Degree of Immunosuppression at Entry into Care

Despite public health recommendations for wider HIV testing in both the U.S. and Canada, a substantial number of people still enter care with advanced HIV infection.

Many people with HIV infection are unaware of their serostatus, and this has important implications both for public health, in terms of the likelihood of transmission, and for the individual's health. Late presentation to care is associated with higher morbidity and mortality, even after antiretroviral therapy (ART) is initiated. To evaluate whether CD4-cell counts at the time of presentation for care have shifted over time, investigators analyzed data from 44,491 HIV-infected individuals who initiated HIV care in the U.S. or Canada between 1997 and 2007.

During the study period, the median age at first presentation for care increased from 40 to 43, and the percentage of white patients decreased from 30% to 24%. The likely mode of HIV transmission also shifted, with a decrease seen for injection-drug use (from 26% to 14%) and an increase seen for both male-to-male sex (from 24% to 33%) and heterosexual risk behavior (from 16% to 23%). All these trends were statistically significant.

The median CD4 count at first presentation increased from 256 to 317 cells/mm³, at an annual rate of about 6 cells/mm³. Increases were seen for both men and women and for all racial/ethnic groups and modes of transmission. However, the increases were not uniform; the greatest increases were seen among Latinos and men who have sex with men, while the smallest occurred among blacks and those who became infected through heterosexual risk behavior. Also notable was a downward shift in CD4-cell counts among older patients. Importantly, the percentage of all patients presenting with a CD4 count ≥350 cells/mm³ increased during the study, from 38% to 46%.

Comment

Although the median CD4-cell count at first presentation increased over the study period, more than half the patients in 2007 were still presenting with CD4 counts <350 cells/mm³, the level at which ART should be initiated according to current guidelines. Greater efforts are needed to ensure that people learn of their HIV infection at higher CD4-cell counts.

Reviewing Author

Carlos del Rio, MD

Disclosures

Grant/Research SupportNIH/National Institute of Allergy and Infectious Diseases; NIH/National Institute on Drug Abuse

Editorial BoardsJAIDS: Journal of Acquired Immune Deficiency Syndromes; Vaccines

Leadership Positions in Professional SocietiesInternational Antiviral Society–USA (Board of Directors); Infectious Diseases Society of America (Past President)