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The challenge and consequences of late diagnosis and late initiation of ART

The challenge and consequences of late diagnosis and late initiation of ART. Brenda Crabtree MD HIV/AIDS Clinic, Department of Infectious Diseases Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán Mexico City, MEXICO.

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The challenge and consequences of late diagnosis and late initiation of ART

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  1. The challenge and consequences of late diagnosis and lateinitiation of ART Brenda Crabtree MDHIV/AIDS Clinic, Department of Infectious Diseases InstitutoNacional de CienciasMédicas y Nutrición Salvador Zubirán Mexico City, MEXICO

  2. 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…” PoznanskyMC, et al. HIV positive patientsfirstpresentingwithan AIDS definingillness: characteristics and survival. Br Med J 1995. 311, 156–158.

  3. DHHS, March 29, 2012 WHO, April 2012

  4. what do we mean by late?Many definitions 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 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.

  5. How frequent are we late? • 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%) 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

  6. % of patients with baseline CD4 <200, selected countries Mónica Alonso González, HIV & STI Regional Project: Panamerican Health Organization, April 2012

  7. Prevalence in Latin America and the Caribbean • 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 Crabtree-Ramírez, CCASAnet et al; PLOS ONE; May 2011,6(5): e20272

  8. Who are at risk of being late? • 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 Fisher M. Curr. Opin. Infect. Dis 2008. 21, 1–3. GirardiEet 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; 18:312-317 Castilla J, et al. AIDS 2002; 16:1945–1951. McDonald AM, AustNZ Public Health 2003; 27:608-13. CDC. MMWR 2003;32:581–586. KrentzHB, HIV Med 2004; 5:93–8. Nogueda MJ, et al, IAS 2011, Rome, Italy Abstract CDD203 Crabtree-Ramírez, CCASAnet et al; PLOS ONE; 2011,6(5): e20272

  9. Trends along time of late presenters • In addition, small reduction in the prevalence of late presenters along time… 2 1 Lundgren J; el at; COHERE; THAB0303, AIDS 2012 Egger, IeDEA, Paper 100, CROI 2012, Seattle, USA

  10. What are the consequences of starting late? Short Term Long Term Higher risk of mortality in the 1st year ART CC and ART LINC, Lancet2006; 367: 817–24 Reduced chance of viral supression Waters L, HIV Med 2011 12(5), 289–298. Increased risk of hospitalization Sabin CA,AIDS 2004; 18:2145–2151 More potential drug-drug interaction Rockstroh JK, Antivir. Ther 2010.15 (S1), 25-30 More likely to have IRIS Barber D, Nature Rev 2011 vol 10: 150 Increased risk of non-AIDS events Reekie, 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 care RY Chen, et al; Clin Infect Dis 2006 Adapted from: Waters and Sabin, Expert Rev Anti Infect Ther. 2011; 9(10), 877-889

  11. Consequences: Mozambique 23,430 T ested for HIV 7,005 T ested HIV positive (30%) 3,049 (43%) not enrolled in care 3,956 Enrolled HIV care <30 days (57%) 910 (23%) No CD4 test drawn 3,046 CD4 test ,30 days after enrollment (77%) 1,506 Eligible for ART Initiation (49%) 1,035 (69%) did not initiate ART 471 Initiated ART <90 days after CD4 test (31%) 65 (14%) LTFU after ART 317 Adherent to ART for 6 months (83%) 9% Micek et al JAIDS 2009

  12. challenges and consequences Consequences Challenges Retention HIV Diagnosis HAART Initiation HAART Adherence Linkage to Care Clinical and virologic Outcome Adapted from: UlettKB, et al, AIDS Patient Care STDs 2009; 23(1): 41- 49

  13. challenges and consequences 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 HIV Diagnosis HIV Diagnosis TUPDC304 TUPE 187 TUPE183 TUPE185

  14. challenges and consequences Challenges Linkage to 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 Linkage to Care WEPE137 WEAE0203 WEAE0301

  15. challenges and consequences Challenges Linkage to 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 Linkage to Care S T I G M A

  16. 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

  17. Conclusions II • 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.

  18. Acknowledgements • Juan Sierra-Madero • Carlos del Río • Francisco Belaunzarán • Stefano Bertozzi • Yanink Caro-Vega • Alicia Piñeirúa • MedicalStaff of HIV/AIDS Clinic, INNSZ • ID Department, INNSZ • AllCCASAnetTeam

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