Prospective Cohort Study

Background: Few studies have monitored late presentation (LP) of HIV infection over the European continent, including Eastern Europe. Study objectives were to explore the impact of LP on AIDS and mortality. Methods and Findings: LP was defined in Collaboration of Observational HIV Epidemiological Research Europe (COHERE) as HIV diagnosis with a CD4 count ,350/mm 3 or an AIDS diagnosis within 6 months of HIV diagnosis among persons presenting for care between 1 January 2000 and 30 June 2011. Logistic regression was used to identify factors associated with LP and Poisson regression to explore the impact on AIDS/death. 84,524 individuals from 23 cohorts in 35 countries contributed data; 45,488 were LP (53.8%). LP was highest in heterosexual males (66.1%), Southern European countries (57.0%), and persons originating from Africa (65.1%). LP decreased from 57.3% in 2000 to 51.7% in 2010/2011 (adjusted odds ratio [aOR] 0.96; 95% CI 0.95–0.97). LP decreased over time in both Central and Northern Europe among homosexual men, and male and female heterosexuals, but increased over time for female heterosexuals and male intravenous drug users (IDUs) from Southern Europe and in male and female IDUs from Eastern Europe. 8,187 AIDS/deaths occurred during 327,003 person-years of follow-up. In the first year after HIV diagnosis, LP was associated with over a 13-fold increased incidence of AIDS/death in Southern Europe (adjusted incidence rate ratio [aIRR] 13.02; 95% CI 8.19–20.70) and over a 6-fold increased rate in Eastern Europe (aIRR 6.64; 95% CI 3.55–12.43). Conclusions: LP has decreased over time across Europe, but remains a significant issue in the region in all HIV exposure groups. LP increased in male IDUs and female heterosexuals from Southern Europe and IDUs in Eastern Europe. LP was associated with an increased rate of AIDS/deaths, particularly in the first year after HIV diagnosis, with significant variation across Europe. Earlier and more widespread testing, timely referrals after testing positive, and improved retention in care strategies are required to further reduce the incidence of LP. Please see later in the article for the Editors’ Summary.

/pdf/risk-factors-and-outcomes-for-late-presentation-for-hiv-12kdl4qt40.pdf

Risk Factors and Outcomes for Late Presentation for HIV-Positive Persons in Europe: Results from the Collaboration of Observational HIV Epidemiological Research Europe Study (COHERE).

Table of Contents

1. Levels of evidence	
1.1 Reference	
2. Introduction	
3. Auditable targets	
4. Table summaries	
4.1 Initial diagnosis	
4.2 Assessment of ART-naive individuals	
4.3 ART initiation	
4.4 Initial assessment following commencement of ART	
4.5 Routine monitoring on ART	
4.6 References	
5. Newly diagnosed and transferring HIV-positive individuals	
5.1 Initial HIV-1 diagnosis	
5.2 Tests to determine whether acquisition of HIV infection is recent	
5.3 Individuals transferring care from a different HIV healthcare setting	
5.4 Communication with general practitioners and shared care	
5.5 Recommendations	
5.6 References	
6. Patient history	
6.1 Initial HIV-1 diagnosis	
6.2 Monitoring of ART-naive patients	
6.3 Pre-ART initiation assessment	
6.4 Monitoring individuals established on ART	
6.5 Assessment of adherence	
6.6 Recommendations	
6.7 References	
7. Examination	
7.1 Recommendations	
8. Identifying the need for psychological support	
8.1 References	
9. Assessment of immune status	
9.1 CD4 T cell counts	
9.2 CD4 T cell percentage	
9.3 References	
10. HIV viral load	
10.1 Initial diagnosis/ART naive	
10.2 Post ART initiation	
10.3 Individuals established on ART	
10.4 Recommendations	
10.5 References	
11. Technical aspects of viral load testing	
11.1 References	
12. Viral load kinetics during ART and viral load ‘blips’	
12.1 References	
13. Proviral DNA load	
13.1 References	
14. Resistance testing	
14.1 Initial HIV-1 diagnosis	
14.2 ART-naive	
14.3 Post treatment initiation	
14.4 ART-experienced	
14.5 References	
15. Subtype determination	
15.1 Disease progression	
15.2 Transmission	
15.3 Performance of molecular diagnostic assays	
15.4 Response to therapy	
15.5 Development of drug resistance	
15.6 References	
16. Other tests to guide use of specific antiretroviral agents	
16.1 Tropism testing	
16.2 HLA B*5701 testing	
16.3 References	
17. Therapeutic drug monitoring	
17.1 Recommendations	
17.2 References	
18. Biochemistry testing	
18.1 Introduction	
18.2 Liver function	
18.3 Renal function	
18.4 Dyslipidaemia in HIV-infected individuals	
18.5 Other biomarkers	
18.6 Bone disease in HIV-infected patients	
18.7 References	
19. Haematology	
19.1 Haematological assessment and monitoring	
19.2 Recommendations	
19.3 References	
20. Serology	
20.1 Overview	
20.2 Hepatitis viruses	
20.3 Herpes viruses	
20.4 Measles and rubella	
20.5 Cytomegalovirus (CMV)	
20.6 References	
21. Other microbiological screening	
21.1 Tuberculosis screening	
21.2 Toxoplasma serology	
21.3 Tropical screening	
21.4 References	
22. Sexual health screening including anal and cervical cytology	
22.1 Sexual history taking, counselling and sexually transmitted infection (STI) screening	
22.2 Cervical and anal cytology	
22.3 Recommendations	
22.4 References	
23. Routine monitoring recommended for specific patient groups	
23.1 Women	
23.2 Older age	
23.3 Injecting drug users	
23.4 Individuals coinfected with HBV and HCV	
23.5 Late presenters	
23.6 References	
Appendix

/pdf/british-hiv-association-guidelines-for-the-routine-25qp2zxz94.pdf

British HIV Association guidelines for the routine investigation and monitoring of adult HIV‐1‐infected individuals 2011

OBJECTIVES

To estimate life expectancy (LE) over 25 years in HIV-positive people and compare their LE with recent estimates for the general population, by education.

