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Delayed HIV Care Persists in Chicago
Minorities Years After CDC Screening Advice
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51st Interscience Conference on Antimicrobial Agents and Chemotherapy (ICAAC), September 17-20, 2011, Chicago
Mark Mascolini
Nearly half of adults with a new HIV diagnosis in a largely black and Hispanic Chicago center first sought care for their infection with a CD4 count under 200, and almost one third had a count under 100 [1]. Hispanic "late presenters" came to care with CD4 counts under 100 significantly more often than black "late presenters."
In 2006 the CDC recommended opt-out HIV testing for anyone between 13 and 64 years old who seeks any medical care, regardless of perceived HIV risk [2]. In opt-out testing, people are told they will be tested for HIV unless they actively decline testing. The policy has been adopted by many hospital emergency departments and other facilities, but its impact on blacks and Hispanics is still being assessed. These two minorities represent a disproportionate number of new HIV infections in the United States, and they often seek care with advanced HIV infection.
Health workers at the CORE Center of Chicago's Rush Medical College, which serves a large black and Hispanic population, planned this study to assess rates of late presentation to HIV care--defined as seeking care with a CD4 count below 200--and to define traits of late presenters. The researchers analyzed CD4 counts, viral loads, and demographics of adults newly diagnosed with HIV who first sought care at the CORE Center from 2006 through 2009.
Among the 1750 newly diagnosed people who made an initial HIV visit, 48% identified themselves as black, 17% as Hispanic, and 10% as white, while race or ethnicity was not identified in 24%. Of these 1750 newly diagnosed people, 775 (44%) had a CD4 count under 200 and 508 (29%) had a count under 100.
Two thirds of these late presenters were black or Hispanic, a result reflecting the population served by the center. Among 750 late presenters analyzed for race/ethnicity, 47% were black, 20% Hispanic, 9% white, 1% Asian, and 24% had an unrecorded race or ethnicity.
Comparing 356 black late presenters with 151 Hispanic late presenters, the investigators found that Hispanics had a significantly younger median age (36.5 versus 40, P < 0.001), a significantly higher viral load (4.7 versus 4.6 log, or about 50,000 versus 40,000 copies, P < 0.05), and a significantly lower proportion of women (18% versus 35%, P < 0.01).
Although median CD4 count at first care was lower in Hispanic late presenters than in black late presenters (53 versus 69), that difference was not statistically significant. However, significantly higher proportions of Hispanic than black late presenters came to care with a CD4 count under 50 (46% versus 44%) or between 50 and 100 (26% versus 18%) rather than between 101 and 199 (28% versus 38%) (P < 0.05 for all comparisons).
The CORE team concluded that "delayed presentation to HIV care is ongoing despite revised CDC 2006 guidelines recommending routine, universal HIV testing."
The researchers believe their findings "highlight missed opportunities to decrease onward transmission [of HIV] and decrease HIV-related morbidity and mortality" if people are diagnosed earlier in the course of HIV infection. They called for "strategies aimed at increasing acceptability and access to routine HIV testing . . . targeted towards racial/ethnic minorities."
References
1. Badri SM, Orsi J, Lubelchek RJ, French AL. Late presentation to HIV care among African-Americans and Hispanics/Latinos since adoption of universal HIV screening: a persistent problem. 51st Interscience Conference on Antimicrobial Agents and Chemotherapy (ICAAC). September 17-20, 2011. Abstract H2-792.
2. Branson BM, Handsfield HH, Lampe MA, et al. Revised recommendations for HIV testing of adults, adolescents, and pregnant women in health-care settings. MMWR Recomm Rep. 2006;55:1-17. http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5514a1.htm.
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