Between 2000–2010, our clinic observed a significant decline in the proportion of patients presenting with advanced HIV infection, illustrated by dramatically fewer presentations with CD4 counts <200 cells/mm3 and fewer patients with concomitant opportunistic infections at enrollment. Importantly, these trends appear to have translated into improved short-term survival, with significant declines observed in 1-year mortality in more recent years. Our study is among the first to evaluate temporal trends in late presentation for HIV care over the time period incorporating the updated CDC HIV testing guidelines and to further evaluate the implications for short-term mortality. Our results indicate a trend towards earlier presentation for outpatient HIV care which preceded the release of the revised HIV testing recommendations in September 2006, suggesting other factors may have contributed. If mirrored across the country, our findings of earlier presentation for outpatient HIV care and associated declines in short-term mortality in more recent years holds considerable promise for individual health outcomes and may have profound public health implications.
It is noteworthy that downward trends in late presentation for outpatient HIV care preceded the release of the revised CDC HIV testing recommendations in September 2006, and that these trends have continued through 2010. The current study is not able to assess HIV testing practices among primary care providers in Alabama to determine the degree to which changes in testing practices, either prior to or following release of the updated CDC guidelines, may have impacted study findings. Other factors may have contributed to the observed trends towards earlier presentation for HIV medical care. In 2006 the Alabama Department of Public Health launched the Enhanced Referral and Treatment System, designed and implemented to identify persons testing positive for HIV infection and track their entry into care. Additionally, the UAB 1917 Clinic launched Project CONNECT, a systems-level new patient navigation program in January 2007. Following implementation of this program, the proportion of patients who failed to enroll in HIV care decreased from 31% to 18%, resulting in improved linkage to outpatient care at the clinic.19,20
These statewide and clinic-level programs may have contributed to the downward trends in late presentation for HIV care that persisted from 2006–2010. Further, socio-demographic shifts were observed over the observation period with increases in non-white males, MSM, and younger patients. It is unclear to what extent these shifts may have contributed to the observed study findings.
Public health and individual benefits of earlier diagnosis and enrollment into HIV-care include improved quality of health, longevity and early survival. Our data demonstrate that between 2000–2010 the proportion of patients entering HIV care is doing so earlier, with a baseline CD4 count <200 cells/mm3
, down 18.1% [2000–2002 (48.7%); 2009–2010 (30.6%)]. It appears similar changes are being observed elsewhere in the US, although data are limited. 21
Prior to opt-out testing recommendations, rates of CD4 counts
at the time of HIV diagnosis and enrollment in care have been documented as high as 36% (1999–2000) and 49% (2002–2004).4,7
A study at the Johns Hopkins Moore HIV Clinic found no significant difference in CD4 counts among patients enrolling in care between 1990–2006.6
Similarly, during a subset of our study period between 2000–2005, we found that nearly one-half of our patients consistently enrolled into HIV care with CD4 counts <200 cells/mm3
. However, between 2006–2010 a significant and clinically meaningful decline in the proportion of patients presenting with advanced immunosuppression was observed in the current study.
The significant improvement in early mortality declining from 4.2% to 1.2% (death with-in 1 year of enrollment), is likely linked to earlier presentation for care, as the strongest factor associated with short-term mortality was an initial CD4 count <200 cells/mm3
, which carried an over eightfold increase in odds of death. The 1-year mortality rate of 4.2% in the earliest study period (2000–2002) elucidates the consequences of late diagnosis and enrollment in clinical care. This problem has been identified in other developed nations as well. Studies in Europe demonstrate 1-year mortality with rates as high as 9% in the Mortalité 2000 and 2005 Surveys of France, upwards of 20% in London, and 3.2% in heterosexuals in England and Wales.22–24
Although race was not found to be associated with early mortality in our study, a disparity in the race of the women enrolling into HIV medical care was seen consistently across our 10-year study period. A disproportionate number of non-white females (18.4%) compared to white females (5.2%), entering HIV medical care was seen. Moreover, a significant increase in the absolute number and proportion of new patients accounted for by non-white males was observed during the study period (36% in 2000–2002 and 50.2% in 2009–2010). These findings indicate that emphasis is needed in reaching racial/ethnic minority populations as steps are taken towards implementing the new CDC HIV opt-out testing guidelines.
The diagnosis of HIV early in its course is beneficial for our public health system, shifting the focus from acute/urgent healthcare to prevention. There is clear potential benefit for secondary HIV prevention efforts to decrease HIV transmission in patients unaware of their status. Those unaware of their HIV infection have 3.5 greater odds of sexual transmission compared to those aware of their HIV infection, where an estimated 80% of newly diagnosed HIV infections occur via sexual transmission.10
In a recent meta-analysis, a 68% reduction in the prevalence of unprotected anal vaginal intercourse (UAV) occurred in HIV positive individuals aware of their serostatus compared to those patients unaware of their HIV status.25
These results indicate that changes in behavior occur as a result of knowledge of HIV serostatus, potentially increasing secondary HIV prevention. Marks et al. have estimated that the transmission rate of HIV in patients unaware of their HIV status compared to those aware of their HIV status is 6.9% vs. 2.0%.10
In the setting of expanded testing, with consequential increased self knowledge of HIV positivity, it is estimated that the number of newly acquired HIV infections could decrease by 31%, as recently demonstrated by a CDC mathematical model presented in 2006.10
The findings of our study are highly germane with regards to the recently released National HIV/AIDS Strategy for the United States.26
Three principle tenets of that document are to: 1) reduce new HIV infections, 2) increase access to care and improve health outcomes for people living with HIV, and 3) reduce HIV-related disparities and inequities. As previously noted, trends toward earlier presentation for HIV medical care, as observed in our study, have strong potential to reduce HIV transmission and new infections. Furthermore, more timely presentation and access to HIV medical care in more recent years has been accompanied by improved short-term mortality, an important health outcome. Finally, our study highlights the continued challenge of addressing HIV-related disparities as racial-ethnic minorities continue to be over-represented among newly diagnosed patients enrolling in HIV care.
Limitations and Conclusion
The findings of our study should be interpreted with respect to the limitations in our study design. As we conducted an observational study, associations can be made but causality cannot be proven. We are able to identify significant temporal trends but cannot definitively ascribe these findings to the revised CDC testing guidelines or other factors that may have contributed. Furthermore, we conducted this study at a single site in the Southeastern United States. Therefore our findings may not be applicable to all patient populations or to other geographical regions. Furthermore, our study evaluated those patients who enrolled into care at our clinic and we are unable to account for patients who have been diagnosed but not enrolled into care in our catchment area.
In conclusion, over the time period of 2000–2010 we observed a significant decline in the proportion of patients presenting with advanced HIV infection (CD4 count <200 cells/mm3 and/or OI at clinic enrollment). These findings have translated to a significant decline in 1-year mortality among patients establishing initial HIV care in more recent years. The improved timeliness of HIV diagnosis and linkage to care has clear implications for individual patients and the public health, meriting further evaluation in larger patient populations.