HIV patients are actually sicker when they begin therapy

It was hoped that as HIV treatment improved and as HIV-related public health initiatives encouraged people to be tested for the disease and seek care, that HIV-infected patients would seek care quickly.

Unfortunately, a new study indicates that patients are actually sicker when they begin therapy. The study is published in the November 15 issue of Clinical Infectious Diseases, currently available online.

The study, carried out in Baltimore, MD, from 1990 through 2006, shows that HIV patients beginning HIV therapy have trended toward increasing levels of immunocompromise. This is probably an indicator that people are getting tested for HIV later after they've contracted the disease than in the past. Also, people in several key demographic groups are not any quicker now to seek care than they were in the past and some are even taking longer.

HIV is a disease that is most effectively treated if caught early in the course of the illness. Early treatment also helps to limit the spread of the virus from one person to another. For these reasons, HIV services in the United States have evolved over time to encourage people to be tested for HIV and seek treatment if infected.

The researchers, Jeanne Keruly, MS and Richard Moore, MD, of Johns Hopkins University School of Medicine in Baltimore, analyzed data from over 3,300 patients seeking HIV care from the Johns Hopkins HIV service. The data were examined both as a whole and as demographic subsets including gender, race, injecting drug use, men who have sex with men, and heterosexuals. They looked at the amount of time between a patient's diagnosis of HIV and the time when that person first sought care; and they looked at the patient's immune status at the time of first care. Ideally, they would have found trends that showed a decrease in the time between diagnosis and treatment and an increase in the immune status.

During the years analyzed, men—and in particular white men and men who have sex with men—did have a trend towards seeking care more quickly after receiving an initial diagnosis of HIV. For all men, the average length between diagnosis and presentation for care was 270 days at the beginning of the study, falling to 183 days by the end.

Women's times to seek treatment, on the other hand, stayed fairly constant. And, unfortunately, injection drug users had a dramatic increase in the time until treatment, from an average of 378 days at the beginning of the study to 630 days at the conclusion.

People in all but one of the demographic categories had a trend of increasing immunocompromise, an indicator of disease development. The level of immunocompromise was such that the person was at increased risk for a poorer clinical outcome from antiretroviral therapy than if they had presented earlier for care. Over time, patients were increasingly likely to present with AIDS or HIV symptoms. The exception was in the men who have sex with men category.

In light of what appears to have been a poor response to efforts to more rapidly diagnose and treat HIV patients in Maryland, the authors call for new strategies to provide earlier HIV testing and referral into care.