Immune status of patients with HIV/AIDS at the time of diagnosis in the Hospital San Juan de Dios

None; None

Abstracts

Objective: To compare the immune status duringthree years of patients diagnosed with HIV/AIDS who were treated at the San Juan de Dios Hospital.   Materials and Methods: Retrospective, descriptive study of the new cases of HIV/AIDS, older than14 years of age, in 2003, 2006 and 2009 at the HIV Outpatient Clinic of the San Juan de Dios Hospital, Costa Rica, according to data in the clinical records. To evaluate the immune status the CD4 + T lymphocytes count at moment of HIV diagnosis was used, establishing as late diagnosis <200 cells. For the analysis, an estimate of the frequency and strength of association between variables was performed.   Results: From the282 cases studied, 46.8% of them were at an advanced stage of the illness. Considering all cases, late diagnosis was more frequent in men (54%) than in women (26%) (p<0.05) and in heterosexual men (57%) than in men who have sex with with men (50%) (p<0.05). In regard to age, there is an increase in risk proportional to the increase in age. It was observed that the percentage of late-diagnosis patients has increased throughout the years herein studied. Even though a decrease in the group of patients who come late for the start of the ART was observed, this decrease is due to an increase in late diagnosis and not because of an increase in timely diagnosis.   Conclusions: Late diagnosis of HIV infection represents a public health problem in the geographical area covered by the services of the San Juan de Dios Hospital. It is necessary to develop strategies that allow the improvement of the resolving capacity of the primary and secondary levels of attention in order to achieve HIV diagnosis in a timely manner. In the geographical area covered by the San Juan de Dios Hospital, the populations with a greater risk of late diagnosis are heterosexual men between the ages of 25 and 64

HIV; AIDS; CD4-positive T lymphocytes; late diagnosis; immunodeficiency

Objetivo: comparar el estado inmunológico al momento del diagnóstico durante 3 años, de los pacientes con VIH/Sida atendidos en el Hospital San Juan de Dios. Materiales y métodos: estudio retrospectivo, descriptivo de los casos nuevos diagnosticados con VIH/Sida, mayores de 14 años, en 2003, 2006 y 2009, en la Clínica de Atención al Paciente con VIH del Hospital San Juan de Dios, Costa Rica, según los datos en los expedientes clínicos. Para evaluar el estado inmunológico se utilizó el recuento de linfocitos T CD4+ al momento del diagnóstico del VIH, estableciéndose como diagnóstico tardío <200 células/μl. Para el análisis se realizó la estimación de las frecuencias y fuerzas de asociación entre las variables. Resultados: de los 282 casos estudiados, el 46,8% se presentó en una etapa avanzada de la enfermedad. En el conjunto de todos los casos, el diagnóstico tardío fue más frecuente en los hombres (54%) que en las mujeres (26%) (p<0,05), y en los hombres heterosexuales (57%) que en los que tienen sexo con hombres (50%) (p<0,05). Con respecto a la edad, hay un aumento en el riesgo que es proporcional al aumento en la edad. Se observó que el porcentaje de pacientes diagnosticados en forma tardía aumentó en el transcurso de los años estudiados, aunque se observa una disminución en el grupo de pacientes que llegan tardíamente para el inicio del TARV; esta disminución obedece a un aumento en el diagnóstico tardío y no a un aumento en el diagnóstico oportuno. Conclusiones: el diagnóstico tardío de la infección por el VIH representa un problema de salud pública en el área de atracción del Hospital San Juan de Dios. Es necesario desarrollar estrategias que permitan mejorar la capacidad resolutiva en el primer y segundo nivel de atención, para el diagnóstico del VIH de forma más oportuna. En el área de atracción del Hospital San Juan de Dios, las poblaciones que tienen mayor riesgo de ser diagnosticadas tardíamente son los hombres heterosexuales, en edades entre 25 y 64 añosel diagnóstico tardío de la infección por el VIH representa un problema de salud pública en el área de atracción del Hospital San Juan de Dios. Es necesario desarrollar estrategias que permitan mejorar la capacidad resolutiva en el primer y segundo nivel de atención, para el diagnóstico del VIH de forma más oportuna. En el área de atracción del Hospital San Juan de Dios, las poblaciones que tienen mayor riesgo de ser diagnosticadas tardíamente son los hombres heterosexuales, en edades entre 25 y 64 años

infección por VIH; sida; linfocitos T CD4+; diagnóstico tardío; inmunodeficiencia

