Late diagnosis in the HAART era: proposed common definitions and associations with mortality.

NMUH Staff Publications

24

<span style="font-size: 8pt;"><br /></span><div style="line-height: 17.999801635742188px;"><h4 style="margin: 0px 0.25em 0px 0px; text-transform: uppercase; float: left;"><span style="font-size: 10pt;">OBJECTIVE:</span></h4><p style="margin: 0px 0px 0.5em;"><span style="font-size: 10pt;">To identify a definition of presentation after clinical or immunological disease progression that will reliably identify an individual at high risk of <span class="highlight">mortality</span> over the first 3 months after HIV <span class="highlight">diagnosis</span> and that can be adopted as a basis for comparing over time and regions.</span></p><h4 style="margin: 0px 0.25em 0px 0px; text-transform: uppercase; float: left;"><span style="font-size: 10pt;">DESIGN:</span></h4><p style="margin: 0px 0px 0.5em;"><span style="font-size: 10pt;">An observational cohort study.</span></p><h4 style="margin: 0px 0.25em 0px 0px; text-transform: uppercase; float: left;"><span style="font-size: 10pt;">METHODS:</span></h4><p style="margin: 0px 0px 0.5em;"><span style="font-size: 10pt;">Individuals seen for the first time at a UK Collaborative HIV Cohort study clinic from 1996 to 2006 were identified. Two immunological (CD4 cell count < 200 cells/microl and CD4 cell count <50 cells/microl) and two clinical (AIDS and severe/moderate AIDS) criteria for presentation with advanced HIV disease were compared, as well as combinations of them. The predictive ability of each <span class="highlight">diagnosis</span> for identifying individuals who died in the first 3 months after HIV <span class="highlight">diagnosis</span> was assessed.</span></p><h4 style="margin: 0px 0.25em 0px 0px; text-transform: uppercase; float: left;"><span style="font-size: 10pt;">RESULTS:</span></h4><p style="margin: 0px 0px 0.5em;"><span style="font-size: 10pt;">Fifteen thousand seven hundred and seventy-four patients were included, of whom 1495 (9.5%), 4231 (26.8%), 1523 (9.7%) and 379 (2.4%) had a CD4 cell count below 50 cells/microl, CD4 cell count below 200 cells/microl, AIDS or severe/moderate AIDS at <span class="highlight">diagnosis</span>; CD4 cell counts were unavailable for 2264 (14.4%) patients. Two hundred and six (1.3%) patients died within the first 3 months. Sensitivities of the individual criteria ranged from 18.0% (severe/moderate AIDS) to 50.5% (CD4 cell count < 200 cells/microl) with specificities ranging from 73.5% (CD4 < 200 cells/microl) to 97.8% (severe/moderate AIDS). Combinations of clinical and immunological criteria increased the sensitivity but decreased the specificity.</span></p><h4 style="margin: 0px 0.25em 0px 0px; text-transform: uppercase; float: left;"><span style="font-size: 10pt;">CONCLUSION:</span></h4><p style="margin: 0px 0px 0.5em;"><span style="font-size: 8pt;"><span style="font-size: 10pt;">We propose that presentation with 'advanced HIV disease' is presentation with a CD4 cell count below 200 cells/microl or AIDS, whereas '<span class="highlight">late</span>' presentation is defined as presentation when the CD4 cell count is below that when treatment should be initiated (currently CD4 cell count < 350 cells/microl or AIDS).</span></span></p></div>