July 12, 2004
It is estimated that up to two thirds of people living with HIV in the United States are unaware of their diagnosis, or are aware of their status but are not receiving care. These individuals with delayed entry into care are at risk of developing HIV-related complications and risk having a potentially decreased response to treatment as their CD4+ cell count falls below 200 cells/mm3. Despite efforts in outreach and education for persons living with HIV in the United States, many individuals still do not present to care until their HIV disease has progressed to significant immunosuppression.
There are multiple factors associated with delay to entering care and treatment, including delay in HIV testing and delay in accessing care once HIV status is known. A better understanding of who presents late to care, and why, is important for programs and policy-makers to more effectively address this ongoing problem in a resource-rich setting.
Using an ongoing database of HIV-infected patients followed at their site, investigators from the University of North Carolina examined the demographics and risk factors associated with delayed entry into care. For the purposes of the study, delayed entry into care was defined as being eligible for HAART (CD4 <350 cells/mm3, viral load >55,000 copies/mL or AIDS) when presenting for the first visit at the site.
The cohort consisted of 348 individuals who entered care between 2000 and 2003. These patients included 35% women, 35% >40 years of age, 78% non-white and 32% uninsured. Forty-six percent had to travel over 60 miles to the clinic, and 36% lived in rural areas (population <50,000). Twenty-three percent engaged in illicit drug use. Fifty percent had an initial CD4+ cell count <200 cells/mm3 (29% <50 cells/mm3), 27% presented with an AIDS-defining illness, and 79% had HAART indicated at their first visit. Sixty-three percent had not been in care prior to presenting to the site.
The investigators studied risk factors associated with delayed entry into care (see Table). In univariate analyses, being male (odds ratios [OR]: 2.4, 95% confidence interval [CI]: 1.2-4.6) and living in a rural area (OR: 2.1, 95% CI: 1.0-4.5) were both associated with delayed entry into care. A number of other factors, including illicit substance use, distance from the clinic, and insurance, were not significant in a multivariate analysis controlling for race, age, insurance, distance to care and illicit drugs/alcohol/depression (male OR: 2.5, 95% CI: 1.2-5.0; rural OR: 2., 95% CI: 1-5.1).
The study looked at whether the delay in care was due to issues of testing or accessing care after diagnosis. They found that 86% of the patients had been diagnosed within the year preceding entry to care, strongly indicating that the problems were in patients being diagnosed, rather than in delay after diagnosis.
This study clearly indicates that patients in the southeastern United States are still presenting extremely late to care, with significant morbidity and potential compromise of their ability to respond fully to HAART. The findings highlight the importance of expanding education, outreach, and access to HIV counseling and testing for this population, and underscore the need for creative strategies to reach rural communities.
Other studies presented at this conference also found delays in entry to care in other communities in the United States, including the city of New York (Wiewel et al), where black men between the ages of 40 and 54 had very high rates of concurrent diagnosis of HIV and AIDS (25% of those diagnosed since June 2000).
Recently increased efforts, including the use of rapid testing and other creative interventions, will hopefully provide some solutions to this ongoing problem. While many of these solutions may be based in public health interventions, clinicians should also ensure that adequate HIV education and access to quality counseling and testing are integrated into primary care and other points of contact within the healthcare system.
The authors concluded that delay in entry to care remains a significant problem, and will require increased outreach and testing to facilitate earlier access to effective care and treatment for all people living with HIV.
|Univariate Analysis OR (95% CI)||Multivariate Analysis OR (95% CI)|
|Male||2.4 (1.2-4.6)||2.5 (1.2-5.0)|
|Age >40||1.8 (0.9-3.6)||1.7 (0.8-3.7)|
|Caucasian||1.2 (0.5-2.8)||1.3 (0.6-3.2)|
|No insurance||1.0 (0.5-2)||1.5 (0.7-3.5)|
|Rural residence||2.1 (1.0-4.5)||2.2 (1-5.1)|
|>60 miles travel to clinic||1.1 (0.6-2.1)||1.6 (0.8-3.2)|
|Substance abuse, alcohol or depression||1.4 (0.7-2.8)||1.3 (0.6-2.6)|
|Please note: Knowledge about HIV changes rapidly. Note the date of this summary's publication, and before treating patients or employing any therapies described in these materials, verify all information independently. If you are a patient, please consult a doctor or other medical professional before acting on any of the information presented in this summary. For a complete listing of our most recent conference coverage, click here.|