Late Diagnosis - More AIDS Deaths

posted: 11/04/2011

12 years of UK HIV data shows that people diagnosed late with HIV (when the CD4 count was under 350) are 6 times more likely to die of AIDS than other people with HIV.Three quarters of all the people who die with an AIDS diagnosis were diagnosed with HIV late – when their CD4 cell count was below 350.
 

The researchers who gave this news to the British HIV Association Conference in Bournemouth last week, used the UK’s national HIV surveillance system data and death certificates at the Office of National Statistics, for the years 1997 to 2008.
 

While HIV deaths have plunged since combination treatments began in the mid 1990s, over 500 people with HIV die each year, and the HIV death rate is still five times higher than for the general population.
 

Over these 12 years, almost half the deaths were due to AIDS (49%). The proportion varied during this time but is not falling steadily, as we would hope.

The researchers milked the data by using advanced statistical tools. That is how they discovered that being diagnosed when the CD4 is below 350 makes people six times more likely than others with HIV to die of AIDS. They also estimate that 74% of all AIDS deaths are explained by late diagnosis. Even among people infected in the UK, 66% of AIDS deaths are linked to late diagnosis.

• Men were more likely than women to die of AIDS.
• But men who have sex with men were less likely to die than heterosexually infected men and women, whether this was in Africa, the UK or anywhere else.
• Injecting drug users had a much higher risk of death than all others.

The most common causes of AIDS deaths were PCP (a type of pneumonia common with advanced HIV illness), other AIDS-related pneumonias, non-Hodgkin's lymphoma, TB and neuro-cerebral causes.
These findings make very clear how important it is to reduce late diagnosis – NorthWest England is the worst region in England for late diagnosis.

Source with link to reference

Growing Life Expectancy

posted: 15/12/2010

Life expectancy with HIV continues to improve. People diagnosed during 2006-08 in the UK who then keep a CD4 count of over 200, now have a life expectancy with HIV the same as the general population. This was the good news from research presented at the 10th Congress on Drug Therapy in HIV Infection in Glasgow this month.
 

Ending late diagnosis would add 10 years

The bad news was that late diagnosis of HIV is still a serious problem in the UK. If everyone with HIV were diagnosed before their CD4 count fell below 200, this would raise life expectancy with HIV in the UK by an astonishing ten years.
 

Average life 13 years less – because so many people are diagnosed late
HIV still cuts 13 years off the average person’s life expectancy, the conference heard, although ten of those lost years are due to people coming for testing late, with CD4 counts already under 200.
 

Men’s average life expectancy loss is twice women’s
Men’s average loss of life expectancy due to HIV is twice that of women. Men tend to neglect their health more than women and are not routinely screened for HIV, whereas sexually active heterosexual women are routinely tested in pregnancy.  Late diagnosis is more common among men affecting men's average life expectancy. 

A great many deaths due to HIV in the UK are simply because people tested late. The death rate in the first year after being diagnosed with a CD4 count already under 200 is 5 times higher. But people who keep a CD4 count over 200 are living longer. People diagnosed in the last 10 years lost 6.5 years on average compared with the general population, and this is still improving. In the last two years the lifespan for people with HIV who keep a CD4 count over 200 has become near-normal, presenter Margaret May said.
 

UK study shows rising life expectancy

The Glasgow conference was hearing results from the UK CHIC cohort study which uses data from 30 different HIV clinics in the UK.

They looked back at nearly 18,000 patients who started HIV treatment between 1996 and 2008. They left out the people most likely to have the highest and lowest life expectancies, the people who started HIV treatment when their CD4 count was above 350, and injecting drug users.
 

Three-quarters of the group were male, 58% gay men, and 60% white. The median age for starting treatment was 37 and the average CD4 count for starting treatment was 166.
Seven per cent,1248 people, died and they worked out the death rates for each of four three-year periods (1996-99, 2000-02, 2003-05 and 2006-08).

These were used to work out an artificial standardised mortality - life expectancy at age 20: the remaining years of life that a person could expect at their 20th birthday, regardless of their age when diagnosed with HIV.
 

