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THE CHALLENGE AND CONSEQUENCES OF LATE DIAGNOSIS AND LATE INITIATION OF ART BRENDA CRABTREE MD HIV/AIDS CLINIC, DEPARTMENT OF INFECTIOUS DISEASES INSTITUTO.

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Presentation on theme: "THE CHALLENGE AND CONSEQUENCES OF LATE DIAGNOSIS AND LATE INITIATION OF ART BRENDA CRABTREE MD HIV/AIDS CLINIC, DEPARTMENT OF INFECTIOUS DISEASES INSTITUTO."— Presentation transcript:

1 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

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…” Poznansky MC, et al. HIV positive patients first presenting with an AIDS defining illness: 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 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/mm 3 +/- AIDS defining event at, or within, a period of time (3, 6 or 12 months) Europe <350 CD4 cells/mm 3 Delayed engagement to care Late HAART Initiators

5 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/mm 3 23–65% where a threshold of <200 cells/mm 3 54–63% where a threshold of <350 cells/mm 3 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

6 % OF PATIENTS WITH BASELINE CD4 <200, SELECTED COUNTRIES Mónica Alonso González, HIV & STI Regional Project: Panamerican Health Organization, April 2012

7 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

8 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 CDD203 Crabtree-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; 18:312-317 Castilla J, et al. AIDS 2002; 16:1945–1951.

9 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 12

10 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 1 st year ART CC and ART LINC, Lancet 2006; 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 Higher risk of mortality in the 1 st year ART CC and ART LINC, Lancet 2006; 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 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 Short Term Long Term

11 Consequences: Mozambique Micek et al JAIDS 2009 23,430 Tested for HIV 7,005 Tested HIV positive (30%) 1,506 Eligible forART 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 317Adherent toART for 6 months (83%) 65 (14%) LTFU after ART 9%

12 CHALLENGES AND CONSEQUENCES HIVDiagnosisHIVDiagnosis LinkagetoCare HAARTInitiationHAARTAdherence Clinical and virologic Outcome RetentionRetention ChallengesChallenges ConsequencesConsequences Adapted from: Ulett KB, et al, AIDS Patient Care STDs 2009; 23(1): 41- 49

13 CHALLENGES AND CONSEQUENCES HIVDiagnosisHIVDiagnosis ChallengesChallenges HIVDiagnosis TUPDC304 TUPE 187 TUPE183 TUPE185

14 CHALLENGES AND CONSEQUENCES LinkagetoCare ChallengesChallenges LinkagetoCare WEPE137 WEAE0203 WEAE0301

15 CHALLENGES AND CONSEQUENCES LinkagetoCare ChallengesChallenges LinkagetoCare 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 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

18 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

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