Factors associated with delayed initiation of HIV medical care among infected persons attending a southern HIV/AIDS clinic.
Background: Despite the proven benefits conferred by early human immunodeficiency virus human immunodeficiency virus
Human immunodeficiency virus (HIV)
A transmissible retrovirus that causes AIDS in humans. (HIV HIV (Human Immunodeficiency Virus), either of two closely related retroviruses that invade T-helper lymphocytes and are responsible for AIDS. There are two types of HIV: HIV-1 and HIV-2. HIV-1 is responsible for the vast majority of AIDS in the United States. ) diagnosis and presentation to care, delays in HIV medical care are common; these delays are not fully understood, especially in the southern United States The Southern United States—commonly referred to as the American South, Dixie, or simply the South—constitutes a large distinctive region in the southeastern and south-central United States. .
Methods: We evaluated the extent of, and characteristics associated with, delayed presentation to HIV care among 1,209 patients at an HIV/AIDS HIV/AIDS Human Immunodeficiency Virus/Acquired Immune Deficiency Syndrome Outpatient Clinic in Birmingham, Alabama Birmingham (pronounced [ˈbɝmɪŋˌhæm]) is the largest city in the U.S. state of Alabama and is the county seat of Jefferson County. between 1996 and 2005.
Results: Two out of five (41.2%) patients first engaged care only after they had progressed to CDC-defined AIDS. Among these, 53.6% were diagnosed with HIV in the year preceding entry to care. Recent presentation (2002-2005), male sex, age [greater than or equal to]25, Medicare or Medicaid insurance coverage, and presentation within six months of HIV diagnosis were independently associated with initiating care after progression to AIDS.
Conclusions: A high proportion of patients entered clinical care after experiencing substantial disease progression. Interventions that effectively improve the timing of HIV diagnosis and presentation to care are needed.
Key Words: HIV, AIDS, health care, access, Alabama, delay
Diagnosis and presentation to appropriate medical care during the early stages of human immunodeficiency virus (HIV) infection have substantial clinical and public health benefits. Decreased HIV-related morbidity and mortality Morbidity and Mortality can refer to:
adj. therapy (ART) (1-6) and opportunistic infection opportunistic infection
An infection by a microorganism that normally does not cause disease but becomes pathogenic when the body's immune system is impaired and unable to fight off infection, as in AIDS and certain other diseases. (OI) prophylaxis prophylaxis (prō'fĭlăk`sĭs), measures designed to prevent the occurrence of disease or its dissemination. Some examples of prophylaxis are immunization against serious diseases such as smallpox or diphtheria; quarantine to confine . (1,5) ART may decrease the likelihood of further HIV transmission by reducing circulating levels of HIV RNA HIV RNA AIDS RNA of HIV origin, a serum marker of a Pt's 'HIV-ness,' now the standard by which Pt response to antiretovirals is evaluated; HIV RNA levels correlate with CD4+ count, response to antiviral therapy, clinical stage and disease progression. . (7-16) Treatment of other sexually transmitted diseases Sexually transmitted diseases
Infections that are acquired and transmitted by sexual contact. Although virtually any infection may be transmitted during intimate contact, the term sexually transmitted disease is restricted to conditions that are largely (STD (Subscriber Trunk Dialing) Long distance dialing outside of the U.S. that does not require operator intervention. STD prefix codes are required and billing is based on call units, which are a fixed amount of money in the currency of that country. ) and coinfections (17-22) may also decrease the likelihood of further HIV transmission. In addition, care providers can help promote safer behaviors among their HIV-infected clients. (23-29)
Despite the benefits of early HIV diagnosis and presentation to care, a large proportion of HIV-infected Americans delay HIV testing and therefore remain unaware of their HIV status. The Centers for Disease Control and Prevention Centers for Disease Control and Prevention (CDC), agency of the U.S. Public Health Service since 1973, with headquarters in Atlanta; it was established in 1946 as the Communicable Disease Center. (CDC See Control Data, century date change and Back Orifice.
CDC - Control Data Corporation ) estimated in 2000 that one-third of an estimated 800,000 to 900,000 HIV-infected persons in the US were unaware of their infection. (30,31) Even among persons with suspected recent exposure, testing may be delayed for months or years. (32,33) As a result, diagnosis during late stages of disease is common; 30 to 40% of persons learn about their HIV status after their condition has already clinically progressed to AIDS, such that they receive both the HIV and AIDS diagnoses concurrently. (34-40) Once individuals learn that they are infected with HIV, substantial risks remain that they will fail to arrange for follow-up with appropriate clinical care providers. As many as 25% of infected persons delay care for up to five years after first testing positive. (28,41,42) Delays of more than one, two, and five years were noted in 39%, 32%, and 18%, respectively, among infected patients in Massachusetts and Rhode Island Rhode Island, island, United States
Rhode Island, island, 15 mi (24 km) long and 5 mi (8 km) wide, S R.I., at the entrance to Narragansett Bay. It is the largest island in the state, with steep cliffs and excellent beaches. . (42) Several studies have reported that 56 to 81% of patients present for initial care with CD4+ cell counts already below 500/[micro]L, and 23 to 30% with counts < 200/[micro]L. (36,42) Based on viral load viral load
The concentration of a virus, such as HIV, in the blood.