Objective: To compare the immune status duringthree years of patients diagnosed with HIV/AIDS who were treated at the San Juan de Dios Hospital. Materials and Methods: Retrospective, descriptive study of the new cases of HIV/AIDS, older than14 years of age, in 2003, 2006 and 2009 at the HIV Outpatient Clinic of the San Juan de Dios Hospital, Costa Rica, according to data in the clinical records. To evaluate the immune status the CD4 + T lymphocytes count at moment of HIV diagnosis was used, establishing as late diagnosis <200 cells. For the analysis, an estimate of the frequency and strength of association between variables was performed. Results: From the282 cases studied, 46.8% of them were at an advanced stage of the illness. Considering all cases, late diagnosis was more frequent in men (54%) than in women (26%) (p<0.05) and in heterosexual men (57%) than in men who have sex with with men (50%) (p<0.05). In regard to age, there is an increase in risk proportional to the increase in age. It was observed that the percentage of late-diagnosis patients has increased throughout the years herein studied. Even though a decrease in the group of patients who come late for the start of the ART was observed, this decrease is due to an increase in late diagnosis and not because of an increase in timely diagnosis. Conclusions: Late diagnosis of HIV infection represents a public health problem in the geographical area covered by the services of the San Juan de Dios Hospital. It is necessary to develop strategies that allow the improvement of the resolving capacity of the primary and secondary levels of attention in order to achieve HIV diagnosis in a timely manner. In the geographical area covered by the San Juan de Dios Hospital, the populations with a greater risk of late diagnosis are heterosexual men between the ages of 25 and 64Late diagnosis of HIV infection represents a public health problem in the geographical area covered by the services of the San Juan de Dios Hospital. It is necessary to develop strategies that allow the improvement of the resolving capacity of the primary and secondary levels of attention in order to achieve HIV diagnosis in a timely manner. In the geographical area covered by the San Juan de Dios Hospital, the populations with a greater risk of late diagnosis are heterosexual men between the ages of 25 and 64

HIV; AIDS; CD4-positive T lymphocytes; late diagnosis; immunodeficiency

¹, Ricardo Boza Cordero^1,2

Author´s affiliation: ¹HIV/ AIDS Patient Care Clinic, San Juan de Dios Hospital, Caja Costarricense de Seguro Social and ²Universidad de Costa Rica´s (University of Costa Rica) School of Medicine Abbreviations: LD, Late Diagnosis;HSJD,San Juan de Dios Hospital; HAART, Highly Active Antirretroviral Treatment; HIV,

Correspondence: cvarme@gmail.com
HIV/AIDS Patient Care Clinic at San Juan de Dios Hospital

Costa Rica, according to data in the clinical records. To evaluate the immune status the 160 CD4 + T lymphocytes count at moment of HIV diagnosis was used, establishing as late diagnosis <200 cells. For the analysis, an estimate of the frequency and strength of association between variables was performed.

Human immunodeficiency virus (HIV) is a retrovirus that causes slow and progressive injury to the immune system; this is why people infected with the virus remain asymptomatic for several years, while continuous damage leads to severe immunosuppression, which could result in serious clinical consequences, favoring opportunistic infections and malignancies, potential causes of death for these patients. ^1,2 In fact, the disease's natural is divided into theree stages: primary infection, which occurs after HIV infection with a significant viremia, and an intense immune response, wich could be a symptomatic stage: the second or chronic phase is a prolonged stage of clinical latency, characterized by continuous viral replication and progressive depletion of CD4+T lymphocytes (TCD4+) where patients often remain asymptomatic, and a final stage or AIDS, where severe immunosuppression is achieved, which may lead to significant clinical deterioration and death.³

^4,5Furthermore, scientific evidence has shown that continuous HIV replication is associated with a number of immune defects that cause irreversible immunosenescence. This is why various international guidelines recommend starting HAART at an immune status that permits a greater chance of recovering normal TCD4+ levels and better immune reconstitution, setting CD4 + <350 cells/ul counts as a parameter. Some, more recent guidelines4-5 are even more aggressive, recommending an earlier initiation of antiretroviral therapy in asymptomatic patients with TCD4 + counts between 350 and 500 cells/L, based on the damage caused by HIV infection in the untreated asymptomatic phase.⁵

⁶

⁷

79 in 2003, 99 in 2006 and 104 in 2009). Study population´s characteristics, by year of diagnosis are shown in Table 1.

