THE CHALLENGE AND CONSEQUENCES OF LATE DIAGNOSIS AND LATEINITIATION OF ART

BRENDA CRABTREE MDHIV/AIDS CLINIC, DEPARTMENT OF INFECTIOUS DISEASES

INSTITUTO NACIONAL DE CIENCIAS MÉDICAS Y NUTRICIÓN SALVADOR ZUBIRÁN

MEXICO CITY, MEXICO

THE CHALLENGE AND CONSEQUENCES OF LATE DIAGNOSIS AND LATE INITIATION OF ART

Poznansky 1995

“Subjects who are HIV positive and present late are a challenge to the control of the

spread of HIV infection…”

Poznansky MC, et al. HIV positive patients first presenting with an AIDS defining illness: characteristics and survival. Br Med J 1995. 311, 156–158.

DHHS, March 29, 2012WHO, April 2012

WHAT DO WE MEAN BY LATE?MANY DEFINITIONS

Fisher M. Curr. Opin. Infect. Dis 2008. 21, 1–3. Wong K-H, et al, AIDS Patient Care STDs 2003; 7, 461–469. Smith RD, et al, AIDS 2010; 24(13), 2109–2115.Fleishman JA, et al, Med. Care 2010; 48(12), 1071–1079 . Waters and Sabin, Expert Rev Anti Infect Ther. 2011; 9(10), 877-889.

Late testing Subjects who first present:

• <50 or <200 CD4 cells/mm3 • +/- AIDS defining event at, or within, a period of time

(3, 6 or 12 months) • Europe <350 CD4 cells/mm3

Delayed engagement to care

Late HAART Initiators

The choice of definition will clearly have an impact on the apparent prevalence of this condition:Prevalence in developed countries:

• 10–55% where a threshold of <50 cells/mm3

• 23–65% where a threshold of <200 cells/mm3

• 54–63% where a threshold of <350 cells/mm3

Higher in studies in which AIDS defining events are included

Worse scenario in developing countries (24 to 77%)

HOW FREQUENT ARE WE LATE?

The UK Collaborative HIV cohort (CHIC) Steering Committee. AIDS 2010; 24, 723–727. Wolbers M, et al, HIV Med 2008. 9(6), 397–405. Fisher M. Curr. Opin. Infect. Dis 2008. 21, 1–3. Waters and Sabin, Expert Rev Anti Infect Ther. 2011; 9(10), 877-889. Althoff KN, Clin Infect Dis 2010; 50(11), 1512–1520. Crabtree-Ramírez, CCASAnet et al; PLOS ONE; May 2011,6(5): e20272

% OF PATIENTS WITH BASELINE CD4 <200, SELECTED COUNTRIES

Mónica Alonso González, HIV & STI Regional Project: Panamerican Health Organization, April 2012

Late HAART initiation (77%): • Late testers (55%): recent diagnosis (<6 mo before initiating HAART) • Late presenters (45%): diagnosis (> 6 mo before initiating HAART )

• Many of these, were also late testers

PREVALENCE IN LATIN AMERICA AND THE CARIBBEAN

Crabtree-Ramírez, CCASAnet et al; PLOS ONE; May 2011,6(5): e20272

Risk factors:• Lack of self perception of risk

• Heterosexuals, elderly population

• Vulnerable population• Immigrant, IVDU, less educated, minority populations

• Social and individual factors• Stigma and discrimination

WHO ARE AT RISK OF BEING LATE?

McDonald AM, Aust NZ Public Health 2003; 27:608-13.CDC. MMWR 2003;32:581–586.Krentz HB, HIV Med 2004; 5:93–8.Nogueda MJ, et al, IAS 2011, Rome, Italy Abstract CDD203Crabtree-Ramírez, CCASAnet et al; PLOS ONE; 2011,6(5): e20272

Fisher M. Curr. Opin. Infect. Dis 2008. 21, 1–3. Girardi Eet al. J Acquir Immune Syndr 2004; 36:951-9.Brannstrom J, et al. Int J STD AIDS 2005; 16:702-706.Sullivan AK, BMJ 2005; 330:1301-1302.Delpierre C, et al. Int J STD AIDS 2007; 18:312-317Castilla J, et al. AIDS 2002; 16:1945–1951.

