Late diagnosis of HIV remains a serious problem across Europe, results of a large study published in PLOS Medicine show.
The research involved approximately 85,000 people diagnosed with HIV between 2000 and 2011 in 35 European countries. Overall, 54% of patients were diagnosed late and a third presented very late. There was a fall in the proportion of people being diagnosed late, but in 2010/11 over half of patients were still presenting for care with a CD4 cell low enough to warrant immediate antiretroviral therapy.
“Late presentation remains a significant issue across Europe and in all HIV exposure groups,” comment the authors. “Late presentation was associated with an increased rate of AIDS/deaths, particularly in the first year after HIV diagnosis.” The investigators believe their findings have important implications for HIV testing strategies.
Previous research has analysed late diagnosis rates in individual countries, but little is known about trends across Europe and data from Eastern Europe are especially scarce.
Investigators from the Collaboration of Observational HIV Epidemiological Research Europe (COHERE) study therefore examined trends and risk factors for late diagnosis between 2000 and 2011. Their study included 84,524 people who presented for HIV care in 35 countries.
Patients were considered to have been diagnosed late if they had a CD4 cell count below 350 cells/mm3 at the time of presentation or developed an AIDS-defining illness within six months of entering care. Very late diagnosis was defined as presentation with a CD4 cell count below 200 cells/mm3.
Overall, 54% of patients were diagnosed late. Rates of late presentation were especially high among heterosexual men (66%), individuals originating from Africa (65%) and patients receiving care in southern Europe (57%).
The data also showed that 8% of patients had not engaged with HIV care three months after their diagnosis. Among patients diagnosed late, 7% had delayed entry into care.
But there were some encouraging data. The rate of late diagnosis declined from 57% in 2000 to 52% in 2010/10. The average CD4 cell count at the time of presentation increased over the same period, from a median of 306 cells/mm3 in 2000 to a median of 363 cells/mm3 in 2009.
Several risk factors were associated with late presentation. Each ten-year increase in age increased the risk of late diagnosis by 41% (OR = 1.41; 95% CI, 1.39-1.43). People from Africa had higher odds of late diagnosis (OR = 1.75; 95% CI, 1.66-1.84), as did people from other regions (OR = 1.40; 95% CI, 1.32-1.48), compared to people from Europe.
The risk of late presentation was lower for men who have sex with men (MSM) than all other risk groups. People receiving care in southern Europe were more likely to be diagnosed late than individuals under care in central Europe (OR = 1.41; 95% CI, 1.33-1.48).
There was a marked fall in the proportion of gay men and heterosexual people in central and northern Europe diagnosed late over the course of the study. The rate of late presentation also decreased over time among heterosexual women in eastern Europe from 56 to 34%.
However, the rate of late diagnoses increased in male injecting drug users in southern Europe and among male and female injecting drug users in eastern Europe.
Late presentation was associated with adverse outcomes. In the entire study population there were 8187 new cases of AIDS or deaths during 327,000 person years of follow-up. Late presentation or very late presentation significantly increased the risk of AIDS/death in the first two years after entry into HIV care (p < 0.001).
Rates of AIDS/death in the first year after late presentation were highest among people in southern Europe (adjusted incidence rate ratio [aIRR] 13.02; 95% CI, 8.19-20.70). In the second year after diagnosis, late presentation was associated with higher rates of AIDS/death among people from southern, central and northern Europe. In southern Europe, late presentation continued to be associated with an increased risk of AIDS/death more than two years after diagnosis (aIRR = 1.38; 95% CI, 1.01-1.88).
“Individuals continue to test late for HIV with consequences in terms of poor prognosis, an increased risk of onward transmission, increased costs to health systems, and suboptimal benefits of ART,” comment the authors. “Increasing awareness of HIV risk factors, increased opportunities for testing, reducing barriers to testing, and increasing the availability of effective ART will help address ongoing HIV transmissions across Europe, and especially in Eastern Europe where the number of newly diagnosed infections continues to be very high.”
Mocroft A et al. Risk factors and outcomes for late presentation for HIV-positive persons in Europe: results from the Collaboration of Observational HIV Epidemiological Research Europe Study (COHERE). PLOS Medicine: 10:9, e1001510, 2013.