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Table 1

Nicaragua. As for the sexual preference of men included, there was a similar proportion of heterosexuals and homosexuals (37.9% and 37.4%, respectively) and 7% were bisexuals.

Table 2 describes cases presented each year, according to their TCD4+ levels, distributed in 3 groups: LD with advanced disease (TCD4+ count <200 cells/ul), late diagnosis to start HAART (CD4 counts between 200-350 cells/ul) and early diagnosis (TCD4+ count >350 cells/μl). The percentage of patients with a late diagnosis increased over the studied years; even though the group of patients who arrived late for the start of HAART decreased, this was due to an increase in late diagnosis, not due to an increase in early diagnosis.

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Table 2

10 in France,11 about 20%, and in a multicenter study made in Europe and North America, the initial diagnosis in the AIDS stage was performed on approximately 25% of patients.12 However, Althoff et al6 and Keruly et al,13 found a decrease in the TCD4+ count at initial diagnosis, throughout a decade, in different series of the United States and Canada, and the initial worryingly low CD4+ count,6 found 41-66% of patients in the late phase. Similarly, a study in India14 reported that more than 80% of patients are diagnosed in advanced stages. Figure 1

Figure 1

^1,7

¹⁵

^2,17

develop strategies to improve first and second level of care´s response capability, diagnosing HIV in a more timely manner.

References

References

1. Fauci AS Lane HC Enfermedad por el virus de la inmunodeficiencia humana: Sida y procesos relacionados En: Braunwald E Kasper DL Longo DL Hauser SL Martin JB Fauci AS Jameson JL Loscalzo Jeditores. Harrison: Principios de Medicina Interna. 17 ed. México: Interamericana; 2009; 1137- 1203.
2. Cohen DE Mayer KH Primary care issues for HIV-Infected patients Infect Dis Clin N Am 2007;21:49-70
3. Miró J. M, Sueda O, Plan M, Pumarola T, Gallart T. Avances en el diagnóstico y tratamiento de la infección aguda por el VIH-1. EnfermInfeccMicrobiolClin 2004; 22:643-59
4.Panel on Antiretroviral Guidelines for Adults and Adolescents.Guidelines for the use of antiretroviral agents in HIV-1-infected adults and adolescents.Department of Health and Human Services.January 10, 2011; 1–166. En: http://www.aidsinfo.nih.gov/ContentFiles/AdultandAdolescentGL.pdf.

» http://www.aidsinfo. nih.gov/ContentFiles/AdultandAdolescentGL.pdf
5. International AIDS Society-USA. When to start antiretroviral therapy. Top HIV Med. 2010; 18:121-126.
6. AlthoffKN Gange SJ Klein MB Brooks JT Hogg RS Bosch RJ et al.Late presentation for human immunodeficiency virus care in the United States and Canada. Clin Infect Dis2010; 50:1512– 1520.
7. Joint United Nations Programme on HIV / AIDS (UNAIDS). Report on the Global AIDS Epidemic 2010 En:http://www.unaids.org/globalreport/Global_report.htm.

» http://www. unaids.org/globalreport/Global_report.htm
8. Castilla J Sobrino P De la Fuente LNoguera I Guerra LParras F. Late diagnosis of HIV infection in the era of highly active antiretroviral therapy: consequences for AIDS incidence.AIDS2002, 16:1945–1951.
9. Oliva J Galindo S Vives N Arrillaga A Izquierdo A Nicolau A et al. Retraso diagnóstico de la infección por el virus de la inmunodeficiencia humana en España. Enferm Infecc Microbiol Clin. 2010; 28: 583- 589.
10. The UK Collaborative HIV Cohort (UKCHIC) Steering Committee. Late diagnosis in the HAART era: proposed common definitions and associations with mortality. AIDS2010, 24: 723-727.
11. Levu S Le Strat Y Barin F Pillonel J Cazein F Bousquet V et al Population- Based HIV-1 Incidence in France 2003-2008: a modelling analysis Lancet Infect Dis 2010;10:682-687
12. Art Cohort Collaboration HIV Treatment Response and Prognosis in Europe and North America in the First Decade of HAART: a collaborative analysis Lancet 2006;368:451-458
13. Keruly J. C, Moore R D. Immune Status at Presentation to Care Did Not Improve among Antiretroviral-Naive Persons from 1990 to 2006. Clin Infect Dis2007; 45:1369–74.
14. Mojumdar K Vajpayee M Chauhan N Mendiratta SLatecpresenters to HIV care and treatment, identification of associated risk factors in HIV-1 infected Indian population. BSCPublic Health 2010, 10:416
15. Marks G, Crepaz N, Janssen RS. Estimating sexual transmission of HIV from persons aware and unaware that they are infected with the virus in the USA. AIDS 2006; 20:1447–1450
16. Mugavero MJ Castellano C Edelman D Hicks C Late Diagnosis of HIV Infection: The Role of Age and Sex. AmJ Med 2007; 120, 370-373.
17. Marco CA Rothman RE.HIV Infection and Complications in Emergency Medicine. Emerg Med Clin NAm 2008;26:367-387