n a measure of the number of virus particles present in the bloodstream, expressed as copies per milliliter. set points (43) and rates of CD4+ cell depletion (44-46) extrapolated from natural history data of untreated HIV disease subjects, approximately 50% of persons presenting to care with CD4+ counts <200 cells/[micro]L have already been infected for a decade or more. (40,47)
Prior research to assess predictors of delayed HIV diagnosis and presentation to medical care in the United States United States, officially United States of America, republic (2005 est. pop. 295,734,000), 3,539,227 sq mi (9,166,598 sq km), North America. The United States is the world's third largest country in population and the fourth largest country in area. has been published from large urban centers, primarily on the East and West coasts. Predictors of delayed presentation to HIV medical care identified by these studies may not be generalized to the South where a larger proportion of infected persons are women, African-American, uninsured or publicly insured, impoverished, and residing in rural communities. The tendency for multiple barriers to exist among individual HIV-infected Southerners and their relative impact are also not fully understood. We report here on the frequency and extent of delayed presentation to HIV medical care and characteristics associated with these delays at a large Birmingham, Alabama HIV/AIDS outpatient clinic that serves both urban and rural Alabama.
The University of Alabama at Birmingham UAB began in 1936 as the Birmingham Extension Center of the University of Alabama. Because of the rapid growth of the Birmingham area, it was decided that an extension program for students who had difficulties which prevented them from studying in Tuscaloosa was needed. (UAB UAB Universitat Autònoma de Barcelona
UAB University of Alabama at Birmingham
UAB Union of Arab Banks
UAB Uzdaroji Akcine Bendrove (Lithuanian: closed stock company
UAB Unix AppleTalk Bridge
UAB Unaccompanied Air Baggage
UAB Until Advised By ) 1917 Outpatient Clinic is an infectious disease Infectious disease
A pathological condition spread among biological species. Infectious diseases, although varied in their effects, are always associated with viruses, bacteria, fungi, protozoa, multicellular parasites and aberrant proteins known as prions. clinic providing primary medical, dental, and palliative care palliative care (paˑ·lē·ā·tiv kerˑ),
n an approach to health care that is concerned primarily with attending to physical and emotional comfort rather , as well as psychosocial psychosocial /psy·cho·so·cial/ (si?ko-so´shul) pertaining to or involving both psychic and social aspects.
Involving aspects of both social and psychological behavior. , research protocols, and ancillary services to HIV-infected persons. Upon presentation to care, demographic, clinical, and patient tracking information is obtained and entered into an electronic database including risk factors for HIV-infection, HIV-related symptoms and diseases, prior ART use or OI prophylaxis, and former or current non-HIV related medical conditions See carpal tunnel syndrome, computer vision syndrome, dry eyes and deep vein thrombosis. . All information is self-reported and, when available, verified by patient medical records received from prior care sources. Information from each visit to the 1917 Outpatient Clinic is added to the database including CD4+ cell counts and viral load quantification.
HIV-infected persons with no reported history of prior HIV medical care and who initiated primary care at the 1917 Outpatient Clinic between January 1, 1996, and January 24, 2005, were considered eligible for these analyses. Among 2,656 persons, excluded were 622 (23.4%) patients with a history of prior HIV medical care elsewhere, defined as those with prior ART or OI prophylaxis histories, and 825 (31.1%) who were being seen for nonprimary HIV medical care reasons only (eg, dental clinic, research protocols, addiction counseling). Information regarding prior HIV medical care in which ART or OI prophylaxis was not prescribed was not consistently available. The final sample included 1,209 eligible patients. The UAB Institutional Review Board (IRB IRB
See: Industrial Revenue Bond ) reviewed and approved the current study.
Outcome and Factors of Interest
The outcome of interest was delayed presentation to HIV medical care, defined as persons presenting for initial care at the 1917 Outpatient Clinic with CDC-defined AIDS according to according to
1. As stated or indicated by; on the authority of: according to historians.
2. In keeping with: according to instructions.
3. the 1993 expanded AIDS-surveillance case definition; specifically, persons presenting with a CD4+ cell count <200 cells/[micro]L and/or with an AIDS-defining disease AIDS-defining disease A disease which, when accompanied by evidence of HIV infection, fulfills the criteria necessary to diagnose AIDS PCP, MAC, AIDS dementia complex, AIDS wasting syndrome, Kaposi's sarcoma, CMV retinitis. . (48) Persons presenting for initial medical care before the onset of CDC-defined AIDS were considered nondelayers. Characteristics of interest included race/ethnicity, sex, age, insurance status, HIV risk exposure group, time since HIV diagnosis, area of residence, distance to clinic in miles, pregnancy at baseline among females, and history of other STDs, diabetes, cardiovascular diseases, non-HIV-related cancer, or mental illness, and year of presentation to care. Year of presentation to care was pertinent to the assessment of time-related trends.
