Re‐audit of patients initiating antiretroviral therapy

To the Editor, In a previous national clinical audit [1], we found significant variation in the baseline tests performed in 942 HIV-infected patients starting antiretroviral therapy (ART) for the first time during 2002. We have used a similar questionnaire survey to obtain data on a further 495 patients who started ART between April and September 2004 at 120 clinical centres in the UK and Ireland, up to a maximum of five per centre. As in 2002, most patients started ART later than guidelines recommend. This was mainly but not solely because of late diagnosis; among the 306 (61.8%) of patients who started ART at a CD4 count of <200 cells/μL, only 61 had been diagnosed with HIV infection more than 6 months before initiating therapy, including 10 with a CD4 count of <50 cells/μL. Reported use of baseline tests increased from 2002 to 2004, as shown in Table 1. New guidelines were issued in 2003 which recommended baseline testing for HIV drug resistance prior to ART initiation [2], but only 158 patients (31.9%) underwent such testing in 2004, compared with 87 (9.2%) in 2002. For 84 patients (17.0%) a sample was stored for possible future testing, 228 patients (46.1%) were not tested and information was lacking for 25 patients (5.1%). In conclusion, use of baseline testing improved over time, but clinically important tests were still often omitted. The low rate of resistance testing is of particular concern. More work is needed to promote earlier HIV diagnosis and to encourage timely uptake of ART among diagnosed patients.