Hofstra of the European Society for translational Antiviral Research introduced
the SPREAD project, which monitors HIV testing in 30 European countries from
Ireland to Russia (in the EU, only the UK, France and Hungary are not members).
It uses an algorithm to collect a representative sample of the European
diagnosed population – in this case, a sample of 8048 people.
first defined ‘late presenter’. Ideally late presentation should be defined by
the period of time between infection and diagnosis, but as this is hard to
establish, it is usually defined by a surrogate marker – the CD4 count at time
of diagnosis. Hofstra used three overlapping definitions of a late presenter:
first, a CD4 count under 350 cells/mm3 at diagnosis; secondly, a CD4
count under 200 cells/mm3; and thirdly presenting with AIDS-related
symptoms at any CD4 count. Using these definitions will catch some ‘fast progressors’
who develop low counts soon after infection, and Hofstra estimated from other surveillance
figures that 27% of patients with CD4 counts under 350 cells/mm3 in
Europe have in fact been infected for less than a year, 7% with CD4 counts
under 200 cells/mm3 and 2.5% with AIDS, totalling 1422 patients.
all participants who had been positive for less than a year resulted in a database of 6266 participants.
Of these, 80% were male, 53% gay men, 34% heterosexual and 6% injecting drug
users. Their average age was 37. Fifty-six per cent were born in western Europe,
20% in eastern Europe and 9% in sub-Saharan Africa. The average CD4 count on
diagnosis in the whole patient sample was 392 cells/mm3 and their
viral load 63,000 copies/ml.
this group, 55% satisfied the widest definition of being a late presenter between
the years 2002 and 2005: by 2008 to 2010, this had reduced to 48%. The proportion
with CD4 counts under 200 cells/mm3 had shrunk from 34 to 27% and who
had AIDS upon diagnosis from 16 to 12%.
men were less likely to be late presenters throughout: the proportion with CD4
counts below 350 shrank from 45 to 39% over the 2002 to 2010 time period, while
in heterosexuals it went down from 66 to 61%. However, while the proportion of
gay men diagnosed with AIDS halved from 12 to 6%, it did not decrease in
either heterosexuals or drug users; in heterosexuals 17 to 18% had an AIDS-related
condition when diagnosed throughout the time period, and in drug users it
actually went up, varying non-significantly between 12 and 16%. In
multivariate analysis, heterosexuals were 2.14 and injecting drug user 2.21
times more likely to be diagnosed late than gay men.
was a slight, but significant, tendency for people from central and eastern
Europe to be diagnosed late (28% more than in western Europe), and immigrants
in all areas were 62% more likely to be diagnosed late.
biggest single risk factor, though, was age. People over 50, throughout Europe,
were 2.55 times more likely to be diagnosed late than others; between 2008 and 2010, 68% of
over-50s were diagnosed with a CD4 count under 350 cells/mm3, 49%
under 200 cells/mm3 and 25% with AIDS. Although this proportion
had declined since the 2002 to 2005 period, it had not done so significantly. The researchers
emphasised the importance of aiming testing programmes at women, people who
inject drugs, migrants and, especially, older people.