Differences between delayers and nondelayers were compared for epidemiologically relevant categorical and continuous variables using chi-square and t tests, respectively. To account for the cross-sectional study cross-sectional study
See synchronic study.
n the scientific method for the analysis of data gathered from two or more samples at one point in time. design, crude and adjusted prevalence ratios (PR) and 95% confidence intervals (95% CI) were obtained using multivariable regression techniques, specifically PROC (language) PROC - The job control language used in the Pick operating system.
["Exploring the Pick Operating System", J.E. Sisk et al, Hayden 1986]. GENMOD regression procedures for binomially distributed variables (SAS Institute SAS Institute Inc., headquartered in Cary, North Carolina, USA, has been a major producer of software since it was founded in 1976 by Anthony Barr, James Goodnight, John Sall and Jane Helwig. , Inc., SAS (1) (SAS Institute Inc., Cary, NC, www.sas.com) A software company that specializes in data warehousing and decision support software based on the SAS System. Founded in 1976, SAS is one of the world's largest privately held software companies. See SAS System. Version 9.0, Cary, NC). Based upon crude analyses, categories for several variables were collapsed in adjusted analyses. The final model included characteristics significantly associated with delayed presentation to care, as well as nonsignificant non·sig·nif·i·cant
1. Not significant.
2. Having, producing, or being a value obtained from a statistical test that lies within the limits for being of random occurrence. characteristics identified as predictors in prior studies elsewhere. Due to the common concern for results to differ within demographic subgroups, we evaluated the consistency of overall results by stratifying on race/ethnicity (white/non-Hispanic, black/non-Hispanic), sex, and age (< 25, [greater than or equal to] 25 yr). To increase statistical efficiency, stratified stratified /strat·i·fied/ (strat´i-fid) formed or arranged in layers.
Arranged in the form of layers or strata. analysis models were restricted to significant predictors identified using backward elimination procedures.
The average age at initial presentation to care among 1,209 patients was 37.0 years (SD [+ or -] 9.5; range: 19 to 68); 75% were men. By race/ethnicity, 48.6% were black/non-Hispanic and 46.3% were white/non-Hispanic (hereafter referred to as blacks and whites), with blacks accounting for 42.0% of men and 69.1% of women. Overall, 498 (41.2%) patients presented for initial care with CDC-defined AIDS; among these, 267 (53.6%) had been diagnosed with HIV in the year preceding their entry to care. The median delay from HIV diagnosis to presentation for care was 91.5 days. Log viral load was higher among delayed presenters than nondelayed presenters to care (4.7 versus 3.8 copies/mL, respectively; P < 0.001). Male sex, age 25 years or older, insured by Medicare or Medicaid, presentation within six months or more than five years after HIV diagnosis, and history of diabetes were each associated with delayed presentation to care in bivariate bi·var·i·ate
Mathematics Having two variables: bivariate binomial distribution.
Adj. 1. analyses (Table 1). Stratified bivariate analyses indicated differences between whites and blacks in the nature and/or magnitude of the associations of several of these variables, most notably year of presentation to care, gender, age, time since HIV diagnosis, and history of diabetes.
No statistically significant time-related trends were observed in multivariable regression analyses. Log viral load was not included in regression analyses to avoid multicollinearity and instability in the parameter estimates. In addition, history of other STDs, cardiovascular diseases, and non-HIV-related cancer were not significantly associated with delayed presentation and therefore were excluded from the final model. Presenting between 2002 and 2005 (PR = 1.3), male sex (PR = 1.7), age >25 years (25-34 yr PR = 2.3; 35-44 yr PR = 2.5; [greater than or equal to]45 yr PR = 2.1), insured by Medicare or Medicaid (PR = 1.8), and presentation within six months of HIV diagnosis (PR = 1.3) were each independently associated with delayed presentation to care (See Table 2 for referent ref·er·ent
A person or thing to which a linguistic expression refers.
Noun 1. referent - something referred to; the object of a reference groups and 95% confidence intervals). A history of mental illness was associated with a decreased likelihood of delayed care (PR = 0.7). Findings did not differ when nonsignificant predictors were excluded from our multivariate models.
