October 7, 2013
Paul E. Sax, M.D., is director of the HIV Program and Division of Infectious Diseases at Brigham and Women's Hospital in Boston.
You know how to make an ID/HIV specialist angry? Frustrated? Sigh loudly?
Tell a clinical anecdote that involves "late" presentation of HIV diagnosis, in particular someone who has been seeking medical care for various ailments for months or even years without getting tested.
You know -- it goes something like this:
"He was seen 3 years ago for zoster [or syphilis or pneumonia or thrombocytopenia], and no one sent an HIV test. Now he's in the hospital with PCP and 10 T-cells."
It makes smoke come out of our ears because first, it's so preventable, and second, it doesn't seem like we're making any progress.
Well, that's not quite true -- we are making some progress, just not very much. In Clinical Infectious Diseases, a new paper summarizes the trend in CD4 cell count at diagnosis for nearly 170,000 patients in studies published from 1992 to 2011. Here's the punch line:
Mean CD4 cell count at presentation increased minimally by 1.5 cells/µL per year (95% CI, -6.1 to 5.5 cells/µL per year), from 307 cells/µL in 1992 to 336 cells/µL in 2011.
Yes, folks, that's a 1.5 cell/year increase! Got to show the figure, which no doubt will be much-cited, with considerable hand-wringing:
Note in particular the lack of infection in the late 1990s -- you know, the years when HIV became treatable.
As the authors note, these findings raise significant questions about the "treatment as prevention" strategy, at least if the goal is complete elimination of the HIV epidemic. They also make many of our "when to start" debates completely irrelevant for more than half the newly diagnosed patients -- their CD4 is already < 350, often substantially so.
The legal impediments to HIV testing are now pretty much gone, thank goodness. So what is the reason for this continued delay in diagnosis?
Paul Sax is Clinical Director of Infectious Diseases at Brigham and Women's Hospital. His blog HIV and ID Observations is part of Journal Watch, where he is Editor-in-Chief of Journal Watch AIDS Clinical Care.