HIV Patients Continue to Present Late, Raising Risk of Death

Daniel M. Keller, PhD

October 20, 2011

October 20, 2011 (Belgrade, Serbia) — Patients infected with HIV who present with AIDS have a much higher risk for death than patients presenting earlier, before their CD4 count drops significantly. This situation did not change from 2003 to 2009.

Patients with AIDS were 10 times more likely to die by 48 months than HIV-infected patients with CD4 counts of at least 350 cells/mm3.

Dominique Costagliola, PhD, senior researcher and research director of the clinical epidemiology, therapeutic strategies, and HIV infection virology unit at INSERM and Pierre and Marie Curie University in Paris, France, told delegates here at the 13th European AIDS Conference of the European AIDS Clinical Society that the difference in mortality was apparent as early as 6 months.

She reported the results of the French Hospital Database on HIV–National Agency of Research on AIDS and Viral Hepatitis (FHDH–ANRS) CO4 study, which evaluated the impact of delayed access to care on the risk for death in HIV-infected people in France.

Late presentation remains a common problem in Europe, Dr. Costagliola noted. Recent guidelines advocate starting combination antiretroviral therapy (cART) for patients with a history of AIDS-defining illness (regardless of CD4 cell count) or with a CD4 count below 350 cells/mm3, which is the consensus definition of late presentation.

The FHDH–ANRS CO4 study involves a hospital-based ongoing multicenter cohort from 70 hospitals in France, and now includes data on 121,091 patients with at least 1 follow-up visit since 1992. The median follow-up is 67 months. Patients were classified by disease stage at enrollment: AIDS, CD4 count below 200 cells/mm3, CD4 count between 200 and 350 cells/mm3, or CD4 count of at least 350 cells/mm3.

From 2003 to 2009, 22,667 patients older than 15 years and naïve to cART were enrolled in the FHDH. After those with missing pertinent information or other issues were excluded, 19,911 patients remained in the analysis.

Late diagnosis and late access to care are a persistent problem. During the study period, the rate of late diagnosis only dropped from 41% to 37%, and the rate of late access to care (late presentation and 3 or more months since HIV diagnosis) went from 14% to 11%.

Using men who have sex with men (40.5% with late presentation) as an odds ratio (OR) reference value of 1, migrant men from sub-Saharan Africa were almost 3 times as likely to present late with HIV infection (OR, 2.9; 95% confidence interval [CI], 2.6 to 3.3); women from the same region had an OR of 2.5 (95% CI, 2.3 to 2.8). The risk for late presentation also increased for each decade of age over 30 years. Patients 60 years or older had an OR of 2.8 (95% CI, 2.3 to 3.3). Time since HIV diagnosis and the period of enrollment had no significant effect on the likelihood of late presentation.

Late Presentation Raises Risk for Death

The risk for death was associated with the disease stage at presentation. Dr. Costagliola said that 13% of people presenting with AIDS have died by 4 years. "The figure is 3.9% for those presenting with a CD4 below 200 cells/mm3, 2.4% for those presenting with a CD4 count between 200 and 350 cells/mm3, and 1.2% for those presenting with a CD4 above 350 cells/mm3."

For patients with AIDS or with CD4 counts below 200 cells/mm3, the risk for death was greatest 0 to 6 months after enrollment, and decreased in each subsequent 6-month period.

Dr. Costagliola concluded that more early testing and treatment needs to be encouraged to improve prognosis, but predicted that some patients will still present late. For those patients, the answer will still be traditional cART.

Referring to the fact that the death rate did not decrease from 2003 to 2009 for patients enrolling in the study with AIDS, session chair Georg Behrens, MD, professor of immunology at Hanover Medical School in Germany, told Medscape Medical News that "in all these studies, I'm a bit concerned because AIDS really lumps very different conditions [together]..., and some definitely have a high mortality. I'm surprised to see that."

However, he said he is not discouraged by the results, because "defining the dilemma and again raising the issue...that a lot of patients are diagnosed later than we realized 2 or 3 years ago," still requires work.

Dr. Behrens agreed with Dr. Costagliola's assessment that the solution to the problem of late presentation and access to care has to be "a combined effect of earlier treatment and the acceptance of testing by more people."

The study received no commercial support. Dr. Costagliola reports receiving travel grants, consultant fees, honoraria, and grant support from several pharmaceutical companies, including Abbott, Boehringer-Ingelheim, Bristol-Myers Squibb, Gilead Sciences, GlaxoSmithKline, Janssen, Merck Sharp & Dohme-Chibret, Roche, and Viiv Healthcare. Dr. Behrens has disclosed no relevant financial relationships.

13th European AIDS Conference of the European AIDS Clinical Society (EACS): Abstract PS8/6. Presented October 14, 2011.

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