We analysed the frequency and predictors of delayed access to care (DAC) for HIV infection, and its influence on survival.
Methods
We studied predictors of DAC among 18,721 patients enrolled between 1997 and 2002 in the French Hospital Database on HIV (FHDH), DAC being defined by a CD4+ T-cell count below 200 copies/mm3 and/or AIDS at FHDH enrolment. The association of DAC with the initiation of combined antiretroviral therapy (cART) and of DAC with survival were analysed with Cox multivariable models.
Results
The overall prevalence of DAC was 35.7%. Compared with patients under 30 years of age, patients over 60 were 3.5 times more likely to have DAC (P<10-4). Compared with non-migrant women, odds ratios (OR) of DAC were higher among migrant women (1.5), non-migrant men (1.6) and migrant men (1.9; all P<10-4). Compared with men who have sex with men, other transmission groups had an estimated OR for DAC of 1.6 (P<10-4). DAC was more frequent among patients with a recent diagnosis of HIV infection [OR=1.3, 95% confidence intervals (CI)=(1.2;1.4)]. Patients with DAC received cART earlier than other patients [hazard ratio (HR)=2.2, 95% CI=(2.1;2.3)]. The DAC/mortality HR was 13.9 in the first 6 months after enrolment in the FHDH, and remained significantly higher than 1 during the subsequent 4 years.
Conclusion
DAC is common in France and was associated with a higher mortality, despite early initiation of cART. Earlier access to care and specific clinical management of patients with DAC should be considered.
References
1.
PalellaF.J.Jr., DelaneyK.M., MoormanA.C.Declining morbidity and mortality among patients with advanced human immunodeficiency virus infection. HIV Outpatient Study Investigators.N Engl J Med1998; 338: 853–860.
2.
Survival after introduction of HAART in people with known duration of HIV-1 infection.The CASCADE Collaboration. Concerted Action on SeroConversion to AIDS and Death in Europe.Lancet2000; 355: 1158–1159.
3.
EggerM., MayM., CheneG.Prognosis of HIV-1-infected patients starting highly active antiretroviral therapy: a collaborative analysis of prospective studies.Lancet2002; 360: 119–129.
Prise en charge thérapeutique des personnes infectées par le VIH.Mise à jour 2004. Recommandations du groupe d'experts sous la direction du Pr JF Delfraissy (Réalisé avec le soutien du Ministère chargé de la Santé). 2004. Paris, France: Flammarion Médecine-Sciences.
6.
CurtisH., SabinC.A., JohnsonM.A.Findings from the first national clinical audit of treatment for people with HIV.HIV Med2003; 4: 11–17.
7.
TassieJ.M., GasnaultJ., BentataM.Survival improvement of AIDS-related progressive multifocal leukoencephalopathy in the era of protease inhibitors. Clinical Epidemiology Group. French Hospital Database on HIV.AIDS1999; 13: 1881–1887.
8.
Ancelle-ParkR.Expanded European AIDS case definition.Lancet1993; 341: 441.
9.
LertF., ObadiaY. VESPA. Comment vit-on en France avec le VIH/SIDA?INED Population et Sociétés2004; 406: 1–5.
SabinC.A.The changing clinical epidemiology of AIDS in the highly active antiretroviral therapy era.AIDS2002; 16Suppl 4: S61–68.
12.
DalmassoC., BroetP., MoreauT.Procedures de comparaisons multiples: principes et limites. Applications a l'etude differentielle de l'expression transcriptionnelle par puces a ADN.Revue d Epidemiologie et de Sante Publique2004; 52: 523–537.
13.
CastillaJ., SobrinoP., De La FuenteL., NoguerI., GuerraL., ParrasF.Late diagnosis of HIV infection in the era of highly active antiretroviral therapy: consequences for AIDS incidence.AIDS2002; 16: 1945–1951.
14.
CouturierE., SchwoebelV., MichonC.Determinants of delayed diagnosis of HIV infection in France, 1993–1995.AIDS1998; 12: 795–800.
15.
GirardiE., AloisiM.S., AriciC.Delayed presentation and late testing for HIV demographic and behavioral risk factors in a multicenter study in Italy.J Acquir Immune Defic Syndr2004; 36: 951–959.
16.
ChauvinP., MortierE., CarratF., ImbertJ.C., ValleronA.J., LebasJ.A new out-patient care facility for HIV-infected destitute populations in Paris, France.AIDS Care1997; 9: 451–459.