Stratified analyses indicated differences by demographic characteristics. Among whites, a trend with increasing age, presentation within six months of initial diagnosis, or presentation more than five years after HIV diagnosis were each associated with delayed presentation to care, while among blacks, recent presentation to care and male sex were associated with delayed care (Table 3). Among women, a history of mental illness was associated with reduced likelihood of delayed care, while among men, history of diabetes was associated with delayed presentation to care (Table 4). Among those younger than 25, black race/ethnicity and recent presentation to care were associated with increased likelihood of delayed presentation to care, while among those age 25 years or older, history of mental illness was associated with reduced likelihood of delayed care (Table 5).
We found that 41.2% of persons presented to our clinic for initial medical care having already progressed to CDC-defined AIDS. Among those presenting to care with CDC-defined AIDS, 267 (53.6%) had been diagnosed with HIV in the year preceding their entry to care, which points to the critically important need to identify infected persons much earlier in the course of their disease. CDC-defined AIDS at presentation to care was particularly common among persons presenting in more recent years--after 2002, men, persons aged 25 or older, patients with Medicare or Medicaid insurance, and those presenting within six months of their first HIV-positive test. Although we observed no overall differences by race in time to presentation to care, younger blacks were four times more likely to delay care than younger whites.
The proportions of persons who delayed care for more than one year (34.1%) or more than five years (17.7%) following their initial HIV diagnosis were similar to results reported in Boston and Providence, Rhode Island
“Providence” redirects here. For other uses, see Providence (disambiguation).
Providence is the capital and the most populous city of the U.S. . (42) Patients presenting to initial medical care with CDC-defined AIDS tended to cluster into two mutually exclusive Adj. 1. mutually exclusive - unable to be both true at the same time
incompatible - not compatible; "incompatible personalities"; "incompatible colors" groups: those presenting soon after a recent HIV diagnosis and those first diagnosed with HIV many years earlier who failed to initiate care for a prolonged period. Among both of these groups, the onset of HIV-related symptoms or illness likely prompted individuals to receive care. However, those in the latter group had an opportunity to access and establish medical care before advanced disease progression. Thus, a distinctly different set of characteristics may be associated with delayed presentation to care for each of these two groups. Studies specifically designed to identify these distinct differences are needed to confirm and further understand these differences not only within the South but throughout the United States. The observed magnitude of clinical AIDS among those accessing care within six months of initial HIV testing suggests that substantial diagnostic delay occurred in our patient population, with approximately 50% of these HIV and AIDS patients being infected for a decade or more before being diagnosed. (40,47) Interventions that promote increased HIV test-seeking behavior and knowledge of serostatus, such as those described in the CDC Serostatus Approach to Fighting the HIV Epidemic (SAFE) initiative, (49) may yield substantial public health and clinical benefits in our patient population and possibly throughout the South.
Our observations that delayed presentation occurred disproportionately among men and persons living in poverty, as indicated by public insurance, are consistent with findings from other studies in other geographic regions of the United States. (40,50-54) The absence of racial differences and delayed presentation to care in our study contrasts with the increased delays reported by others among African-Americans. (55-60) This discrepancy may be due to selection bias in our study. Despite the relative heterogeneity of the 1917 Outpatient Clinic patient population, a large proportion of HIV-infected African Americans and infected persons who relied on public funding Public funding is money given from tax revenue or other governmental sources to an individual, organization, or entity. See also
Few prior studies were large enough to assess the role of other chronic conditions, like diabetes, overall and among subgroups. We postulated pos·tu·late
tr.v. pos·tu·lat·ed, pos·tu·lat·ing, pos·tu·lates
1. To make claim for; demand.
2. To assume or assert the truth, reality, or necessity of, especially as a basis of an argument.
3. that an existing connection to the medical community as a result of a pre-existing condition would reduce delays in being diagnosed and accessing care. What we observed were clear gender-related differences. Among women, pregnancy and a history of mental illness were associated with reduced likelihood of presenting with CDC-defined AIDS; that tendency seemed to confirm our hypothesis. However, diabetic men experienced delayed presentation to HIV care; that observation was opposite to our prior hypothesis. Although these results may have resulted by chance from multiple data comparisons, the association between diabetes and delayed care in men merits further investigation for several reasons. Blood monitoring by medical providers is a standard component of diabetic medical care and disease management. HIV-positive persons receiving diabetic medical care might therefore be expected to have more opportunities for HIV testing, and through their established connection to the medical community, an increased likelihood of successfully accessing HIV care. However, symptoms associated with HIV, such as weight loss, pneumonia, and thrush thrush, in medicine
thrush, in medicine, infection caused by the fungus Candida albicans, manifested by white, slightly raised patches on the mucous membrane of the tongue, mouth, and throat. , are conditions that may be categorized cat·e·go·rize
tr.v. cat·e·go·rized, cat·e·go·riz·ing, cat·e·go·riz·es
To put into a category or categories; classify.
cat as diabetic complications. Medical providers of diabetic patients may be more likely to consider these as diabetic complications and not recognize the need for HIV testing. Alternatively, our results may simply be another reflection that men are less connected to the medical care system. This observation is supported by the tendency for women in our population with other medical conditions to be less likely to present with CDC-defined AIDS. Studies specifically designed to assess other medical conditions, in particular diabetes, and their influence on timely HIV diagnosis and presentation to medical care are needed to confirm that the current results did not occur by chance alone.
