title: Factors associated with initiation of primary medical care for HIV-infected persons.
abstract: OBJECTIVE
  To examine the degree of immune dysfunction of human immunodeficiency virus (HIV)-infected patients at the time of presentation and to identify factors associated with early and late initial primary medical care for HIV infection as measured by CD4+ lymphocyte count.
  
  
  METHODS
  Two hundred fifty-one consecutive outpatients without prior primary care for HIV infection were assessed at a municipal hospital HIV intake clinic (derivation group). Sociodemographic and clinical variables were examined for their association with CD4+ cell count on presentation in bivariate and stepwise linear regression analyses. Variables of interest were examined in 123 similar patients at a second site to assess the generalizability of our findings (validation group).
  
  
  RESULTS
  In the derivation group, 30% of patients presented for initial primary care with CD4+ cell counts less than 200/mm3, 51% had counts from 201/mm3 to 500/mm3, and only 19% had counts greater than 500/mm3. Twenty-seven percent of patients had delayed seeking medical care for longer than 1 year and 12%, for more than 2 years after an initial positive HIV serologic evaluation. Three variables were significant and independent predictors of CD4+ cell count on presentation: Haitian ethnicity (P = 0.05) and HIV-related symptoms (P = 0.005) were associated with lower CD4+ cell counts; and female sex (P = 0.009) was associated with higher CD4+ cell counts. With HIV-related symptoms excluded from the model, a history of cocaine use was also a significant predictor for higher CD4+ cell count (P = 0.02). In the validation group, which included few Haitians, results for female sex and HIV-related symptoms showed a similar association.
  
  
  CONCLUSIONS
  Most HIV-infected patients presented for primary care with advanced immune dysfunction. A substantial percentage of patients waited over a year to initiate medical care after testing positive for HIV. Haitian patients presented later for primary HIV care as measured by CD4+ cell count. Women presented with significantly higher CD4+ cell counts than did men. Since few characteristics examined could clearly identify the majority of late-presenting HIV-infected patients, improved general and targeted efforts are needed to link all HIV-infected people with primary medical care before the development of advanced disease.
authors.affiliation: Section of General Internal Medicine, Boston City Hospital, Boston University School of Medicine, Massachusetts.
authors.forename: J H
authors.initials: JH
authors.lastname: Samet
authors.forename: M J
authors.initials: MJ
authors.lastname: Retondo
authors.forename: K A
authors.initials: KA
authors.lastname: Freedberg
authors.forename: M D
authors.initials: MD
authors.lastname: Stein
authors.forename: T
authors.initials: T
authors.lastname: Heeren
authors.forename: H
authors.initials: H
authors.lastname: Libman
mesh_terms: D000328:Adult; D000704:Analysis of Variance; D018791:CD4 Lymphocyte Count; D005260:Female; D015658:HIV Infections / Q000276:immunology* / Q000628:therapy*; D006801:Humans; D016014:Linear Models; D008297:Male; D013997:Time Factors