, immunological and virological outcomes for individuals presenting for care with low CD4 cell counts. METHODS Individuals aged > 16 years presenting for care for the first time were identified between 1 January 1996 and 31 December 2002. Late presenters were those with CD4 cell count < 50 x 10(6) cells/l. Follow-up was until last contact, death or 31 December 2002. RESULTS Late presenters formed 15.3% (110) of the group; they were more likely to be female (35% versus 24%), heterosexual (53% versus 38%), and of Black-African ethnicity (39% versus 27%) than other individuals. Over a median follow-up of 2.5 years, 13% of late presenters died. Ninety-nine patients started antiretroviral treatment; Of the 11 patients who did not start antiretroviral treatment, eight died within 3 months of presentation. Among those starting treatment, 87 (87.9%) achieved a viral load < 400 copies/ml and median CD4 cell counts increased from 43 x 10(6) cells/l at 0-2 months after presentation to 204 x 10(6) cells/l at 1 year. Over the first year, 71 patients attended at least one outpatient visit (median, 4.5; range, 0-39), 21 attended at least one day case visit (median, 0; range, 0-15) and 49 were admitted as an inpatient (median, 0; range, 0-4). CONCLUSIONS Those presenting for care with very low CD4 cell counts may make large demands on clinical resources, particularly over the first few months. While some patients do have a poor outcome on highly active antiretroviral therapy, many will benefit from this therapy and will experience good immunological and virological responses.
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Affiliation(s)
- Caroline A Sabin
- Royal Free and University College Medical School, Royal Free NHS Trust, London, UK.
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Giard M, Gambotti L, Besson H, Fabry J, Vanhems P. Facteurs associés à une prise en charge tardive des patients infectés par le VIH : revue de la littérature. SANTE PUBLIQUE 2004; 16:147-56. [PMID: 15185592 DOI: 10.3917/spub.041.0147] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
In the United States, Australia and Europe, many HIV infected individuals are still diagnosed and/or treated late in the course of the disease. This literature review of studies published over a ten year period between 1993 and 2003 has identified the following principle factors associated with the late diagnosis of HIV: male gender, aged older than 45 years, heterosexual intercourse, the lack of previous screening. It also identified the factors linked to the delay in beginning anti-retroviral treatment as being male gender, the lack of awareness or denial of the possibility of HIV infection, intravenous drug use, lack of post-screening follow-up or counseling, lack of social protection, and the lack of regular medical visits and care. Early detection and suitable early treatment of the HIV virus are the main determining factors which will effectively contribute to the control and maintenance of the virus in as much as they are focused upon these particular at-risk populations.
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Affiliation(s)
- M Giard
- Laboratoire d'Epidémiologie et de Santé Publique, INSERM U271, et Service d'Epidémiologie, Hôpital Edouard Herriot, Faculté de Médecine, 8, avenue Rockefeller, 69373 Lyon, France
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Klein D, Hurley LB, Merrill D, Quesenberry CP. Review of medical encounters in the 5 years before a diagnosis of HIV-1 infection: implications for early detection. J Acquir Immune Defic Syndr 2003; 32:143-52. [PMID: 12571523 DOI: 10.1097/00126334-200302010-00005] [Citation(s) in RCA: 135] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Early detection of HIV infection improves prognosis and reduces transmission, but 30%-40% of cases are diagnosed late. A comprehensive and systematic review of medical encounters before diagnosis has not been done. This study reviews 5 years of medical encounters before the diagnosis of HIV infection in members of a large managed care organization where access to care is reasonably good. Patient characteristics, HIV risk factors, and clinical events preceding diagnosis were examined and tested for association with late diagnosis (CD4 cell count of <200/microL at diagnosis). Of 440 HIV-infected patients, 62% had CD4 cell counts of <350/microL, 43% had CD4 cell counts of <200/microL, and 18% had CD4 cell counts of <50/microL at diagnosis. Twenty-six percent of all patients had risks documented >1 year before diagnosis. Only 22% of patients had one of eight clinical indicators suggested in the literature as reasons to test for HIV >1 year before diagnosis. In multiple logistic regression, older age, male sex, race, risk group, no prior HIV testing, physician-initiated testing, and having any of eight clinical indicators before diagnosis were each associated with late diagnosis (p <or=.05). Late diagnosis remains a challenge despite good access to care. In our setting, effective risk assessment before symptoms arise offers greater potential for raising the mean CD4 cell count at diagnosis than does increased awareness of selected HIV-associated clinical prompts.
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Affiliation(s)
- Daniel Klein
- Kaiser Permanente Medical Center, Hayward, California, USA.
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Don't leave us this way: ethnography and injecting drug use in the age of AIDS. THE INTERNATIONAL JOURNAL OF DRUG POLICY 2002. [DOI: 10.1016/s0955-3959(02)00118-4] [Citation(s) in RCA: 76] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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