Late diagnosis of HIV in Europe: Definitional and public health challenges

Department of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, UK.
AIDS Care (Impact Factor: 1.6). 12/2008; 21(3):284-93. DOI: 10.1080/09540120802183537
Source: PubMed


With universal access to antiretroviral therapy (ART), people can access effective treatment but are only able to benefit from these advances if they are aware of their status and are effectively accessing testing services. Although it was anticipated in the mid-1990s that the availability of ART would lead to earlier testing, this trend has not been observed in practice, with stagnant or even increasing rates of late diagnosis in Europe. Ahead of a gathering of key European stakeholders in Brussels in November 2007, we reviewed definitions of late diagnosis and approaches to surveillance of late HIV diagnosis in Europe. We found that there is no common or consistent reporting of late diagnosis across Europe and that the multiplicity of definitions for late diagnosis is likely proving a hindrance to providing information on the magnitude of the problem, determining trends, and informing understanding of reasons for changes in trends. We also show that existing evidence points to high rates of late diagnosis across Europe - between 15 and 38% of all HIV cases - and concur that trends that are increasing or at best stagnant. We identify risk factors that are associated with individuals being more likely to present late and we explore the reasons for late presentation. We reflect on the need to review surveillance and testing policies, notably in relation for population groups that are heavily represented in late presenters and make recommendations for a coherent, cross-European approach to surveillance and monitoring in order to support improvements in service provision and, ultimately, public health.

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    • "Despite the aforementioned efforts to encourage earlier and more frequent HIV testing and targeting at-risk populations, late presentation (presentation with low CD4 count) is unfortunately not a rarity. A consensus definition has been agreed in order to identify the extent to which it occurs [38, 39]. A common definition of late presentation is important. "
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    ABSTRACT: HIV infection in Western Europe is mainly concentrated among men who have sex with men, heterosexuals who acquired HIV from sub-Saharan African countries, and in people who inject drugs. The rate of newly diagnosed cases of HIV has remained roughly stable since 2004 whereas the number of people living with HIV has slowly increased due to new infections and the success of antiretroviral therapy in prolonging life. An ageing population is gradually emerging that will require additional care. There are large differences across countries in HIV testing rates, proportions of people who present to care with low CD4+ cell counts, accessibility to treatment and care, and rates of retention once in care. Improved collection of HIV surveillance data will benefit countries and help to understand their epidemic better. However, social inequalities experienced by people with HIV still remain in some regions and urgently need to be addressed.
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    • "These figures are consistent with previous reports from industrialized countries. In Europe among 10,222 newly diagnosed HIV infection cases with CD4 cell counts reported in 2009, 51% had a first CD4 cell count below 350/mmc [4] and a series of surveys show that 29–39% of individuals with a new HIV diagnosis have less than 200 CD4 cells/mmc at first presentation [19]. Similarly, more than half of the individuals enrolled in cohort studies in North America from 1997–2007 had fewer than 350 CD4 cells/mmc when they first presented for HIV care [6]. "
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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.
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    • "Despite important advances in the rollout of ART worldwide, 1.7 million people died of HIVrelated pathologies in 2011 [1]. This high mortality could be explained by many factors including late presentation of HIV [2] [3] [4] [5], poor engagement in medical care [6] [7] [8] [9], poor retention in pre-ART care [10] [11] [12], late or no initiation of ART [13] [14] [15], high levels of attrition from care after ART initiation [16] [17], and poor virological suppression in patients on ART [18]. When designing programmes aimed at providing treatment, care, and support to people living with HIV, it is important to understand the contributions of these factors to the overall HIV mortality, in order to improve the efficiency of HIV spending. "
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    ABSTRACT: HIV treatment, care, and support programmes in low- and middle-income countries have traditionally focused more on patients remaining in care after the initiation of antiretroviral therapy (ART) than on earlier stages of care. This study describes the cumulative retention from HIV diagnosis to the achievement of virological suppression after ART initiation in an HIV cohort study in India. Of all patients diagnosed with HIV, 70% entered into care within three months. 65% of patients ineligible for ART at the first assessment were retained in pre-ART care. 67% of those eligible for ART initiated treatment within three months. 30% of patients who initiated ART died or were lost to followup, and 82% achieved virological suppression in the last viral load determination. Most attrition occurred the in pre-ART stages of care, and it was estimated that only 31% of patients diagnosed with HIV engaged in care and achieved virological suppression after ART initiation. The total mortality attributable to pre-ART attrition was considerably higher than the mortality for not achieving virological suppression. This study indicates that early entry into pre-ART care along with timely initiation of ART is more likely to reduce HIV-related mortality compared to achieving virological suppression.
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