Late diagnosis in the HAART era: proposed common definitions and associations with mortality.
OBJECTIVE
To identify a definition of presentation after clinical or immunological disease progression that will reliably identify an individual at high risk of mortality over the first 3 months after HIV diagnosis and that can be adopted as a basis for comparing over time and regions.


METHODS
An observational cohort study.


METHODS
Individuals seen for the first time at a UK Collaborative HIV Cohort study clinic from 1996 to 2006 were identified. Two immunological (CD4 cell count < 200 cells/microl and CD4 cell count <50 cells/microl) and two clinical (AIDS and severe/moderate AIDS) criteria for presentation with advanced HIV disease were compared, as well as combinations of them. The predictive ability of each diagnosis for identifying individuals who died in the first 3 months after HIV diagnosis was assessed.


RESULTS
Fifteen thousand seven hundred and seventy-four patients were included, of whom 1495 (9.5%), 4231 (26.8%), 1523 (9.7%) and 379 (2.4%) had a CD4 cell count below 50 cells/microl, CD4 cell count below 200 cells/microl, AIDS or severe/moderate AIDS at diagnosis; CD4 cell counts were unavailable for 2264 (14.4%) patients. Two hundred and six (1.3%) patients died within the first 3 months. Sensitivities of the individual criteria ranged from 18.0% (severe/moderate AIDS) to 50.5% (CD4 cell count < 200 cells/microl) with specificities ranging from 73.5% (CD4 < 200 cells/microl) to 97.8% (severe/moderate AIDS). Combinations of clinical and immunological criteria increased the sensitivity but decreased the specificity.


CONCLUSIONS
We propose that presentation with 'advanced HIV disease' is presentation with a CD4 cell count below 200 cells/microl or AIDS, whereas 'late' presentation is defined as presentation when the CD4 cell count is below that when treatment should be initiated (currently CD4 cell count < 350 cells/microl or AIDS).
Research Department of Infection and Population Health, UCL Medical School, London, UK.
Sabin
Caroline A
CA
Schwenk
Achim
A
Johnson
Margaret A
MA
Gazzard
Brian
B
Fisher
Martin
M
Walsh
John
J
Orkin
Chloe
C
Hill
Teresa
T
Gilson
Richard
R
Porter
Kholoud
K
Easterbrook
Philippa
P
Delpech
Valerie
V
Bansi
Loveleen
L
Leen
Clifford
C
Gompels
Mark
M
Anderson
Jane
J
Phillips
Andrew N
AN
D000328:Adult; D023241:Antiretroviral Therapy, Highly Active / Q000401:mortality*; D018791:CD4 Lymphocyte Count; D015331:Cohort Studies; D057210:Delayed Diagnosis / Q000401:mortality*; D018450:Disease Progression; D005260:Female; D015658:HIV Infections / Q000175:diagnosis / Q000276:immunology / Q000401:mortality*; D015497:HIV-1; D006801:Humans; D008297:Male; D011379:Prognosis