METHODS

Patients aged 20 years or older enrolled in the Swiss HIV Cohort Study 1988-2013 were eligible. Patients alive in 2001 were matched to up to 100 Swiss residents, by sex, year of birth, and education. LE at age 20 was estimated for monotherapy (1988-1991), dual therapy (1992-1995), early combination antiretroviral therapy (cART, 1996-1998), later cART (1999-2005) and recent cART (2006-2013) eras. Parametric survival regression was used to model life expectancy.

RESULTS

16,532 HIV-positive patients and 927,583 residents were included. LE at age 20 of HIV-positive individuals increased from 11.8 years (95% CI 11.2-12.5) in the monotherapy era to 54.9 years (95% CI 51.2-59.6) in the most recent cART era. Differences in LE across educational levels emerged with cART. In the most recent cART period, LE at age 20 years was 52.7 years (95% CI 46.4-60.1) with compulsory education, compared to 60.0 years (53.4-67.8) with higher education. Estimates for the general population were 61.5 years and 65.6 years, respectively. Male sex, smoking, injection drug use and low CD4 counts at enrolment were also independently associated with mortality.

CONCLUSION

In Switzerland educational inequalities in LE were larger among HIV-infected persons than in the general population. Highly educated HIV-positive people have an estimated LE similar to Swiss residents with compulsory education. Earlier start of cART and effective smoking cessation programs could improve HIV-positive LE further and reduce inequalities.

/pdf/life-expectancy-in-hiv-positive-persons-in-switzerland-41w2app3cp.pdf

Life expectancy in HIV-positive persons in Switzerland: matched comparison with general population.

Background 
Late presentation for human immunodeficiency virus (HIV) care is a major impediment for the success of antiretroviral therapy (ART) outcomes. The role that stigma plays as a potential barrier to timely diagnosis and treatment of HIV among people living with HIV/AIDS (acquired immunodeficiency syndrome) is ambivalent. This review aimed to assess the best available evidence regarding the association between perceived HIV related stigma and time to present for HIV/AIDS care.


Methods 
Quantitative studies conducted in English language between 2002 and 2016 that evaluated the association between HIV related stigma and late presentation for HIV care were sought across four major databases. This review considered studies that included the following outcome: ‘late HIV testing’, ‘late HIV diagnosis’ and ‘late presentation for HIV care after testing’. Data were extracted using a standardized Joanna Briggs Institute (JBI) data extraction tool. Meta- analysis was undertaken using Revman-5 software. I2 and chi-square test were used to assess heterogeneity. Summary statistics were expressed as pooled odds ratio with 95% confidence intervals and corresponding p-value.


Results 
Ten studies from low- and middle- income countries met the search criteria, including six (6) and four (4) case control studies and cross-sectional studies respectively. The total sample size in the included studies was 3,788 participants. Half (5) of the studies reported a significant association between stigma and late presentation for HIV care. The meta-analytical association showed that people who perceived high HIV related stigma had two times more probability of late presentation for HIV care than who perceived low stigma (pooled odds ratio = 2.4; 95%CI: 1.6–3.6, I2 = 79%).


Conclusions 
High perceptions of HIV related stigma influenced timely presentation for HIV care. In order to avoid late HIV care presentation due the fear of stigma among patients, health professionals should play a key role in informing and counselling patients on the benefits of early HIV testing or early entry to HIV care. Additionally, linking the systems and positive case tracing after HIV testing should be strengthened.

/pdf/significant-association-between-perceived-hiv-related-stigma-2b7v3ivevv.pdf

Significant association between perceived HIV related stigma and late presentation for HIV/AIDS care in low and middle-income countries: A systematic review and meta-analysis

Objectives Across Europe, almost a third of individuals infected with HIV do not enter health care until late in the course of their infection. Surveillance to identify the extent to which late presentation occurs remains inadequate across Europe and is further complicated by the lack of a common clinical definition of late presentation. The objective of this article is to present a consensus definition of late presentation of HIV infection.

Methods Over the past year, two initiatives have moved towards a harmonized definition. In spring 2009, they joined efforts to identify a common definition of what is meant by a ‘late-presenting’ patient.

Results Two definitions were agreed upon, as follows. Late presentation: persons presenting for care with a CD4 count below 350 cells/μL or presenting with an AIDS-defining event, regardless of the CD4 cell count. Presentation with advanced HIV disease: persons presenting for care with a CD4 count below 200 cells/μL or presenting with an AIDS-defining event, regardless of the CD4 cell count.

Conclusion The European Late Presenter Consensus working group believe it would be beneficial if all national health agencies, institutions, and researchers were able to implement this definition (either on its own or alongside their own preferred definition) when reporting surveillance or research data relating to late presentation of HIV infection.

https://onlinelibrary.wiley.com/doi/pdf/10.1111/j.1468-1293.2010.00857.x

D Costagiola

Papers

Late presentation of HIV infection: a consensus definition