Potential impact of routine testing of patients with HIV indicator disease in preventing late HIV diagnosis

Potential impact of routine testing

of patients with HIV indicator

disease in preventing late HIV

diagnosis

Istituto Nazionale per le Malattie Infettive “Lazzaro Spallanzani”

ROME –ITALY

Enrico Girardi, P. Scognamiglio, G. Chiaradia, F. Salvatori, P. Elia, M. Giuliani, S. Aviani, L. Tacconi, S. Schito, A. De Filippis, S. Grisetti, A. Sampaolesi, S. Pittalis, G. De Carli, V. Puro, G. Ippolito, N. Orchi

In Europe between 15% and 38% of individuals with HIV have an advanced immunosuppression at the time they first test positive.

Late diagnosis is associated with an increased risk for HIV-associated morbidity and mortality and with an

increased potential for onward transmission of the virus.

Routine testing of individuals with infections that

share route of transmission with HIV or whose onset is favoured by HIV (so called

HIV indicator diseases

to evaluate the proportion of individuals with late HIV diagnosis who could have been diagnosed earlier if tested at the time of an indicator disease.

to estimate association of having had an least one HIV indicator disease before HIV diagnosis with delayed HIV diagnosis

Study population:

Adults with a new diagnosis of HIV infection observed

from 1 October 2004 to 30 April 2009

counselling and testing public sites in Lazio region, Italy. Data collected at diagnosis:

-clinicians recorded demographic, epidemiological, and clinical data (CD4 cell count, AIDS diagnosis);

-every patient was asked to fill a questionnaire

(socio-demographic characteristics, risk behaviours, HIV-testing and clinical history)

Inclusion criteria:

Antiretroviral naïve patients who completed the

questionnaire and with a CD4 count available within 3 months from HIV diagnosis.

Definitions:

Late diagnosis: a CD4 cells count < 350 cells/ mmc or clinical AIDS at HIV diagnosis

HIV indicator diseases: viral hepatitis infection (HBV or HCV), STD (syphilis, gonorrhoea, genital herpes,

genital condylomatosis), tuberculosis, seborrhoeic

dermatitis

Statistical analysis: Logistic regression analysis was performed to estimate association of having had “at least 1 HIV indicator disease occurred before HIV diagnosis” with “late HIV diagnosis”.

Covariates: gender; age (continuous variable); area

of birth (Italy versus other); HIV exposure category; previous negative HIV test

Demographic, clinical and epidemiological characteristics N=713 Age (median) 36 yy (18-71) Gender Male 593 83.2 % Area of birth No Italy 139 19.5 %

HIV exposure category

Heterosexual MSM IVDU Other/not known 246 414 28 25 34.5 % 58.1 % 3.9 % 3.5 %

Previous negative test 447 62.7 %

At least 1 previous HIV

indicator disease 314 44.0 %

30/302 (9.9%) patients with late diagnosis reported an HIV indicator disease occurred when they probably were already infected, not

followed by HIV testing.

newly HIV diagnosis included in our analysis CD4>350 or seroconverted 411 (57.6%) Late diagnosis302 (42.4%) 350< CD4+< 200 127 (17.8%) within 5 years* 15 200< CD4 or AIDS 175 (24.5%) 1877 713

HIV indicator disease before HIV diagnosis not followed by a negative HIV test

within 8 years*

15

Results

Time from HIV indicator disease and HIV diagnosis in 30 late HIV diagnosed patients and type of indicator diseases

350< CD4+< 200 months pts 200< CD4 or AIDS pts Median=15.6 Median=32.4 0 1 2 3 4 5 6 Hepatitis C Hepatitis B Syphilis Gonorrhoea genital herpes condylomatosis seborrhoeic derm. tuberculosis Hepatitis C Hepatitis B Syphilis Gonorrhoea genital herpes condylomatosis seborrhoeic derm. tuberculosis

Variable HIV indicator disease N=30 Others N=272 Age (median) 37 (22-61) 36 (18-71) Gender Male 27 (90%) 216 (79%) Area of birth Outside Italy 5 (17%) 60 (22%) HIV exposure category

Heterosexual MSM IVDU Other/not known 9 (30%) 18 (60%) 2 (7%) 1 (3%) 126 (46%) 120 (44%) 11 (4%) 15 (6%) Previous negative test 22 (73%) 112 (41%)

Results

Demographic, clinical and epidemiological characteristics of 302 patients with late HIV diagnosis

Variable Late

N(%) No LateN(%) OR (95%CI) MLOR (95%CI)

Age (median) 39 (18-71) 34 (19-69) 1.05 (1.03-1.07) 1.04 (1.02-1.06) Gender Female 59 (20) 61 (15) 1.5 (1.0-2.3) 0.9 (0.5-1.5) Area of birth No Italy 65 (22) 74 (18) 1.3 (0.9-1.9) 1.4 (0.9-2.1) HIV exposure category Heterosexual MSM IVDU Other/not known 135 (45) 138 (46) 13 (4) 16 (5) 110 (27) 276 (67) 15 (4) 10 (2) 1 0.4 (0.3-0.6) 0.7 (0.3-1.6) 1.3 (0.6-2.9) 1 0.6 (0.4-0.9) 1.3 (0.6-3.0) 1.2 (0.5-2.9) Previous negative test 134 (44) 313 (76) 0.2 (0.2-0.3) 0.3 (0.2-0.4) HIV indicator disease 115 (38) 199 (48) 0.7 (0.5-0.9) 0.9 (0.7-1.3)

Results

Demographic, clinical and epidemiological characteristics according to

Over a 5-years period, we recorded a high proportion (302/713; 42.3%) of late diagnosis among people testing HIV positive; 24.9% (175/713) had an advanced stage of disease (CD4<200/mmc).

Increasing age was associated with an increased risk for HIV late diagnosis.

Man who have sex with men and individuals with a previous HIV negative test were less likely to receive a late diagnosis

One tenth of delayed HIV diagnoses could have been anticipated, by a median of 21.8 months, trough HIV testing at the time of an HIV indicator disease.

Routine testing of individuals with HIV indicator diseases, such as STDs, could have a positive, although limited, impact in the prevention of late HIV diagnosis.

This intervention should be part of a larger strategy of active offer of HIV testing

SENDIH 2004-2009

U.O. AIDS S. Eugenio Roma

A. De Filippis

CRAIDS Ospedale Frosinone

I. Gallo, E. Anzalone

CRAIDS Ospedale Rieti

A. Pitorri

CRAIDS Ospedale Viterbo

A. Caterini, S. Aviani CRAIDS

Ospedale Latina Coordinating Center

Dipartimento di Epidemiologia, INMI L.Spallanzani

E. Girardi, V. Puro, N. Orchi

Laboratorio Monitoraggio Farmaci,INMI

C.F. Perno, R. D’Arrigo, C.Gori

Laboratorio Virologia, INMI

M. Capobianchi, S. Zaniratti, M Selleri

U.O. CRAIDS INMI L.Spallanzani

V. Puro, G.De Carli, N. Orchi, S.Pittalis, P.Scognamiglio.

U.O. AIDS Istituto S.Gallicano Roma

A. Di Carlo , M Giuliani

U.O. AIDS ASL RMB Ospedale Pertini Roma

R. Brancatella, T. Maggi

U.O. AIDS ASL RME Via Catone

P. Gattari, L. Spizzichino

U.O. AIDS ASL RMD Ospedale GB Grassi