Late diagnosis/entry into HIV care can result in early deaths among infected

Study highlights human year toll

Despite public health initiatives pushing routine HIV testing, too many people infected with the virus are diagnosed later in the disease, leading to poor health outcomes, a study suggests.

"We're still finding over the past several years that patients are presenting fairly late in the course of their illness," says Jeanne C. Keruly, MS, CRNP, an assistant professor of medicine at Johns Hopkins University, and the director of the Ryan White Adult Programs in Baltimore, MD.

"We found that if you look at CD4 cell count strata over four years, especially among those individuals who have CD4 cell counts below 200, there are significant years of life lost," Keruly says.

Investigators extrapolated that data to an estimated 11,000 patients over four years who would be newly diagnosed with HIV in Maryland, and determined that there would be a significant number of years (2,673 person-years of life) potentially lost due to late presentation to care.1

"So, our conclusions were that because of late presentation, life is lost, and we need to find other ways in which to expand screening to get patients in for care earlier," Keruly says.

The analysis involved 1,617 patients who newly presented for HIV care from 2000 to 2004. Among these patients, about 43 percent had CD4 cell counts of less than 200, and about 23 percent had CD4 cell counts of 201 to 350.1

Despite the CDC's recommendations for routine HIV testing in health care settings, there remain institutional and public barriers to making this a reality, Keruly notes.

For example, in Maryland, and in a number of other states, there are laws requiring health care providers to provide formal written informed consent to everyone who is offered an HIV test, she says.

"In Maryland, the state administration is looking at whether we need to revise this law," Keruly says.

For states and hospitals to adopt opt-out testing procedures, it will be necessary to change the informed consent laws, she adds.

"The laws were there to protect patients' confidentiality," Keruly says. "Twenty years ago, HIV was a death sentence, and it affected employment, insurability, and laws were enacted to make certain patients knew they were being tested and why they were being tested, as a means of protection."

Now that HIV has become a chronic disease under the more potent antiretroviral regimens, the same laws that once protected HIV-infected individuals might harm them — particularly if they are unaware of their disease status and risk.

The key is to get HIV patients into care earlier and to provide them with treatment and knowledge about how to stop transmission of the disease, Keruly says.

"Individuals who know they're infected do reduce their risk behaviors," she adds. "In addition, getting people into treatment so they can have a suppressed viral load may result in fewer infections."

Another factor that could impact the loss of person-years is starting antiretroviral treatment earlier than clinicians have in the past.

The Department of Health and Human Services (DHHS)'s Adult and Adolescent Antiretroviral (ART) guidelines, updated Jan. 29, 2008, now recommend that antiretroviral therapy for asymptomatic patients should be initiated when the CD4 cell counts fall below 350 cells/mm3. The previous version, published July 14, 2003, had indicated that clinical trial evidence suggested that antiretroviral therapy begin when CD4 T cells were less than 200, but evidence for starting therapy when CD4 T cell counts were higher was unknown.2,3

The ART guideline changes reflect the findings of both observational and clinical trials research, which suggest that people who are started on ARTs later in their infection are not able to achieve as positive results as those who are started on therapy when their CD4 counts are higher, Keruly says.

"So that makes you think we should be starting treatment earlier," she adds. "This is based on evidence from several cohorts."2

Reference:

  1. Moore RD, et al. Person-years lost by late presentation for HIV care in Maryland. Poster presented at the 15th Conference on Retroviruses and Opportunistic Infections, held Feb. 3-6, 2008, in Boston, MA. Poster: 805.
  2. Guidelines for the use of antiretroviral agents in HIV-1-infected adults and adolescents. Developed by the Department of Health and Human Services (DHHS) Panel on Antiretroviral Guidelines for Adults and Adolescents -- A Working Group of the Office of AIDS Research Advisory Council. Jan. 29, 2008; 1-28. Available on-line at http://www.aidsinfo.nih.gov.
  3. Guidelines for the use of antiretroviral agents in HIV-1-infected adults and adolescents. Developed by the Panel on Clinical Practices for Treatment of HIV Infection, convened by the Department of Health and Human Services; July 14, 2003.