In our study, persons aged 25 or older were more likely than younger individuals to present to care with CDC-defined AIDS. That finding contrasts with the belief that persons of younger age are at increased risk of delayed diagnosis (52,61) and delayed medical care. (62) Our results may simply reflect more recent seroconversion seroconversion /se·ro·con·ver·sion/ (-con-ver´zhun) the change of a seronegative test from negative to positive, indicating the development of antibodies in response to immunization or infection. and less progression to clinical AIDS among persons younger than 25. Our analyses stratified by age indicated that young men and young African-Americans may experience increased delays accessing HIV care when compared with their young female and young white counterparts. Prior studies have reported inconsistent results with regard to the effect of age on delayed HIV care. (39,40,51,54,63) The inconsistencies of age-related assessments may indicate true study population differences, or they may raise questions about internal validity Internal validity is a form of experimental validity . An experiment is said to possess internal validity if it properly demonstrates a causal relation between two variables  . . The more pronounced age effect we observed among women than men may be consistent with prior results from elsewhere. One possible explanation is that for these women, the primary risk factors are attributable to their male sexual partners, and therefore are not necessarily modifiable, or even identifiable, by the women at risk. Alternatively, women, particularly those with children, (41,53,64) may defer their own medical needs. (32,41,52,65,66)
Our study had several limitations that could have influenced the findings. Selection bias may have distorted our assessments of race/ethnicity, insurance, and HIV risk exposure group. The cross-sectional study design limited our ability to assess temporal relationships and to adjust for time. In regard to the latter, spurious conclusions could result by varying stages of the epidemic within subpopulations, for example, whites versus blacks and men versus women. Misclassification was also possible. Although 23.4% of persons were excluded for having prior ART or OI prophylaxis, some patients with other forms of prior HIV medical care may have been included and our estimate of persons presenting to care with CDC-defined AIDS may be inflated. Similarly, recall bias and socially desirable reporting may have occurred with self-reported variables. Missing data for education, income, tobacco use, and alcohol use limited our ability to assess these variables. The current analysis was also limited to clinical and demographic variables. Other potential predictors, such as the effects of disclosing HIV status, social support, HIV knowledge and awareness, and religious affiliation, could not be assessed. We were also unable to account for rate of disease progression. Because delayed presentation to care was defined using clinical measures, a disproportionate prevalence of rapid progressors could have introduced information bias. Finally, multiple comparisons across our data may have led to chance associations, particularly in the results of stratified analyses.
Certain valuable aspects of the current study are worth highlighting. Despite the disproportionate burden of the HIV/AIDS epidemic in the southern United States, particularly recently, this is one of very few studies that have focused on delayed HIV medical care in our region. Our study population provided sufficient power to assess several characteristics that smaller studies could not assess, and to detect associations that were not uniformly distributed among epidemiologically important subgroups. In the face of multiple barriers to HIV diagnosis and care in individual HIV-infected Southerners, the ability to identify these relationships is essential and raises the encouraging prospect of further informative work in this setting.
Southern medical care providers and the research and public health communities would benefit from more deliberate attention to delayed HIV diagnosis and medical care. Most needed are interventions that effectively increase HIV risk awareness and the availability of HIV testing and HIV medical care, particularly among men. Recent FDA FDA
Food and Drug Administration
n.pr See Food and Drug Administration.
