alcohol and social care problems are highly prevalent among people who
develop serious AIDS-defining illnesses well after their diagnosis with HIV, UK
research published in Sexually
Transmitted Infections shows. The retrospective study involved people who
received care at the Chelsea and Westminster Hospital, London, between 2005 and
2010. An extremely large proportion of the people who developed AIDS despite
being established in care were lost to follow-up for a protracted period after
their diagnosis and discontinued antiretroviral therapy.
and non-compliance in HIV care remain challenges that must be addressed by
clinicians to prevent avoidable mortality,” write the authors.
antiretroviral therapy, the prognosis of most people living with HIV in the UK is
excellent. However, cases of AIDS still occur. People who develop an
AIDS-defining condition fall into two broad categories. The first comprises people who are diagnosed late (with a low CD4 count) and have an AIDS-defining illness at the time
of their HIV diagnosis. The second group involves people who
are known to be HIV positive but who nevertheless experience disease
progression despite medical follow-up. The authors described this second
category of people as post-HIV diagnosis AIDS patients (PHDA).
Little is known
about the characteristics of people in this PHDA group.
therefore searched the medical records of the 6000 people who received care
at the Chelsea and Westminster Hospital during the study period and identified people who developed severe AIDS-defining opportunistic infections:
cryptococcal meningitis, cerebral toxoplasmosis or Pneumocystis jirovecii pneumonia (PCP).
A total of 101 people met the authors’ inclusion criteria. There were 54 PHDA patients (53%)
and 47 late presenters (47%).
significant demographic differences between these two groups.
PHDA patients were
more likely to be migrants or visitors than late presenters (54 vs 34%, p =
0.047). A higher proportion of PHDA patients were injecting drug users compared
to the late presenters (9 vs 0%, p = 0.032).
The median period
between diagnosis with HIV and development of a serious opportunistic infection
among the PHDA patients was seven years (range 4 to 13 years).
Prior to admission
with the opportunistic infection, the PHDA patients had more psychiatric
co-morbidities than the late presenters (35 vs 13%, p = 0.009) and were also
more likely to report problematic use of alcohol (24 vs 4%, p = 0.005),
problematic substance use (22 vs 2%, p = 0.003) and social care problems (25 vs 0%).
“This cohort has
potentially modifiable risk factors contributing to their disease progression,”
note the authors.
of PHDA patients were lost to follow-up for at least one period of four months
or longer after their diagnosis. The median duration of absence from care was
eleven months. Common reasons for dropping out of care were travel abroad
(13%), social care issues (13%), moving care to another centre (7%), treatment avoidance
(6%) and religious issues (4%).
“For patients with
extended LTFU [lost to follow-up] periods, assertive outreach should be established
to engage these individuals with care,” urge the investigators.
(63%) of PHDA patients had previously taken HIV therapy, and the median duration
of this treatment was 48 months. But 20 people (59%) discontinued their
treatment. The median duration of each treatment break was twelve months.
Reasons for stopping therapy were side-effects (27%), lifestyle issues (12%),
religious views (9%), travel abroad (6%), social issues (6%), negative views
about HIV therapy (6%) and a belief in alternative remedies (3%).
“PHDA patients are
a distinct subgroup from late presenters,” the authors conclude. “Many default
from clinical care and have poor ART compliance.”