TRENDS ALONG TIME OF LATE PRESENTERS

In addition, small reduction in the prevalence of late presenters along time…

1. Lundgren J; el at; COHERE; THAB0303, AIDS 2012 2. Egger, IeDEA, Paper 100, CROI 2012, Seattle, USA

1 2

WHAT ARE THE CONSEQUENCES OF STARTING LATE?

Adapted from: Waters and Sabin, Expert Rev Anti Infect Ther. 2011; 9(10), 877-889

Higher risk of mortality in the 1st yearART CC and ART LINC, Lancet 2006; 367: 817–24

Reduced chance of viral supressionWaters L, HIV Med 2011 12(5), 289–298.

Increased risk of hospitalizationSabin CA, AIDS 2004; 18:2145–2151

More potential drug-drug interactionRockstroh JK, Antivir. Ther 2010.15 (S1), 25-30

More likely to have IRISBarber D, Nature Rev 2011 vol 10: 150

Increased risk of non-AIDS eventsReekie, AIDS. 2011;25(18):2259-68

Increased risk of neurocognitive impairment

Ellis RJ, AIDS 2011;25(14):1747-51

Potentially increased risk of HIV transmission

Cohen MS, N Engl J Med. 2011;365(6):493-505

Higher direct cost of careRY Chen, et al; Clin Infect Dis 2006

Short Term Long Term

Consequences: Mozambique

Micek et al JAIDS 2009

23,430 Tested for HIV

7,005 Tested HIV positive (30%)

1,506 Eligible for ART Initiation (49%)

3,956 Enrolled HIV care <30 days (57%)

3,049 (43%) not enrolled in care

3,046 CD4 test ,30 days after enrollment (77%)

910 (23%) No CD4 test drawn

471 Initiated ART <90 days after CD4 test (31%)

1,035 (69%) did not initiate ART

317 Adherent to ART for 6 months (83%)

65 (14%) LTFU after ART

9%

CHALLENGES AND CONSEQUENCES

HIVDiagnosis

Linkageto

Care

HAART

Initiation

HAART

Adherence

Clinical and virologic Outcome

Retention

Challenges Consequences

Adapted from: Ulett KB, et al, AIDS Patient Care STDs 2009; 23(1): 41- 49

CHALLENGES AND CONSEQUENCES

HIVDiagnosis

Challenges

• Improve testing in the general population

• Avoid missing opportunities of testing

• Identify and eliminate barriers for testing

• Innovative strategies • “hot spots”• incentive use• self-testing

HIVDiagnosis

TUPDC304 TUPE 187 TUPE183 TUPE185

CHALLENGES AND CONSEQUENCES

Linkageto

Care

Challenges

Linkageto

Care

• Access to care services

• Proper information

• Be as effective as possible • CD4 count • comorbidities

• Identify people at risk to LTFU

• Active tracing

• Decrease administrative barriers

WEPE137WEAE0203 WEAE0301

CHALLENGES AND CONSEQUENCES

Linkageto

Care

Challenges

Linkageto

Care

• Access to care services

• Proper information

• Be as effective as possible • CD4 count • comorbidities

• Identify people at risk to LTFU

• Active tracing

• Decrease administrative barriers

S T I G M A

CONCLUSIONS

• Late diagnosis and presentation to care is a significant

barrier that limits the benefit of HAART• Early mortality and morbidity• Transmission of infection

• There is a need for establish the prevalence and risk

factors for late HAART initiation in different regions

• Diagnose HIV infection earlier by: widespread testing,

reaching vulnerable populations, identify and fight

stigma

• Innovative Strategies to improve linkage to care and

retention should be evaluated and implemented

• CD4 at point of care

• Addressing LTFU in every step with aggressive

mechanisms for linkage or reengagement to care

• Active tracing: text message, home visits, etc.

CONCLUSIONS II

ACKNOWLEDGEMENTS

Juan Sierra-Madero

Carlos del Río

Francisco Belaunzarán

Stefano Bertozzi

Yanink Caro-Vega

Alicia Piñeirúa

Medical Staff of HIV/AIDS Clinic, INNSZ

ID Department, INNSZ

All CCASAnet Team