n.pr the abbreviation for the Food and Drug Administration. approval of rapid HIV testing strategies yielding results within the same hour (67) could certainly increase the proportion of persons receiving an early diagnosis (68); however, the utility of these testing procedures depends upon their local availability and accessibility, and on individual awareness of these types of tests. Making HIV testing a routine part of medical care, as described in the CDCs Advancing HIV Prevention initiative, (67) could also increase knowledge of serostatus among infected persons. The benefits conferred by routinely recommended testing are dependent on access to general medical care and may vary among subgroups, particularly by gender. Finally, US federal legislation may help address poverty-related barriers. As of 2000, all Ryan White Care Act The Ryan White Comprehensive AIDS Resources Emergency (CARE) Act (Ryan White Care Act, Ryan White, Pub.L. 101-381, 104 Stat. 576, enacted 1990-08-18) was an Act of the U.S. grantees have been required to respond to an "unmet need" defined as "HIV positive individuals that are aware of their status and not receiving regular medical care." (69) The Early Treatment for HIV Act The Early Treatment for HIV Act (or ETHA) (S. 860 is a bill introduced in the U.S. Senate on March 13, 2007. Sponsored by Senator Gordon Smith (R-OR) and Hillary Clinton (D-NY) with 30 cosponsors, the bill is currently in committee. (ETHA ETHA Early Treatment for HIV Act
ETHA East Texas Historical Association
ETHA Erythromelalgia ), which is still pending as of early 2005 (Bill number S. 311; status confirmed on October 3, 2005 at http://thomas.loc.gov), is intended to provide the option for states to cover low-income HIV-infected persons before developing disability. (70) Southern states Southern States
government of 11 Southern states that left the Union in 1860. [Am. Hist.: EB, III: 73]
popular name for Southern states in U.S. and for song. [Am. Hist. may disproportionately benefit from ETHA compared with other regions of the country, given the high prevalence of state-based Medicaid and AIDS Drug Assistance Program (ADAP ADAP AIDS Drug Assistance Program
ADAP Alcohol and Drug Awareness Program
ADAP Agricultural Development in the American Pacific
ADAP Airport Development Aid Program
ADAP Advanced Digital Antenna Production ) restrictions. (71)
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Defect in immunity that impairs the body's ability to resist infection. The immune system may fail to function for many reasons. Immune disorders caused by a genetic defect are usually evident early in life. virus-associated opportunistic infections Opportunistic infections
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One of the two main types of nucleic acid (the other being DNA), which functions in cellular protein synthesis in all living cells and replaces DNA as the carrier of genetic and the risk of perinatal perinatal /peri·na·tal/ (-na´t'l) relating to the period shortly before and after birth; from the twentieth to twenty-ninth week of gestation to one to four weeks after birth.
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Any of various enzymes, including the proteinases and peptidases, that catalyze the hydrolytic breakdown of proteins. and nonnucleoside reverse transcriptase inhibitors nonnucleoside reverse transcriptase inhibitor AIDS Any of the antiretroviral–ie, anti-HIV agents–eg, delavirdine and nevirapine which inhibit viral nonnucleoside reverse transcriptase and are combined with nucleoside RTIs to manage HIV infection. . J Virol 1997;71:6271-6275.
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18. Kreiss JK, Coombs Coombs can refer to:
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Christopher S. Krawczyk, PHD, Ellen Funkhouser, MS, DRPH, J. Michael Kilby, MD, Richard A. Kaslow, MD, MPH, Amita K. Bey, MPH, and Sten H. Vermund, MD, PHD
From the University of Alabama at Birmingham Schools of Public Health and Medicine, Birmingham, AL.
Reprint requests to Christopher S. Krawczyk, PhD, Office of AIDS, California Department of Health Services Department of Health Services may refer to:
Christopher S. Krawczyk, PhD, is now affiliated with the California Department of Health Services, Office of AIDS. Sten H. Vermund, MD, PhD, is now affiliated with Vanderbilt University Vanderbilt University, at Nashville, Tenn.; coeducational; chartered 1872 as Central Univ. of Methodist Episcopal Church, founded and renamed 1873, opened 1875 through a gift from Cornelius Vanderbilt. Until 1914 it operated under the auspices of the Methodist Church. School of Medicine.
Supported in part through National Institutes of Health (NIH "Not invented here." See digispeak.
NIH - The United States National Institutes of Health. ) grants to the University of Alabama at Birmingham (UAB): Acute Infection and Early Disease Research Program (AI41530), UAB Center for AIDS Research (5P30AI027767-18), UAB General Clinical Research Center (M01 RR-00032).
Accepted January 25, 2006.
RELATED ARTICLE: Key Points
* Nearly half of all subjects (41.2%) first engaged with an HIV medical provider after they had already progressed to CDC-defined AIDS.
* Among these, 53.6% had received their initial HIV diagnosis in the year preceding entry to care, indicating substantial HIV diagnostic delay in our patient population.
* Characteristics associated with delayed presentation to care included presentation in the most recent time period (2002 to 2005), male sex, age [greater than or equal to] 25 years old, and Medicare or Medicaid insurance coverage.
