Late HIV diagnoses a problem across the health care system

Better testing practices could increase awareness and reduce the risk for transmission.

Issue: July 2007

One of the biggest issues in HIV/AIDS prevention and treatment is that of late diagnoses. Some estimates put the number of people who will develop AIDS within 12 months of an HIV diagnosis as high as 40%, and it is well known that knowledge of infection can reduce risky behavior and allow for earlier initiation of treatment.

Ronald O. Valdiserri, MD, MPH, of the Department of Veterans Affairs, discussed the need for earlier testing and diagnosis at the American Conference for the Treatment of HIV, held recently in Dallas.

Although the findings of a number of studies have illustrated the prevalence of late diagnosis of HIV, Valdiserri pointed out one study in particular that included 2,139 people in San Francisco who were diagnosed between 2001 and 2005. Of these people, 830 (38.8%) were diagnosed with AIDS within 12 months of their first HIV diagnosis. Researchers of this study also found that late testing is more likely among people without reported risk (OR=2.88), those younger than 30 (OR=1.99), heterosexual people (OR=1.88) and people born outside the United States (OR=1.64).

“One important point to remember is that late diagnosis is not necessarily limited to people with poor access to medical care,” Valdiserri said. Data published in 2003 reported on a study composed of 440 people newly diagnosed with HIV in 1998 who had at least 12 months of membership in Kaiser-Permanente health care system (median of 5.7 years of membership). Among these patients, 88% had CD4 counts done within 60 days, and 43% of those were less than 200 (immunologic AIDS). “The bottom line is that late diagnosis is a challenge even in patients with good access to care,” Valdiserri said. Also, only 26% of patients had risk factors documented in medical charts.

Veterans Affairs patients

Another group of individuals who appear to have problems with late diagnosis and late treatment initiation are veterans, Valdiserri said. Among 270,901 high-risk Veterans Affairs patients, only 21% were tested between 1999 and 2005. A retrospective analysis of 3,760 highly active antiretroviral therapy-naive veterans newly presenting for care between 1998 and 2002 found that 55% had baseline CD4 counts below 200, and 36% had an AIDS complication within one year of presentation. Furthermore, 40% of these patients had used VA services prior to HIV presentation with a median duration of 3.7 years.

“Also, a significant number of veterans were initiating retroviral therapy later than the guidelines recommend,” Valdiserri said. “This was a manifestation of late diagnosis of HIV infection.”

A further example of this widespread problem was found in a 2006 study involving patients diagnosed with HIV at a comprehensive urban health system in Denver. Of 348 newly diagnosed cases of HIV, 34% had at least one clinical encounter with the health system in the three years preceding diagnosis; only 8% of these had a previous HIV test. Furthermore, among those who had baseline CD4+ counts, 29% had immunologic AIDS. The results of this study stressed the fact that risk-based testing is insufficient. “If we limit ourselves to risk-based testing, we are going to miss seeing infected patients,” Valdiserri said.

Routine screening benefits

Routine screening for HIV may be an effective solution for the problem of late diagnosis. It eliminates the need for health care providers to assess HIV risk, a process they may be uncomfortable with or may not have time to include. Patients may also not be comfortable revealing risks or may be unaware of their risk factors. Another perceived problem with routine screening is cost, but Valdiserri said that “there is growing [evidence] in the literature showing that routine HIV screening is cost-effective.”

Patients who are aware of their positive HIV status also have been shown to substantially reduce high-risk sexual activity, illustrating that routine screening may reduce transmission rates and the number of new cases each year. One analysis found that the transmission rate is 3.5 times higher among those infected individuals who are unaware of their status compared with those who are aware.

“We have a problem in the United States with late diagnosis of HIV infection,” Valdiserri said. Routine screening would allow for fewer HIV–positive individuals to be missed, for earlier treatment initiation and could potentially lower the transmission rate significantly. – by Dave Levitan

For more information:

Valdiserri RO. Early diagnosis of HIV infection: Gateway to treatment and prevention. Presented at: The American Conference for the Treatment of HIV; May 31–June 3, 2007; Dallas.