Review of Medical Encounters in the 5 Years Before a Diagnosis of HIV-1 Infection: Implications for Early Detection

Kaiser Permanente Medical Center, Hayward, California, USA.
JAIDS Journal of Acquired Immune Deficiency Syndromes (Impact Factor: 4.56). 02/2003; 32(2):143-52. DOI: 10.1097/00126334-200302010-00005
Source: PubMed


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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    • "Many individuals with substance use disorders do not undergo HIV testing until they become clinically symptomatic and present with late-stage disease in hospitalized settings. Approximately 40% of HIV diagnoses are made after the disease has progressed to the point at which the person has advanced HIV infection, or acquired immune deficiency syndrome (AIDS) (Castilla et al. 2002; Dybul et al. 2002; Klein et al. 2003). As a result, symptomatic patients with substance use disorders or those who have health concerns may be more likely to undergo HIV testing than their asymptomatic counterparts (Anderson et al. 2005; Bond, Lauby & Batson 2005). "
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    ABSTRACT: Abstract Routine testing is the cornerstone to identifying HIV, but not all substance abuse treatment patients have been tested. This study is a real-world evaluation of predictors of having never been HIV tested among patients initiating substance abuse treatment. Participants (N = 614) from six New England clinics were asked whether they had ever been HIV tested. Eighty-five patients (13.8%) reported having never been tested and were compared to those who had undergone testing. Clinic, male gender (adjusted odds ratio (AOR) = 1.91, 95% confidence interval (CI) = 1.07-3.41), and having fewer employment (AOR = 0.31; 95% CI = 0.11-0.88) and medical problems (AOR = 0.40, 95% CI = 0.17-0.99) were independently correlated with having never been HIV tested. Thus, there is still considerable room for improved testing strategies as a clinically significant minority of substance abuse patients have never undergone HIV testing when they initiate treatment.
    Journal of psychoactive drugs 07/2014; 46(3):208-214. DOI:10.1080/02791072.2014.915363 · 1.10 Impact Factor
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    • "To our knowledge, few reports have analyzed the association between diagnosis of an indicator disease and probability of receiving an earlier HIV diagnosis [23-28]. Klein et al. have reviewed medical encounters before HIV diagnosis in the US concluding that increased recognition of clinical indicators for HIV testing prompted earlier HIV diagnosis in 22% of individuals [23]. Recently, Ellis S. et al. found that in the United Kingdom, among 1,112 newly diagnosed HIV-infected patients, a quarter of them were identified as having missed an opportunity for earlier diagnosis [24]. "
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    ABSTRACT: The aim of our work was to evaluate the potential impact of the European policy of testing for HIV all individuals presenting with an indicator disease, to prevent late diagnosis of HIV. We report on a retrospective analysis among individuals diagnosed with HIV to assess whether a history of certain diseases prior to HIV diagnosis was associated with the chance of presenting late for care, and to estimate the proportion of individuals presenting late who could have been diagnosed earlier if tested when the indicator disease was diagnosed. We studied a large cohort of individuals newly diagnosed with HIV infection in 10 counselling and testing sites in the Lazio Region, Italy (01/01/2004-30/04/2009). Considered indicator diseases were: viral hepatitis infection (HBV/HCV), sexually transmitted infections, seborrhoeic dermatitis and tuberculosis. Logistic regression analysis was performed to estimate association of occurrence of at least one indicator disease with late HIV diagnosis. In our analysis, the prevalence of late HIV diagnosis was 51.3% (890/1735). Individuals reporting at least one indicator disease before HIV diagnosis (29% of the study population) had a lower risk of late diagnosis (OR = 0.7; 95%CI: 0.5-0.8) compared to those who did not report a previous indicator disease. 52/890 (5.8%) late presenters were probably already infected at the time the indicator disease was diagnosed, a median of 22.6 months before HIV diagnosis. Our data suggest that testing for HIV following diagnosis of an indicator disease significantly decreases the probability of late HIV diagnosis. Moreover, for 5.5% of late HIV presenters, diagnosis could have been anticipated if they had been tested when an HIV indicator disease was diagnosed.However, this strategy for enhancing early HIV diagnosis needs to be complemented by client-centred interventions that aim to increase awareness in people who do not perceive themselves as being at risk for HIV.
    BMC Infectious Diseases 10/2013; 13(1):473. DOI:10.1186/1471-2334-13-473 · 2.61 Impact Factor
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    • "Health institutions represent a key point of contact with HIV-infected individuals. However, research shows that many opportunities for early diagnosis and care are often missed, both in high- and low-income settings [22–24]. These missed opportunities translate into increased health care costs and continued transmission of HIV. "
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    ABSTRACT: The Argentinean AIDS Program estimates that 110,000 persons are living with HIV/AIDS in Argentina. Of those, approximately 40% are unaware of their status, and 30% are diagnosed in advanced stages of immunosuppression. Though studies show that universal HIV screening is cost-effective in settings with HIV prevalence greater than 0.1%, in Argentina, with the exception of antenatal care, HIV testing is always client-initiated. We performed a pilot study to assess the acceptability of a universal HIV screening program among inpatients of an urban public hospital in Buenos Aires. Over a six-month period, all eligible adult patients admitted to the internal medicine ward were offered HIV testing. Demographics, uptake rates, reasons for refusal and new HIV diagnoses were analyzed. Of the 350 admissions during this period, 249 were eligible and subsequently enrolled. The enrolled population was relatively old compared to the general population, was balanced on gender, and did not report traditional high risk factors for HIV infection. Only 88 (39%) reported prior HIV testing. One hundred and ninety (76%) patients accepted HIV testing. In multivariable analysis only younger age (OR 1.02; 95%CI 1.003-1.05) was independently associated with test uptake. Three new HIV diagnoses were made (undiagnosed HIV prevalence: 1.58%); none belonged to a most-at-risk population. Our findings suggest that universal HIV screening in this setting is acceptable and potentially effective in identifying undiagnosed HIV-infected individuals. If confirmed in a larger study, our findings may inform changes in the Argentinean HIV testing policy.
    PLoS ONE 07/2013; 8(7):e69517. DOI:10.1371/journal.pone.0069517 · 3.23 Impact Factor
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