Rising life expectancy
During the earliest period (1996-99 when effective HIV treatment started improving life expectancy) life expectancy was 30 years; in other words, a person diagnosed with HIV between 1996-1999 could expect, if they were 20, to live until they were 50. (Please do not panic if you were diagnosed during these years and are now in your late 40s. You should have more than a few years left: life expectancy rises as we age, because people who survive are more likely to continue to live.)
 

People diagnosed between 2006-08 on average have seen a one-third improvement to 46 years; in other words, they could expect to live until 66.
 

Fewer years than the general population
However, this is still 13 years less than the average life expectancy at age 20 in the general UK population. In the general population the life expectancy difference between men and women has narrowed, with improvements in early death due to heart disease in men, to only two years; a 20 year old man can now expect to live till 80 and a woman till 82.
 

But in the population of HIV-positive people as a whole, men have a life expectancy at age 20 of 40 years (implying that a man diagnosed with HIV can expect to live until the age of 60) and women of 50 years: exactly why this is the case will take more research.
 

Life expectancies are continuing to rise, however. For people diagnosed with HIV during 2006-08 who keep a CD4 count of over 200, life expectancy at age 20 is now equal to that in the general population.
 

Margaret May said that if everyone got diagnosed with a CD4 count of over 200, this would improve life expectancies by ten years.
“In conclusion,” she said, “we join the advocacy for improved diagnosis and timely treatment, which could improve the life expectancy of people with HIV in the UK.”
 

Conference website

Image Get Tested, Live Longer

source with reference

HIV in the UK

posted: 03/12/2010

The latest report on HIV in the UK has appeared from the Health Protection Agency. They found  the number of people living with HIV in the UK reached an estimated 86,500. A quarter of these people don’t know they have HIV.
 

New diagnoses among men who have sex with men stayed high (2,760); four out of five gay and bi men probably got HIV in the UK.
 

Of the people newly diagnosed in 2009, 1,130 probably acquired their infection heterosexually, within the UK, accounting for a third of heterosexuals diagnosed.
 

One in six gay and bi men, and one in sixteen heterosexuals got HIV within the previous 4-5 months before their diagnosis.
 

6,600 new people diagnosed

A total of 6,630 people were newly diagnosed as HIV-infected. This represents a fourth year-on-year decline, largely due to fewer diagnoses among people infected heterosexually abroad, mostly in Sub-Saharan Africa – there have been fewer migrants who happen to come from countries with HIV rates of HIV.
 

Older worries

Some 65,000 individuals accessed HIV care, of whom one in five were aged 50 years or over. Since 2000 there has been a three-fold increase in the number of individuals accessing care and a fourfold increase among older (greater than 50 years) individuals.

Sue Peters, regional director of the Terrence Higgins Trust in Brighton, said they are concerned at the number of older people becoming diagnosed in recent years. She pointed out that gay and bi men over 50 have lived through the worst years of HIV and men who remain HIV negative may now feel they are not going to catch it. Some men think that they do catch HIV past their 50th birthday, they are old enough for it not to cause any really serious harm.
“The same issue is with younger people who may still not be aware of the dangers of what is a life long infection. I think people sometimes feel they are immune but they aren’t and it is something that concerns us.”
 

Becoming HIV positive after the age of 50 is not recommended. The immune system becomes less able to fight serious health problems the older we get. People over 50 with HIV tend to be diagnosed late and often need to start HIV treatment immediately. Treatment for HIV becomes more complicated with older age because we often have other long-term health problems to do with being older.

Late too
Half of adults were diagnosed with HIV at a late stage of infection in 2009 (CD4 counts less than 350 within three months of diagnosis), the stage at which treatment is recommended to begin.
 

Thirty-seven English primary care trusts (PCTs) had a prevalence of diagnosed HIV greater than 2 per 1,000 population, the threshold at which expanded HIV testing should be implemented – in NW England these are Manchester, Salford and Blackpool.
 

Uptake of HIV testing was 95% in antenatal clinics and 77% among STI clinic attendees in England.
 

The quality of HIV care received is high. Based on London data, 80% of newly diagnosed patients were seen in an HIV clinic within one month of diagnosis; 90% had an undetectable viral load (less than 50) one year after starting therapy; and 93% of those in care for more than a year had a CD4 count above 200.
 