17.
ChauvinP., MortierE., ValleronA.J., LebasJ.Outpatients care of HIV-1-infected destitute people: a study in Paris, France.Lancet1996; 348: 480.
18.
LanoyE., Mary-KrauseM., TattevinP.Predictors identified for losses to follow-up among HIV-seropositive patients.J Clin Epidemiol2006; 59: 829–835.
19.
Late versus early testing of HIV - 16 sites, United States, 2000–2003.MMWR Morb Mortal Wkly Rep2003; 52: 581–586.
20.
BaratinD., MarceillacE., TrepoC.Characteristics of patients diagnosed with AIDS shortly after first detection of HIV antibodies in Lyon University hospitals from 1985 to 2001.HIV Med2004; 5: 273–277.
21.
GirardiE., SampaolesiA., GentileM., NurraG., IppolitoG.Increasing proportion of late diagnosis of HIV infection among patients with AIDS in Italy following introduction of combination antiretroviral therapy.J Acquir Immune Defic Syndr2000; 25: 71–76.
22.
McDonaldA.M., LiY., DoreG.J., ReeH., KaldorJ.M.Late HIV presentation among AIDS cases in Australia, 1992–2001.Aust N Z J Public Health2003; 27: 608–613.
23.
PorterK., WallP.G., EvansB.G.Factors associated with lack of awareness of HIV infection before diagnosis of AIDS.BMJ1993; 307: 20–23.
24.
KleinD., HurleyL.B., MerrillD., QuesenberryC.P.Jr.Review of medical encounters in the 5 years before a diagnosis of HIV-1 infection: implications for early detection.J Acquir Immune Defic Syndr2003; 32: 143–152.
25.
ManaviK., McMillanA., OgilvieM., ScottG.Heterosexual men and women with HIV test positive at a later stage of infection than homo- or bisexual men.Int J STD AIDS2004; 15: 811–814.
26.
SametJ.H., FreedbergK.A., SavetskyJ.B., SullivanL.M., SteinM.D.Understanding delay to medical care for HIV infection: the long-term non-presenter.AIDS2001; 15: 77–85.
27.
GrabarS., KousignianI., SobelA.Immunologic and clinical responses to highly active antiretroviral therapy over 50 years of age. Results from the French Hospital Database on HIV.AIDS2004; 18: 2029–2038.
28.
GrabarS., WeissL., CostagliolaD.HIV infection in older patients in the HAART era.J Antimicrob Chemother2006; 57: 4–7.
29.
RotilyM., BentzL., PradierC., ObadiaY., CavaillerP.Factors related to delayed diagnosis of HIV infection in southeastern France. EVALVIH group.Int J STD AIDS2000; 11: 531–535.
30.
CostagliolaD., ChawlowA.J., SimonD., EschwegeE.Some keys factors in the clinical diagnosis of non insulin-dependent diabetes: a multinational comparison.Diabetes Metab1989; 15: 51–52.
DragstedU.B., MocroftA., VellaS.Predictors of immunological failure after initial response to highly active antiretroviral therapy in HIV-1-infected adults: a EuroSIDA study.J Infect Dis2004; 190: 148–155.
33.
LewdenC., SalmonD., MorlatP.Causes of death among human immunodeficiency virus (HIV)-infected adults in the era of potent antiretroviral therapy: emerging role of hepatitis and cancers, persistent role of AIDS.Int J Epidemiol2005; 34: 121–130.
34.
BraitsteinP., BrinkhofM.W., DabisF.Mortality of HIV-1-infected patients in the first year of antiretroviral therapy: comparison between low-income and high-income countries.Lancet2006; 367: 817–824.
35.
KatlamaC., CarcelainG., DuvivierC.Interleukin-2 accelerates CD4 cell reconstitution in HIV-infected patients with severe immunosuppression despite highly active antiretroviral therapy: the ILSTIM study - ANRS 082.AIDS2002; 16: 2027–2034.
36.
SmurzynskiM., CollierA., KoletarS., WuK., BoschR., BensonC.Opportunistic infections occurring after initiation of randomized HAART regimens in treatment-naive HIV-1-infected patients followed in the ACTG Longitudinal Linked Randomized Trials Study.13th Conference on Retroviruses & Opportunistic Infections. Denver, Colorado, USA, 5–8 February 2006. Abstract 782.
