One in four gay men in England and Wales is being diagnosed with HIV after their CD4 cell count has fallen below 200 cells/mm3, resulting in a tenfold greater risk of death within one year, according to findings published in the 25th March edition of AIDS.
The study also found that late diagnosis was associated with living outside London, non-white ethnicity and older age. However, short-term mortality was not affected by ethnicity.
Despite these trends, the proportion of men being diagnosed late has been decreasing over time, and short-term mortality has been lower since the advent of highly active antiretroviral therapy (HAART).
“The results show that although HAART decreased the short-term mortality for all men who have sex with men (MSM), irrespective of CD4 cell counts at diagnosis, those diagnosed late were still approximately ten times more likely to die within a year of diagnosis than comparable individuals who were not diagnosed late,” conclude the authors. “We suggest that there are many pre-treatment deaths that could be prevented.
“Although late diagnosis is less common among MSM than other HIV-infected individuals our study supports findings of a continued high proportion of late diagnoses among MSM. … Our analysis … shows that late diagnosis is a strong determinant of short-term mortality.”
They conclude, “there is a clear need to diagnose HIV-infected MSM at an earlier age and earlier in the course of infection.”
Investigators from London’s Health Protection Agency wished to analyse the trends in late HIV diagnosis and short-term mortality among gay men in England and Wales. They analysed HIV surveillance information reported to the Communicable Disease Surveillance Centre for the years 1993 to 2002, linking it to data on CD4 cell counts collected by the national CD4 Surveillance Scheme and deaths by the Office of National Statistics. Missing CD4 cell count values were estimated using an inverse probability weighting method.
There were 14,158 new diagnoses over the ten-year period, of which 4425 (31%) occurred when CD4 cell counts had fallen to below 200 cells/mm3. The median CD4 cell count in men diagnosed late was 61 cells/mm3, in comparison to 450 cells/mm3 in the other men.
Late diagnoses were more common in men diagnosed outside London (38 vs. 27%, p < 0.01), non-white men (35 vs. 31%, p < 0.01) and older men (p < 0.01). However, there was a trend for decreased late diagnoses over time, falling from 38% in 1993 to 25% in 2002 (p < 0.01).
Seven hundred and ten (5%) men died within one year of diagnosis, with less that 5% of these deaths being due to suicides, drug overdoses or accidents. However, early deaths were more common in men diagnosed late (14 vs. 1%; adjusted odds ratio [OR]: 10.8, 95% confidence interval [CI]: 7.7 – 15.9).
Short-term mortality has been lower since 1996, when HAART was introduced (3 vs. 10%, p < 0.01). It was associated with increased age (p < 0.01) and diagnosis outside London (8 vs. 4%, p < 0.01).
The study’s authors estimate that diagnosis of these men before their CD4 cell counts had fallen to below 200 cells/mm3 would have had a dramatic effect on death rates. “Early diagnosis of all MSM in 2001 could have reduced short-term mortality by 84% and all mortality in that year by 22%,” they conclude.