Cavassini.qxp 6/8/08 11:43 am Page 36
HIV and AIDS
Table 1: Late HIV Diagnosis and Missed Opportunities in Industrialised Countries Between 1996 and 2007
Study Country Time Period Number of Proportion of Characteristics and Main Findings
HIV Patients Late Diagnosis (%)
Krentz
3
Canada 1996–2001 241 39 Associated factors: older age, male heterosexuality, black.
Girardi
9
Italy 1997–2000 713 39 Associated factors: older age, no previous HIV-negative test.
Chadborn
7
England 1998–2001 5,655 29 MSM population only: older, non-white and living outside of
London had higher proportions of late diagnosis. One-year mortality
among late-diagnosed patients was approximately 10-fold higher.
Delpierre
10
France 1996–2005 4,516 38 Associated factors: heterosexual men, living in a couple with
children, unemployment among homosexual men.
Chadborn
6
England 2000–2004 10,503 42 Heterosexual population only. Late diagnosis was more frequent if
and Wales old, non-pregnant or man. Short-term mortality increased if white
because of older age.
Castilla
11
Spain 2000–2004 1,807 40 Associated factors: men, older age.
CDC
4
US 2001–2005 4,315 41 AIDS diagnosed within one year of the HIV diagnosis
Missed opportunities (1–4 years) for earlier diagnosis in 73% of the
patients. Very often the visits were not related to HIV.
Sullivan
5
UK and Ireland 2003 977 33 Associated factors: older heterosexual patients, black patients.
Protective factors: homosexual, young, non-black.
Missed opportunities with symptomatic patients from HIV: 17%.
Orchi
8
Italy 2004–2007 976 29.5 55% of older patients (aged >50) presented with a late diagnosis.
Wolbers
15
Switzerland 1998–2007 1,915 31 Associated factors: Heterosexual, older age, non-white.
Protective factors: MSM, IVDUs, living alone, previous test.
CDC = Centers for Disease Control and Prevention; MSM = men who have sex with men; IVDU = intravenous drug user.
Table 2: Reasons of Patients for an Early or Late HIV Test
short-term mortality by 56% (-249 deaths) and overall mortality by
32% between 2000 and 2004.
6
In 2001, the same group showed a
Reasons of Patients
short-term mortality rate of 9.9% for MSM with late HIV diagnosis
For an Early HIV Test For a Late HIV Test
compared with 0.5% for the MSM diagnosed earlier, i.e. >350 CD4
Feels at risk Does not consider him/herself at risk
Good knowledge of HIV: Lack of knowledge on HIV:
cells/µl.
7
Previously, in Spain Castilla et al. reported that 35%
• knows that an early diagnosis • does not know that an early diagnosis
of 7,825 AIDS cases diagnosed between 1998 and 2000 were
influences the outcome influences the outcome unaware of their HIV status and that 10% of these cases died within
New partner Fear of test because:
three months.
12
Pregnancy • would have to ‘deal’ with stable partner
Decreased morbidity • would have to deal with stigma
The risk of developing AIDS according to different baseline CD4 cell
Decreased mortality • would have to practice safer sex
count strata has been well observed in cohort studies (see Figure 1).
24
Decreased risk of social disclosure • may face liability issues if he/she infects
(less hospitalisation and thus someone else
In cases of low CD4 count at HIV diagnosis, the rate of
fewer questions)
hospitalisations, drug interactions and immune reconstitution and
Decreased risk of redundancy May have consequences on inflammatory syndrome are also increased. Moreover, survival after
(fewer working days missed and employment/social network/family
severe AIDS-defining events is sometimes followed by life-long physical
thus less suspicion from employers)
damage and invalidity. Altogether, AIDS-related increased morbidity
Decreased risk of sexual transmission
linked to late diagnosis is correlated with increase in costs.
26
Inpatient
care costs are obvious but outpatients costs also grow as patients
Considering the advantages of highly industrialised countries with starting HAART with a low CD4 count tend to have more visits and
access to care and prevention, the prevalence of late diagnosis is more concomitant drugs (in conjunction with HAART).
3
In a US HIV
clearly outrageously high. The highest prevalence of late diagnosis has clinic, yearly healthcare service costs were 2.5-fold higher for patients
been observed in marginalised patients or in patients presumably at presenting with CD4 count <50 cells/µl than for those presenting
low risk, e.g. a 59-year-old white heterosexual man who is married earlier in the course of HIV.
26
Moreover, high morbidity and mortality
and has two children. in HIV-infected individuals are also due to non-AIDS-related events
such as renal disease, non-AIDS-defining cancers and cardiovascular
Consequences of Late Diagnosis disease. This was shown by Strategies for Management of
Late diagnosis with a low baseline CD4 cell count is the strongest Antiretroviral Therapy (SMART), the largest randomised trial assessing
prognostic factor for early mortality in resource-limited settings or intermittent treatment versus continuous treatment according to the
high-income countries.
23,24
However, as HAART is potent most patients level of CD4-cell counts.
27
Higher rates of opportunistic infections and
diagnosed with AIDS and treated in industrialised countries will cardiovascular events were observed in the patients who discontinued
survive.
25
Nevertheless, Chadborn et al. reported in England a one-year HAART, suggesting that HIV may directly affect blood vessel
mortality rate of 6.1% (271/4425) for heterosexual patients with late endothelia. Despite data showing an increased risk of cardiovascular
diagnosis compared with 0.7% (41/6078) among other patients adverse events with some antiretroviral drugs, time spent on HAART
(p<0.01). They estimated that an earlier diagnosis would have reduced with undetectable viral load may no longer be considered as a risk
36 EUROPEAN INFECTIOUS DISEASE
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