Improvement in early diagnosis, some still late
Improvement in early diagnosis, some still late
Need more people identified sooner
Investigators analyzing data from 1996 to 2007 of more than 35,000 HIV-infected patients have found that people appear to have higher CD4 counts when entering care now than they did 14 years ago. But they're not high enough.
"What we saw was a such a small increase in median CD4 count over the years that the difference was very small; we were hoping to see much more," says Keri Althoff, PhD, MPH, an assistant scientist at Johns Hopkins Bloomberg School of Public Health in Baltimore, MD.
"Due to public health efforts to get people tested, we were hoping to see that individuals were starting into care earlier, but we have to look at the data," she says. "Overall, we were disappointed that we were not doing better."
Althoff and co-investigators found that CD4 count at first presentation for HIV care had increased each year in the 11-year period studied, but still remained less than 350 cells/mm3.1
There were 38% of patients who presented with a CD4 count of greater than 350 in 1997, and this increased to 46% in 2007.1
Still, the findings were not a sign that national testing and early treatment campaigns are working.
"The individual variation of CD4 counts makes this small increase we found clinically insignificant, plus more than half of individuals presenting for care were at a CD4 count below what is recommended in the guidelines," Althoff says. "It's hard to interpret our research findings as indicative of increases in early HIV care."
If anything, HIV clinicians and public health officials should renew efforts to identify people with new HIV infections and consider even earlier treatment when they do find them, she suggests.
"There are 325,000 individuals in the United States and Canada who don't know their HIV status and are not in care, so we should not be satisfied," Althoff says. "We need to do more to get people identified sooner and to start care at the clinically appropriate time for care."
Unlike another recent study in which investigators with the Uniformed Services University of the Health Sciences analyzed CD4 counts over time and found they were decreasing at the time period of seroconversion, Althoff's study does not include data on seroconversion.
"We don't know how long they were living with HIV prior to coming into care, and we don't know how much they knew about their HIV status prior to coming into care," Althoff says. "All we know is their immune status when they came into care."
In the late presentation for HIV care research, investigators uncovered some clues showing differences in immune status at first presentation for HIV care between some demographic groups. For instance, people whose HIV risk was through heterosexual contact did not see any increase over time of their CD4 counts, Althoff says.
"That's very important because heterosexual high risk plays an important role in the North American epidemic," he says.
Discouraging findings among blacks
Also, investigators found that African American HIV-infected individuals had a lower mean increase in CD4 counts over time than did white, Latino, and other groups.
"We still see that African Americans are not presenting for care at the higher CD4 cell counts, and that's highly discouraging because that group is disproportionately impacted," Althoff says.
The Uniformed Services University study and Althoff's late presentation for HIV care study are complementary, she notes.
"We've known for a long time that when someone is diagnosed with HIV, the sooner we can get them into care the better their prognosis," she says. "The successful models for testing and linking people to care need to be further evaluated and replicated."
Both studies suggest HIV clinicians consider early treatment for patients, particularly when there's reason to believe their disease is progressing quickly.
This work reinforces other recent research into the impact of starting highly active antiretroviral therapy (HAART) at the standard time period of when patients' CD4 counts fall below 500 cells/mm3. A 2009 New England Journal of Medicine study found that deferred antiretroviral treatment of patients with a 351 to 500 CD4 count was associated with a 69% increase in the risk of death as compared with an early initiation of therapy.2,3
There now is considerable evidence that the benefit of early treatment outweighs its risk.
For instance, community viral load research shows decreases in HIV risks in communities where viral load is decreasing over time, Althoff says.
"Evidence is pointing toward this initiation of care at higher CD4 counts than 350," she adds.
The take-home message for HIV clinicians is that they should serve as community advocates for universal HIV testing, Althoff suggests.
"HIV clinicians should be educators for their colleagues on the importance of providing HIV testing," she adds. "HIV clinicians can help support the movement to make HIV testing part of routine care, like cholesterol testing."
References
- Althoff KN, Gange SJ, Klein MB, et al. Late presentation for human immunodeficiency virus care in the United States and Canada. Clin Infect Dis. 2010;50:1512-1520.
- Kitahata MM, Gange SJ, Abraham AG, et al. Effect of early versus deferred antiretroviral therapy for HIV on survival. N Engl J Med. 2009;360:1-12.
- Sax PE, Baden LR. Editorial: When to start antiretroviral therapy – ready when you are? N Engl J Med. 2009;360:1897-1899.
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