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How Successful Is the Push for Early HIV Diagnosis?

Not at all, in a large Baltimore cohort: Patients are presenting at progressively later stages of infection.

The first challenge of developing effective antiretroviral therapy was synthesizing the drugs; the second has been delivering them in time to prevent the ravages of AIDS. To this end, counseling and testing initiatives have been launched during the last decade, with the goal of identifying asymptomatic infected individuals and referring them for care. How successful have these initiatives been?

Baltimore investigators reasoned that one indicator of success would be progressively fewer patients presenting for initial care in the late, symptomatic stages of disease. However, they found just the reverse when they analyzed the presenting CD4-cell count and clinical status of more than 3000 treatment-naive patients who enrolled at Johns Hopkins–affiliated HIV clinics between 1990 and 2006. Overall, the median presenting CD4 count dropped from 371 cells/mm³ in 1990–1994 to 276 cells/mm³ in 2003–2006. This pattern held for both blacks and whites, for both sexes, and for those infected through drug use and heterosexual transmission; the only group for which the median presenting CD4 count increased (from 280 to 332 cells/mm³) was men who had sex with men. The percentage of patients with a history of an AIDS-defining illness remained relatively constant during the study at 13% to 15%.

Time between self-reported date of HIV diagnosis and presentation for care followed a sinusoidal pattern, from 271 days in 1990–1994 to 416 days in 1995–1998 to 176 days in 1999–2002 and then 196 days in 2003–2006. During each time period, the interval between diagnosis and presentation was substantially greater among injection-drug users than among other risk groups.

Comment: These authors cite data indicating that their discouraging local statistics may be representative of both national and international trends; certainly, there have been no reports of a large influx of asymptomatic early-stage patients into care that would contradict these findings. Has the widespread perception that AIDS is now a treatable condition undermined the public health message calling for early detection? Two editorialists suggest that the problem may reflect a larger crisis of access to healthcare: "Universal HIV testing also requires ‘universal’ health care ... it is a shameful commentary on our own health care system that the average CD4⁺ T-cell count before the initiation of antiretroviral therapy in North America is similar to that of some underdeveloped countries in Africa."

— Abigail Zuger, MD

Published in AIDS Clinical Care November 5, 2007

Citation(s):

Keruly JC and Moore RD. Immune status at presentation to care did not improve among antiretroviral-naive persons from 1990 to 2006. Clin Infect Dis 2007 Nov 15; 45:1369.

• Medline abstract (Free)

Goicoechea M and Smith DM. Universal HIV testing: Is it enough? Clin Infect Dis 2007 Nov 15; 45:1375.

• Medline abstract (Free)