• HPA recommendations
  
• High proportions of recently acquired HIV infections among newly diagnosed gay and bi men of all age groups underscores the need for ongoing prevention efforts tailored to all ages in this group.
• The national recommendation of universal testing for all attendees of STI clinics should be audited and improved in many clinics; the existing national standard for HIV testing in STI clinics should be reviewed so as to encourage better performance.
• In high prevalence areas (greater than 2 per 1,000 people diagnosed HIV infection) the routine offer and recommendation to accept an HIV test for all adult general practice registrants and general medical admissions should be widely implemented given the recently reported success of pilot projects. The upper age limit for application of this policy should be set with regard to local circumstances.
• Roll-out of clinical outcome indicators to assess the quality of HIV care received by patients, already in place in London, should be extended to the rest of the country.

Sources

Health Protection Agency - HIV in the UK 2010, report and PowerPoint slides

Aidsmap 
 

Brighton Argus

PinkNews

Over 50s HIV Infections Double

posted: 18/08/2010

New HIV infections among people over 50 have doubled in England, Wales and Northern Ireland in the last seven years, and almost half the over 50s were diagnosed late, according to a new study in the latest issue of AIDS.
 

More and more HIV experts are now thinking hard about older people with HIV. Not only are the numbers of older people with HIV rising steeply, older people are also getting HIV, health prospects are worse when you are over 50, and it is clear that there are some different problems in living with HIV when older.
 

This latest study looked at older people with HIV in England, Wales and Northern Ireland between 2000 and 2007. The starting point for ‘older’ is age 50 or over.
 

While the numbers of over 50s with HIV tripled between 2000 and 2007, there was also a sharp rise in the number of older adults getting HIV. Is the tripling of the number of people with HIV over 50 because people are living longer because of HIV treatments, or is it because more people are getting HIV after 50?

To find out the Health Protection Agency decided to analyse the national HIV data for the time between 2000 and 2007.
 

Nearly 1 in 10 new infections among people over 50
They found 8% of all new HIV diagnosis were among people over 50. But the new infection rate among over 50s is still rising and in 2007 it reached 9%. The number of older people who were newly diagnosed more than doubled, from 299 in 2000, to 710 in 2010. Almost three-quarters of these new diagnoses were people aged between 50 and 59.
 

Gay and other men who have sex with men were 40% of all the people diagnosed over 50. A third of the newly diagnosed were heterosexual men, and 25% heterosexual women.
Almost all (94%) the gay men are of white backgrounds. Older heterosexual men and women were rather more likely to be white than heterosexual men and women under 50.
 

8000 and rising
A total of 8255 older adults used HIV clinics between 2000 and 2007. This is 16% of all the people using HIV clinics.
 

Late diagnosis and AIDS
20% of the older adults developed an AIDS defining condition in the years 2000 - 2007. Mostly (91%) an AIDS condition was diagnosed within three months of diagnosis with HIV – this means HIV was diagnosed at a really late stage. This is twice the rate of AIDS diagnoses found among the under 50s.
The Health Protection Agency definition of late HIV diagnosis is when the CD4 count is below 200 at diagnosis. People diagnosed over 50 are significantly more likely to have a CD4 count this low than the under 50s (48% for over 50s, 33% for under 50s).

HIV treatment is now started normally when the CD4 count is around 350, so really many more people were diagnosed late than these HPA figures suggest. By the time the CD4 has fallen to 200 avoidable health harm has already been done.

More deaths, sooner
538 (13%) of the people over 50 died between 2000 and 2007. People diagnosed with a CD4 below 200 were 14 times more likely to die than younger patients with this CD4 count (14% for the over 50s, 1% for the under 50s).
 

Moreover, over 50s who are diagnosed late were approximately two and a half times more likely to die within a year of their diagnosis than under 50s with a CD4 count below 200.
 

The overall mortality rate amongst older patients was 25 per 1000 person-years. In contrast, the mortality rate for younger patients was half that - 12 per 1000 person-years.
 

Half got HIV after 50th birthday
Based on CD4 cell count at the time of diagnosis, they worked out that 48% of the older people with HIV got HIV when they were aged 50 and over. This percentage hasn’t changed between 2000 and 2007.
 

