Advanced immunosuppression at entry to HIV care in the Southeastern United States and associated risk factors

University of North Carolina at Chapel Hill, North Carolina, United States
AIDS (Impact Factor: 5.55). 04/2006; 20(5):775-8. DOI: 10.1097/01.aids.0000216380.30055.4a
Source: PubMed


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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Available from: Cynthia L Gay,
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    • "While survival times and quality of life for people with HIV (PLHIV) have improved dramatically since the introduction of ART, reductions in morbidity and mortality depend on timely HIV care linkage and retention [10-15]. Yet in the South, delayed entry into HIV care appears to be a common phenomenon [16-18]. An estimated 61% of PLHIV in Alabama, and 62% in Mississippi, for instance, are not in HIV care [19,20]. "
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    ABSTRACT: In a significant geographical shift in the distribution of HIV infection, the US South - comprising 17 states - now has the greatest number of adults and adolescents with HIV (PLHIV) in the nation. More than 60% of PLHIV are not in HIV care in Alabama and Mississippi, contrasted with a national figure of 25%. Poorer HIV outcomes raise concerns about HIV-related inequities for southern PLHIV, which warrant further study. This qualitative study sought to understand experiences of low-income PLHIV on the AIDS Drug Assistance Program in engagement and retention in continuous HIV care in two sites in Alabama. The study was designed using grounded theory. Semi-structured interviews with 25 PLHIV explored experiences with care linkage, reported factors and behaviors affecting engagement/retention in continuous HIV care, including socio-economic factors. To triangulate sources, 25 additional interviews were conducted with health and social service providers from the same clinics and AIDS Service Organizations where clients obtained services. Across the narratives, we used the HIV care continuum to map where care delays and drop out occurred. Using open coding, constant comparison and iterative data collection and analysis, we constructed a conceptual model illustrating how participants described their path to HIV care engagement and retention. Most respondents reported delayed HIV care, describing concentric factors: psychological distress, fear, lack of information, substance use, incarceration, lack of food, transport and housing. Stark health system drop out occurred immediately after receipt of HIV test results, with ART initiation generally occurring when individuals became ill. Findings highlight these enablers to care: Alabama's 'social infrastructure': 'twinning' medical with social services, 'social enablers' who actively link PLHIV to care, and 'enabling spaces' that break down PLHIV isolation, facilitating HIV care linkage/retention. Ryan White-funded programs, together with housing, food and psychological support were pre-conditions for participants' entry and retention in HIV care. The path to achieving continuous HIV care for individuals at risk of lack of entry or delayed HIV care requires robust social-level responses, like in Alabama, that address physical and mental health of clients and directly engage the particular social and economic contexts and vulnerabilities of southern PLHIV.
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    • "In the U.S. Southeast, a substantial proportion of people living with HIV are diagnosed or enter care late in the course of illness. In the hospital outpatient clinic where our study was conducted, 75% of all patients have an indication for antiretroviral therapy at their first clinic visit, and 50% have a CD4+ T-cell count less than 200 cells/mm 3 (Gay et al., 2006). Likewise, in Birmingham, Alabama, 41% of patients presenting to an HIV/AIDS outpatient clinic had progressed to Centers for Disease Control and Prevention (CDC) defined AIDS (Krawczyk et al., 2006a). "
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    ABSTRACT: Persons with unrecognized HIV infection forgo timely clinical intervention and may unknowingly transmit HIV to partners. However, in the USA, unrecognized infection and late diagnosis are common. To understand barriers and facilitators to HIV testing and care, we conducted a qualitative study of 24 HIV infected persons attending a Southeastern HIV clinic who presented with clinically advanced illness. The primary barrier to HIV testing prior to diagnosis was perception of risk; consequently, most participants were diagnosed after the onset of clinical symptoms. While most patients were anxious to initiate care rapidly after diagnosis, some felt frustrated by the passive process of connecting to specialty care. The first visit with an HIV care provider was identified as critical in the coping process for many patients. Implications for the implementation of Centers for Disease Control and Prevention HIV routine screening guidelines are discussed.
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