Late presentation to HIV/AIDS testing, treatment or continued care: Clarifying the use of CD4 evaluation in the consensus definition
Alpert Medical School of Brown University and The Miriam Hospital, Providence, RI, United States; Massachusetts General Hospital Center for Global Health, Harvard Medical School, Boston, MA, United States; Mbarara University of Science and Technology, Mbarara, Mbarara District, Uganda; Department of Global Health and Population, Boston, MA, United States; Institute of Global Health, University of Southern California, Los Angeles, CA, United States
Objectives: Late presentation to HIV/AIDS services compromises treatment outcomes and misses opportunities for biomedical and behavioural prevention. There has been significant heterogeneity in how the term 'late presentation' (LP) has been used in the literature. In 2011, a consensus definition was reached using CD4 counts to define and measure late presenters and, while it is useful for clinical care, the consensus definition has several important limitations that we discuss in this article. Methods: Using the spectrum of engagement in HIV care presented by Gardner and colleagues, this article highlights issues and opportunities associated with use of the consensus definition. Results: The consensus definition is limited by three principal factors: (1) the CD4 count threshold of 350cells/μL is being increasingly questioned as the biomedical justification grows for earlier initiation of treatment; (2) CD4 evaluations are conducted at multiple services providing HIV care; thus it remains unclear to which service the patient is presenting late; and (3) the limited availability of CD4 evaluation restricts its use in determining the prevalence of LP in many settings. Conclusions: The consensus definition is useful because it describes the level of disease progression and allows for consistent evaluation of the prevalence and determinants of LP. Suggestions are provided for improving the application of the consensus definition in future research. © 2013 British HIV Association.
antiretrovirus agent; acquired immune deficiency syndrome; article; CD4 lymphocyte count; disease course; evaluation study; health care; health care utilization; HIV test; human; Human immunodeficiency virus; Human immunodeficiency virus infection; late presentation; prevalence; priority journal; treatment outcome; virus replication; virus transmission; CD4 evaluations; HIV/AIDS; late presentation; testing; treatment; CD4 Lymphocyte Count; CD4-Positive T-Lymphocytes; Delayed Diagnosis; Disease Progression; HIV Infections; Humans; Time Factors