en_bart6

Received: May 7th, 2011 Accepted: April 12th, 2012

References

1. Fauci AS Lane HC Enfermedad por el virus de la inmunodeficiencia humana: Sida y procesos relacionados En: Braunwald E Kasper DL Longo DL Hauser SL Martin JB Fauci AS Jameson JL Loscalzo Jeditores. Harrison: Principios de Medicina Interna. 17 ed. México: Interamericana; 2009; 1137- 1203.
2. Cohen DE Mayer KH Primary care issues for HIV-Infected patients Infect Dis Clin N Am 2007;21:49-70
3. Miró J. M, Sueda O, Plan M, Pumarola T, Gallart T. Avances en el diagnóstico y tratamiento de la infección aguda por el VIH-1. EnfermInfeccMicrobiolClin 2004; 22:643-59
4.Panel on Antiretroviral Guidelines for Adults and Adolescents.Guidelines for the use of antiretroviral agents in HIV-1-infected adults and adolescents.Department of Health and Human Services.January 10, 2011; 1–166. En: http://www.aidsinfo.nih.gov/ContentFiles/AdultandAdolescentGL.pdf.

» http://www.aidsinfo. nih.gov/ContentFiles/AdultandAdolescentGL.pdf
5. International AIDS Society-USA. When to start antiretroviral therapy. Top HIV Med. 2010; 18:121-126.
6. AlthoffKN Gange SJ Klein MB Brooks JT Hogg RS Bosch RJ et al.Late presentation for human immunodeficiency virus care in the United States and Canada. Clin Infect Dis2010; 50:1512– 1520.
7. Joint United Nations Programme on HIV / AIDS (UNAIDS). Report on the Global AIDS Epidemic 2010 En:http://www.unaids.org/globalreport/Global_report.htm.

» http://www. unaids.org/globalreport/Global_report.htm
8. Castilla J Sobrino P De la Fuente LNoguera I Guerra LParras F. Late diagnosis of HIV infection in the era of highly active antiretroviral therapy: consequences for AIDS incidence.AIDS2002, 16:1945–1951.
9. Oliva J Galindo S Vives N Arrillaga A Izquierdo A Nicolau A et al. Retraso diagnóstico de la infección por el virus de la inmunodeficiencia humana en España. Enferm Infecc Microbiol Clin. 2010; 28: 583- 589.
10. The UK Collaborative HIV Cohort (UKCHIC) Steering Committee. Late diagnosis in the HAART era: proposed common definitions and associations with mortality. AIDS2010, 24: 723-727.
11. Levu S Le Strat Y Barin F Pillonel J Cazein F Bousquet V et al Population- Based HIV-1 Incidence in France 2003-2008: a modelling analysis Lancet Infect Dis 2010;10:682-687
12. Art Cohort Collaboration HIV Treatment Response and Prognosis in Europe and North America in the First Decade of HAART: a collaborative analysis Lancet 2006;368:451-458
13. Keruly J. C, Moore R D. Immune Status at Presentation to Care Did Not Improve among Antiretroviral-Naive Persons from 1990 to 2006. Clin Infect Dis2007; 45:1369–74.
14. Mojumdar K Vajpayee M Chauhan N Mendiratta SLatecpresenters to HIV care and treatment, identification of associated risk factors in HIV-1 infected Indian population. BSCPublic Health 2010, 10:416
15. Marks G, Crepaz N, Janssen RS. Estimating sexual transmission of HIV from persons aware and unaware that they are infected with the virus in the USA. AIDS 2006; 20:1447–1450
16. Mugavero MJ Castellano C Edelman D Hicks C Late Diagnosis of HIV Infection: The Role of Age and Sex. AmJ Med 2007; 120, 370-373.
17. Marco CA Rothman RE.HIV Infection and Complications in Emergency Medicine. Emerg Med Clin NAm 2008;26:367-387

