LONDON, March 31 /PRNewswire/ --
-- Between 15 to 38 percent of HIV-infected persons in Europe do not present for screening and treatment until late in infection.(1) Late presentation has been show to result in increased morbidity(1) and decreasing quality of life.(2,3)
Almost three decades after the discovery of HIV/AIDS, and despite big medical advances, there are still a significant number of HIV-infected persons who present late in the disease course and with severe immunosuppression. This often results in less than optimal outcomes, with increased mortality, morbidity and decreased quality of life.(2,3) In Europe, between 15 to 38 percent of those infected with HIV do not present for testing until late in infection, when their CD4 cell counts are low, viral load high, and the immune system has been significantly compromised.(1) To address this issue, leading HIV experts from across Europe convened today at a meeting titled "Late Presentation for HIV Treatment in Europe" sponsored by Bristol-Myers Squibb Company (NYSE: BMY). Topics that were covered include research on late presentation, its public health implications in Western Europe, early HIV testing, and the management of late presenters.
"Late presentation can have negative consequences for both the individual and the larger population. Late HIV presenters typically have a poor disease outcome, are less likely to respond to treatment once initiated, and are more likely to transmit the disease to others," said conference co-chair Margaret Johnson, MD, clinical director and consultant physician of general medicine, HIV/AIDS and thoracic medicine at the Royal Free Hospital in London. "This meeting is extremely timely given the gravity of the issue in Western Europe. As clinicians and concerned citizens, we must act now to encourage earlier HIV testing and treatment, and help reduce the stigma of HIV diagnosis in all communities."
Although the rates of late presentation vary based on countries and definitions used,(1) some studies indicate that:
- 28 percent of patients in Spain had a first positive HIV test in the
month of or immediately before AIDS diagnosis(4)
- 33 percent of patients in the United Kingdom,(5) 38 percent in
France,(6) and 39 percent in Italy(7) received their diagnosis when
their CD4 cell count was less than 200/mm3, and/or disease progressed
to clinical AIDS during the year of diagnosis
- In Sweden, 45 percent of patients were diagnosed with HIV less than
three months before AIDS diagnosis(8)
- In Germany, 30 percent of patients were diagnosed with a CD4 cell count
less than 200/mm3(1)
These patients are more likely to acquire opportunistic infections, and to present with multiple illnesses within a short time period.(3) Delayed presenters may also have a poorer treatment response when they do start highly active antiretroviral therapy (HAART).(3) Antiretroviral drug resistance is also an issue in this population.(3)
It has been shown that earlier HIV diagnosis results in more favourable outcomes in short-term mortality (56 percent overall improvement) and heterosexually-acquired AIDS mortality (32 percent improvement).(1) Earlier HIV diagnosis may also help control the spread of the epidemic.(9) Recent changes to HIV treatment guidelines confirm the need for patients and physicians to consider treatment as early as CD4 cell count of 350-500 cells/mm3.(9,10) The 2008 International AIDS Society (IAS) treatment supports new data and considerations for initiating therapy before CD4 cell count falls below 350 cells/mm3,(10) an update to the 2006 version of the IAS guidelines, which recommended antiretroviral therapy for asymptomatic patients whose CD4 cell count is equal to or less than 200 cells/mm3.(11) Additionally, the 2008 guidelines state that, in patients with a count of 350 CD4 cells/mm3 or more, the decision to begin therapy should be individualized based on the presence of comorbidities, risk factors for progression to AIDS and non-AIDS diseases, and patient readiness for treatment.(10)
"Early treatment allows for greater immunological recovery, a reduction of AIDS progression, a reduced risk of related illnesses, and lower mortality," said conference co-chair Jürgen Rockstroh, MD, director of the Bonn University Clinic and professor in the department of medicine at University of Bonn, Germany. "Thanks to advances in medical research, there are a number of HIV treatment options available for low CD4 cell count patients, including the late presentation population. Antiretroviral therapy now makes it possible for many HIV-infected persons to live long, and fairly normal, lives."
*About Late Presentation
Although there is no standard definition of late presentation, in clinical literature late presenters have been most frequently defined as patients who present with low CD4 cell count (less than 200/mm3) and those who receive HIV diagnosis within three months of AIDS diagnosis.(1) Some studies have also defined late presenters as those who present with CD4 cell count of less than 350.(1) In addition, delayed presenters have been defined as patients with more than six months between their first HIV positive test and presentation for HIV care,(12) or simply those who present for HIV care after it may have been beneficial to begin treatment.(1)
Research shows that as many as 77 percent of all AIDS-related deaths could be considered late presenters,(1) and that baseline CD4 cell count is strongly associated with the probability of progression to death.(13) Among late presenters, there is significant short-term mortality, at a rate much higher than those who receive an earlier HIV diagnosis.(3)
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References
(1) Adler, A., et al. Late Diagnosis of HIV in Europe: Definitional and Public Health Challenges. AIDS Care; 2008; 1-10.
(2) Sanders, GD., et al. Cost-Effectiveness of Screening for HIV in the Era of Highly Active Antiretroviral Therapy. N Engl J Med; 2005; 352; 6.
(3) Girardi, E., et al. Late Diagnosis of HIV Infection: Epidemiological Features, Consequences and Strategies to Encourage Earlier Testing. J Acquir Immune Defic Syndr. 2007; 46: S3-S8.
(4) Castilla, J., et al. Late Diagnosis of HIV Infection in the Era of Highly Active Antiretroviral Therapy: Consequences on AIDS Incidence. AIDS. 2002; 16: 1945-51.
(5) Sullivan, A., et al. Newly Diagnosed HIV Infections: Review in UK and Ireland. BMJ. 2005; 330: 1301-2.
(6) Delpierre, C., et al. High-Risk Groups for Late Diagnosis of HIV Infection: A Need for Rethinking Testing Policy in the General Population. AIDS Patient Care and STDs. 2006; 20: 838-47.
(7) Borghi, V., et al. Late Presenters in an HIV Surveillance System in Italy During the Period 1992-2006. J Acquir Immune Defic Syndr. 2008; Nov 1; 49(3): 282-6.
(8) Brannstrom et al. Patients Unaware of their HIV Infection until AIDS Diagnosis in Sweden 1996-2002 - A Remaining Problem in the Highly Active Antiretroviral Therapy Era. INT J STD AIDS. 2005; 16: 702-6.
(9) BHIVA Treatment Guidelines Writing Group. British HIV Association Guidelines for the Treatment of HIV-1-infected Adults with Antiretroviral Therapy 2008. HIV Medicine. 2008; 9, 563-608.
(10) Hammer, S., et al. Antiretroviral Treatment of Adult HIV Infection - 2008 Recommendations of the International AIDS Society-USA Panel. JAMA. 2008; 300(5): 555-570.
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