Table 1. Comparison of patient characteristics at presentation to care, by status of CDC-defined AIDS: Birmingham, AL, 1996-2005 (a) Patients presenting to care with CDC-defined AIDS All n Characteristic n (%) (b) Sample 1209 498 (41.2) Mean log viral load 4.2 (1.2) 4.7 (1.2) ([+ or -] SD) P value (d) <0.001 Race/Ethnicity 1209 White/non-Hispanic 560 226 (40.4) Black/non-Hispanic 588 250 (42.5) Other 20 7 (35.0) Unspecified 41 15 (36.6) P value (d) 0.7 Year 1996-1998 489 198 (40.5) 1999-2001 380 154 (40.5) 2002-2005 337 146 (43.3) P value (d) 0.7 Gender Male 904 397 (43.9) Female 301 100 (33.2) P value (d) 0.001 Age, years < 25 102 24 (23.5) 25-34 401 166 (41.4) 35-44 466 207 (44.4) [greater than or equal to] 240 101 (42.1) 45 P value (d) 0.002 Insurance status Private 455 178 (39.1) Medicare or Medicaid 336 167 (49.7) Ryan White Care Act 185 70 (37.8) Private & public (e) 106 46 (43.4) None or unspecified 124 37 (29.8) P value (d) 0.002 Risk exposure group Heterosexual 329 131 (39.8) MSM 432 200 (46.3) IDU 72 31 (43.1) MSM & IDU 27 11 (40.7) Other or unspecified 349 125 (35.8) P value (d) 0.1 Time since HIV diagnosis 0-6 months 584 254 (43.5) 7-12 months 44 13 (29.6) > 1-2 years 66 22 (33.3) > 2-5 years 130 54 (41.5) > 5 years 214 102 (47.7) Unspecified 171 53 (31.0) P value (d) 0.006 Area of Residence Alabama MSA 836 342 (40.9) Alabama non-MSA 312 135 (43.3) Out of state 57 21 (36.8) P value (d) 0.6 Distance to clinic (miles) [less than or equal to] 5 541 228 (42.1) miles 6-19 139 68 (48.9) 20-49 112 43 (38.4) 50-99 204 70 (34.3) [greater than or equal to] 204 85 (41.7) 100 P value (d) 0.09 Pregnancy (among females) 26 5 (19.2) No 270 93 (34.4) P value (d) 0.1 History of other STDs 251 106 (42.2) No 958 392 (40.9) P value (d) 0.7 History of diabetes 34 20 (58.8) No 1175 478 (40.7) P value (d) 0.03 History of CVD 158 66 (41.8) No 1051 432 (41.1) P value (d) 0.9 History of cancer 20 6 (30.0) No 1189 492 (41.4) P value (d) 0.3 History of mental illness 145 55 (37.9) No 1064 443 (41.6) P value (d) 0.4 Patients presenting to care with CDC-defined AIDS White n Black n Characteristic (%) (c) (%) (c) Sample 226 250 Mean log viral load 4.6 (1.3) 4.8 (1.1) ([+ or -] SD) P value (d) <0.001 <0.001 Race/Ethnicity White/non-Hispanic 226 - Black/non-Hispanic - 250 Other - - Unspecified - - P value (d) Year 1996-1998 110 (43.8) 83 (36.4) 1999-2001 62 (36.1) 79 (43.9) 2002-2005 54 (39.7) 88 (49.2) P value (d) 0.3 0.03 Gender Male 200 (41.4) 182 (47.9) Female 26 (33.8) 68 (32.7) P value (d) 0.2 <0.001 Age, years < 25 5 (15.6) 19 (29.7) 25-34 64 (35.4) 95 (45.9) 35-44 102 (42.9) 96 (47.5) [greater than or equal to] 55 (50.5) 40 (34.8) 45 P value (d) 0.002 0.02 Insurance status Private 95 (40.3) 74 (37.8) Medicare or Medicaid 68 (51.9) 92 (49.7) Ryan White Care Act 29 (33.7) 36 (41.4) Private & public (e) 18 (36.0) 27 (51.9) None or unspecified 16 (28.6) 21 (31.8) P value (d) 0.02 0.03 Risk exposure group Heterosexual 37 (45.1) 86 (38.4) MSM 117 (43.2) 75 (52.8) IDU 15 (44.1) 16 (44.4) MSM & IDU 9 (39.1) 1 (33.3) Other or unspecified 46 (33.6) 62 (37.8) P value (d) 0.09 0.1 Time since HIV diagnosis 0-6 months 121 (45.5) 123 (41.7) 7-12 months 4 (19.1) 9 (47.4) > 1-2 years 9 (34.6) 13 (34.2) > 2-5 years 24 (36.9) 26 (44.8) > 5 years 52 (49.5) 46 (49.5) Unspecified 16 (20.8) 33 (38.8) P value (d) <0.001 0.6 Area of Residence Alabama MSA 136 (39.8) 191 (42.4) Alabama non-MSA 78 (44.3) 53 (43.1) Out of state 12 (30.8) 6 (40.0) P value (d) 0.3 0.9 Distance to clinic (miles) [less than or equal to] 5 81 (42.2) 140 (42.7) miles 