Africans in London continue to present with advanced HIV disease in the era of highly active antiretroviral therapy

Our findings show that despite the numerous advances in the management of HIV disease, this has not resulted in earlier presentation in Africans or non-Africans. African patients are still presenting with significantly more advanced disease than non-Africans, and are more likely to have AIDS at presentation in 1998–1999 than in 1982–1995. An urgent need exists to identify the factors associated with delayed presentation, both to optimize clinical outcomes and reduce the possibility of onward transmission. From anonymous testing it is estimated that almost a third of individuals with HIV living in the UK are unaware of their HIV seropositivity; among heterosexuals the proportion undiagnosed is closer to 50% [1]. The majority of heterosexually acquired HIV infections in the UK occur in individuals who are from or have spent time in sub-Saharan Africa, and Africans now form the second largest group affected by HIV/AIDS in this country (PHLS AIDS and STD Centre – Communicable Disease Surveillance Centre, and Scottish Centre for Infection and Environmental Health. Unpublished Quarterly Surveillance Tables No. 49, 00/4 Table 7a). Up until 1996 it was known that African individuals presented later with HIV disease than non-Africans [2]. Delayed presentation is a major personal, epidemiological and health economic concern. It denies individuals and their partners the opportunity to access effective therapies and support, and potentiates the risk of the onward transmission of the infection. Advances in HIV therapy, health promotion, and antenatal testing have all potentially changed the attitudes of individuals towards, and opportunities for, HIV testing. This study aimed to determine if the presentation of HIV infection has changed in the era of highly active antiretroviral therapy (HAART). A retrospective review of all adults diagnosed HIV positive from January 1998 to December 1999 attending two specialist HIV clinics in London was conducted. Information on demography, clinical stage (CD4 cell count, viral load, AIDS diagnoses), reasons for HIV test, and previous health service utilization was collected from the case notes. Comparison with data from a retrospective study [2] of all HIV-infected Africans and a comparison group of non-Africans from 1982 to 1995 attending the same centres was performed to assess the change over time (see Table 1). A total of 143 patients born in Africa and of black ethnicity were defined as African; all others (243) were considered to be non-African. The European AIDS criteria were used to define the clinical stage of AIDS [3]. Mann–Whitney, ‘t ', and chi-squared tests were used, and logistic regression was used to adjust for ethnicity differences between studies.Table 1: Demographic and baseline characteristics of study population at the time of HIV diagnosis. Thirty-five per cent of African patients had an AIDS-defining illness within one month of their HIV diagnosis, compared with 13% of non-Africans (P < 0.0005). The median CD4 cell count was 188 × 106 cells/l for Africans and 380 × 106/l for non-Africans (P < 0.0005). Comparison over time shows that patients overall were more likely to have AIDS at presentation in 1998–1999 than in 1982–1995 [adjusted odds ratio (OR) 2.40, 95% confidence interval (CI) 1.63–3.55]; the change was greater for Africans (OR 3.09, 95% CI 1.89–5.05) than non-Africans (OR 1.58, 95% CI 0.86–2.92), although not significantly so (P = 0.095, test for interaction). The mean log10 (CD4 cell count) changed by −0.124 (−0.250–0.002) for Africans, and 0.021 (−0.090–0.133) for non-Africans (P = 0.090, test for interaction). Time spent in the UK before HIV diagnosis for Africans remained constant over time (36 months, range 1–480 in 1998–1999, and 2–132 in 1982–1995). The reasons for HIV testing and the utilization of health services before testing differed between the two groups (Table 1). Africans were more likely to test because of a preceding event suggesting the possibility of HIV infection. This included the development of AIDS or a positive diagnosis in a symptomatic child. Africans were also more likely to be diagnosed via antenatal screening. Non-Africans were more likely to test because of patient request or known contact with an HIV-infected individual. Non-Africans were more likely to have had a previous negative HIV test or been diagnosed with a sexually transmitted disease before their HIV diagnosis. These data show that Africans continue to present at more advanced stages of disease compared with non-Africans. This may relate to a lack of the perceived risk of HIV, a lack of perceived benefit in the knowledge of their HIV status and potential interventions, or an inability to access appropriate services. The majority of non-Africans were gay white men who were more likely to have previously tested for HIV (and tested more recently), visited a sexually transmitted disease clinic, or been diagnosed with a sexually transmitted infection (P < 0.0005). Although this suggests a failure in potential preventative opportunities (53% had a previous negative test), it also indicates that different patterns of health service utilization exist for Africans. Fifteen per cent of Africans and 29% of non-Africans had HIV tests because of contact with someone known to be HIV positive. This highlights the importance of the further development of a partner notification strategy. The introduction of antiretroviral therapy has led to a marked decline in HIV/AIDS-associated morbidity and mortality [4]. Individuals are only able to benefit from these advances if they are aware of their HIV status. Improved survival from the AIDS diagnosis has also been associated with a longer awareness of the HIV diagnosis before the diagnosis of AIDS [5]. Regeneration of the immune system has been demonstrated with HAART; however, recent evidence suggests that those individuals with a CD4 cell count of less than 200 cells/mm3 before the initiation of HAART have a poorer prognosis [6]. An early diagnosis of HIV facilitates access to treatment and care services, and allows individualized prevention strategies to reduce the onward transmission of infection. Acknowledgements The authors would like to thank Graham Ramalingham, Denise Thorburn and Joanne Baruah for data extraction, Dr Julia Del Amo for permission to use her data, Sade Badejo for data input, and Bloomsbury and Greenway Clinic reception staff for clerical assistance. Fiona M. Burnsa Ade O. Fakoyab Andrew J. Copasc Patrick D. Frencha