en_bart6

Received: May 7th, 2011 Accepted: April 12th, 2012

Publication Dates

Publication in this collection
07 May 2013
Date of issue
Sept 2012

History

Received
07 May 2011
Accepted
12 Apr 2012

[1] 1. Fauci AS Lane HC Enfermedad por el virus de la inmunodeficiencia humana: Sida y procesos relacionados En: Braunwald E Kasper DL Longo DL Hauser SL Martin JB Fauci AS Jameson JL Loscalzo Jeditores. Harrison: Principios de Medicina Interna. 17 ed. México: Interamericana; 2009; 1137- 1203.

[2] 2. Cohen DE Mayer KH Primary care issues for HIV-Infected patients Infect Dis Clin N Am 2007;21:49-70

[3] 3. Miró J. M, Sueda O, Plan M, Pumarola T, Gallart T. Avances en el diagnóstico y tratamiento de la infección aguda por el VIH-1. EnfermInfeccMicrobiolClin 2004; 22:643-59

[4] 4.Panel on Antiretroviral Guidelines for Adults and Adolescents.Guidelines for the use of antiretroviral agents in HIV-1-infected adults and adolescents.Department of Health and Human Services.January 10, 2011; 1–166. En: http://www.aidsinfo.nih.gov/ContentFiles/AdultandAdolescentGL.pdf.

» http://www.aidsinfo. nih.gov/ContentFiles/AdultandAdolescentGL.pdf

[5] 5. International AIDS Society-USA. When to start antiretroviral therapy. Top HIV Med. 2010; 18:121-126.

[6] 6. AlthoffKN Gange SJ Klein MB Brooks JT Hogg RS Bosch RJ et al.Late presentation for human immunodeficiency virus care in the United States and Canada. Clin Infect Dis2010; 50:1512– 1520.

[7] 7. Joint United Nations Programme on HIV / AIDS (UNAIDS). Report on the Global AIDS Epidemic 2010 En:http://www.unaids.org/globalreport/Global_report.htm.

» http://www. unaids.org/globalreport/Global_report.htm

[8] 8. Castilla J Sobrino P De la Fuente LNoguera I Guerra LParras F. Late diagnosis of HIV infection in the era of highly active antiretroviral therapy: consequences for AIDS incidence.AIDS2002, 16:1945–1951.

[9] 9. Oliva J Galindo S Vives N Arrillaga A Izquierdo A Nicolau A et al. Retraso diagnóstico de la infección por el virus de la inmunodeficiencia humana en España. Enferm Infecc Microbiol Clin. 2010; 28: 583- 589.

[10] 10. The UK Collaborative HIV Cohort (UKCHIC) Steering Committee. Late diagnosis in the HAART era: proposed common definitions and associations with mortality. AIDS2010, 24: 723-727.

[11] 11. Levu S Le Strat Y Barin F Pillonel J Cazein F Bousquet V et al Population- Based HIV-1 Incidence in France 2003-2008: a modelling analysis Lancet Infect Dis 2010;10:682-687

[12] 12. Art Cohort Collaboration HIV Treatment Response and Prognosis in Europe and North America in the First Decade of HAART: a collaborative analysis Lancet 2006;368:451-458

[13] 13. Keruly J. C, Moore R D. Immune Status at Presentation to Care Did Not Improve among Antiretroviral-Naive Persons from 1990 to 2006. Clin Infect Dis2007; 45:1369–74.

[14] 14. Mojumdar K Vajpayee M Chauhan N Mendiratta SLatecpresenters to HIV care and treatment, identification of associated risk factors in HIV-1 infected Indian population. BSCPublic Health 2010, 10:416

[15] 15. Marks G, Crepaz N, Janssen RS. Estimating sexual transmission of HIV from persons aware and unaware that they are infected with the virus in the USA. AIDS 2006; 20:1447–1450

[16] 16. Mugavero MJ Castellano C Edelman D Hicks C Late Diagnosis of HIV Infection: The Role of Age and Sex. AmJ Med 2007; 120, 370-373.

[17] 17. Marco CA Rothman RE.HIV Infection and Complications in Emergency Medicine. Emerg Med Clin NAm 2008;26:367-387

<b>Immune status of patients with HIV/AIDS at the time of diagnosis in the Hospital San Juan de Dios</b>

Abstracts

References

References

Publication Dates

History