Three-quarters of individuals aged over 50 when they became HIV positive are men, and 54% were gay men.

Source

Reference Smith RD et al. HIV transmission and high rates of late diagnoses among adults aged 50 years and over. AIDS 24: 2109-2115, 2010.
 

Late HIV Diagnosis Warning

posted: 23/04/2010

Far too many people in the UK with HIV are being diagnosed late, when they may have had the virus for as long as 10 years and are likely to have passed the infection to other people, sexual health experts warned. In Manchester, the British HIV Association (BHIVA) and British Association for Sexual Health and HIV (BASHH) conference is under way.
 

Urgent action is needed to make routine testing the norm in areas where HIV prevalence is high – and this includes Manchester, Salford and Blackpool in NW England. HIV rates in the UK are steadily rising, and delays in diagnosing infection increase deaths and onward transmission.

NW is late diagnosis hotspot

NW England has the worst rate of late diagnosis of all regions in England. Manchester last year had the largest number diagnosed late, 54 out of 142 people: 38% diagnosed late. But this is next door to Manchester's twin city Salford, where just 23.9% were late (11 out of 46). The national average rate for late diagnosis is a high 32%.

"It is in the interest of everyone for local health authorities and healthcare professionals to take a real stance on this issue," said Dr Keith Radcliffe, president of the British Association for Sexual Health and HIV.
 

1 in 3 diagnosed late
The conference heard that more than a third of HIV infections were still being diagnosed late. If infection is missed at an early stage there may be no symptoms for 10 years, until the patient falls seriously ill with a potentially fatal AIDS-related condition.
 

There is a window of opportunity to diagnose HIV early, during what is known as sero-conversion, when the body produces antibodies to the virus. It is also the time when people with HIV are the most infectious. The person is likely to have a flu-like illness including a rash and a sore throat.
 

Missed chances
But Dr Mark Pakianathan, a London-based HIV consultant, said GPs and A&E staff may not realise it could be HIV – or may not want to suggest a test.
 

Sometimes doctors are reluctant to raise the possibility because of their own assumptions about the person’s lifestyle. "They think it can't be HIV – it must be something else," said Pakianathan. The doctor may assume it is glandular fever or even swine flu. "An opportunity could be lost for 10 years," he added.
 

Later clues
There can be an intermediate phase, when patients may be diagnosed with illnesses such as fungal nail infection, related to the erosion of their immune system by the virus. But often patients are not diagnosed until they develop an AIDS-related illness such as a lymphoma or bacterial meningitis, which can be life threatening.
 

More than 7,000 new HIV diagnoses are made every year in England, Wales and Northern Ireland. At the end of 2008 there were an estimated 83,000 people infected, according to the Health Protection Agency.
 

Testing is a lottery
Studies presented at the conference showed what Radcliffe called the "lottery" in HIV testing. An investigation of HIV testing patterns in a large inner city hospital with high local prevalence found that 41% of HIV-positive patients had been in contact with a health professional, with a HIV-related symptom, in the last two years but had not been offered a HIV test.
 

A second study, lasting six months, of acute general medical admissions, found that only one third of undiagnosed HIV-positive patients were correctly advised to have a HIV test by clinicians. The two-thirds who were missed would have been identified if HIV testing was made routine for all general hospital admissions.
 

Testing urged because of treatment successes
Pakianathan said some clinicians seemed not to have caught up with the massive change in the prospects for people with HIV that has come about in the last decade with the availability of drugs that can keep people not only alive but well and active for the foreseeable future. He had visited GP surgeries in London to talk to them about de-stigmatising HIV testing.
 

"I still get [doctors and nurses] saying: 'When I offered a test, the patient got up and left the room'. It is about how  you offer the test as well," he said.
 

Professor Ian Gilmore, president of the Royal College of Physicians, said: "Someone in their early 20s promptly diagnosed with HIV can today, with the current treatments available, look forward to a relatively normal life, whereas delayed diagnosis and treatment increase the rate of illness, premature death and the unknowing spread of the disease. Changing patterns of HIV transmission further underscore the need to raise awareness among physicians and make the test a standard first-line investigation in many secondary care settings."
 

BHIVA HIV Testing Guidelines

Source