3. Promoting HIV Testing in Diverse Populations
Risks of Delayed HIV Diagnosis and Treatment
Just as significant benefits are associated with early diagnosis and treatment of
HIV infection, so also are serious risks involved for both individual patients and their communities when cases of HIV infection remain undetected and untreated. The capsule version of the risks associated with the presence of undiagnosed and untreated HIV disease includes the following concerns:
- Declining immune function
- Increased morbidity and hospitalization for opportunistic infections
- Higher baseline HIV-1 RNA level when treatment is begun
- Increased risk for non-AIDS–defining conditions (eg, cardiovascular disease, malignancies)
- Emergence of drug-resistant viral populations
- Greater costs of treatment
- Risk of continuing HIV transmission
In the pre-HAART era (ie, before the mid-1990s), opportunistic infections (OIs)—such as Pneumocystis jirovecii pneumonia (PCP), Mycobacterium avium complex, toxoplasmosis, and Kaposi’s sarcoma (KS)—were associated with extensive morbidity and mortality in HIV-positive individuals.[Kaplan 2009] Even today, in some populations, studies have found that 25% to 50% of individuals who have CD4+ cell counts < 200 cells/mm3 when initially diagnosed with HIV infection are diagnosed at the same time with an AIDS-defining condition. [Brooks 2009] For more than 15 years, clinicians have realized that patients with lower CD4+ cell counts are more susceptible to a variety of infections, as well as malignancies. [Bartlett 2009, Hanson 1995, Biggar 2007]
As discussed in the preceding section, earlier detection of HIV infection may also be associated with other benefits, including both improved immunologic function and lower rates of therapy-related adverse events, [Kitahata 2009, Kitahata 2010, Lichtenstein 2009] adding to patients’ quality of life. Earlier detection and treatment may also lead to CD4+ cell count preservation and potential immune reconstitution to normal levels. [Connick 2000, Landay 2007] Moreover, timely initiation of HAART has public health implications, as successful therapy has been shown to be associated with reductions in rates of transmission and communities’ viral load. [Attia 2009]
Martinez-Colubi and colleagues recently presented the findings of a European study demonstrating that the average monthly costs associated with treating an HIV-infected patient whose diagnosis has been delayed was €1302 (approximately $1,738) vs €290 (approximately $387) for patients whose HIV disease was diagnosed early, ie, an average monthly difference of €1012 (approximately $1,351) for patients whose HIV infection was not detected in a timely way. [Martinez-Colubi]
Considered together, studies such as these underline the serious personal and socioeconomic concerns that can be associated with delayed identification and treatment of HIV-positive individuals—and point to the significant benefits associated with routine HIV screening programs.