6-19 34 (50.0) 32 (49.2) 20-49 24 (34.8) 16 (43.2) 50-99 40 (35.4) 27 (34.6) [greater than or equal to] 45 (39.8) 33 (42.9) 100 P value (d) 0.3 0.5 Pregnancy (among females) 1 (25.0) 4 (20.0) No 25 (34.3) 62 (33.9) P value (d) 1.0 0.3 History of other STDs 47 (39.5) 54 (45.8) No 179 (40.6) 196 (41.7) P value (d) 0.8 0.4 History of diabetes 7 (70.0) 13 (56.5) No 219 (39.8) 237 (42.0) P value (d) 0.09 0.2 History of CVD 31 (49.2) 33 (39.8) No 195 (39.2) 217 (43.0) P value (d) 0.1 0.6 History of cancer 3 (21.4) 3 (50.0) No 223 (40.8) 247 (42.4) P value (d) 0.1 0.7 History of mental illness 33 (39.8) 21 (36.2) No 193 (40.5) 229 (43.2) P value (d) 0.9 0.3 (a) Patients with missing information included: Gender (n = 4), insurance status (n = 3), area of residence (n = 4), distance to clinic (n = 7), and pregnancy (n = 5). (b) Row percent where denominator is the row value given under "n." (c) Row percent where denominator is the number of white/black patients with row characteristic. (d) Comparison of characteristic levels for a difference between delayed and nondelayed presenters to HIV medical care. (e) Private insurance and Medicare, Medicaid, or Ryan White Care Act. CDC, Centers for Disease Control and Prevention; AIDS, acquired immunodeficiency syndrome; MSM, men who have sex with men; IDU, intravenous drug user; MSA, metropolitan statistical area; STDs, sexually transmitted diseases; CVD, cardiovascular disease. Table 2. Crude and adjusted associations of delayed presentation to initial HIV medical care: Birmingham, AL, 1996-2005 Crude Adjusted (a) Adjusted (a) Characteristic PR PR 95% CI Year (vs. 1996-1998) 1999-2001 1.0 1.0 (0.7,1.3) 2002-2005 1.1 1.3# (1.0,1.8)# Race/Ethnicity (vs. white/non-Hispanic) Black/non-Hispanic 1.1 1.1 (0.9,1.5) Other or unspecified 0.9 0.9 (0.5,1.7) Male sex (vs. female) 1.3 1.7# (1.2,2.3)# Age, years (vs. <25) 25-34 1.8 2.3# (1.4,3.8)# 35-44 1.9 2.5# (1.5,4.1)# [greater than or equal to] 45 1.8 2.1# (1.2,3.6)# Insurance status (vs. private) Medicare or Medicaid 1.3 1.8# (1.3,2.4)# Other or unspecified (b) 0.9 1.0 (0.7,1.3) Risk exposure group (vs. heterosexual) MSM 1.2 1.2 (0.8,1.7) Other or unspecified (c) 0.9 1.0 (0.7,1.4) Time since HIV diagnosis (vs. 7-60 months) 0-6 months 1.2 1.3# (1.0,1.9)# > 5 years 1.3 1.4 (0.9.2.1) Unspecified 0.8 0.7 (0.5,1.2) Area of Residence (vs. Alabama MSA) Alabama non-MSA 1.1 1.2 (0.8,1.7) Out of state 0.9 1.1 (0.6,2.2) Distance to clinic, miles (vs. [less than or equal to] 5) 6-19 1.2 1.3 (0.8,2.0) 20-99 0.9 0.8 (0.5,1.3) [greater than or equal to] 100 0.9 0.8 (0.6,1.1) Pregnancy, among females (vs. no) 0.6 0.4 (0.1,1.1) History of diabetes (vs. no) 1.4 1.8 (0.9,3.7) History of mental illness (vs. no) 0.9 0.7# (0.5,1.0)# Numbers in bold represent P value < 0.05. (a) Model adjusted for all variables listed in Table 2. (b) Includes Ryan White Care Act, combined private and public, none, and unspecified. (c) Includes IDU, IDU and MSM, other, and unspecified. PR, prevalence ratio; CI, confidence interval; MSM, men who have sex with men; IDU, intravenous drug user; MSA, metropolitan statistical area. Note: Represent P value < 0.05 indicated with #. Table 3. Adjusted associations of delayed presentation to initial HIV medical care, stratified by race/ethnicity: Birmingham, AL, 1996-2005 (a) White/non-Hispanic Black/non-Hispanic (n = 560) (n = 588) Characteristic PR 95% CI PR 95% CI Year (vs. 1996-1998) 1999-2001 0.7 (0.4, 1.0) 1.2 (0.8, 1.8) 2002-2005 0.9 (0.5, 1.4) 2.0 (1.3, 3.1) Male sex (vs. female) 1.3 (0.8, 2.3) 2.2 (1.5, 3.2) Age, years (vs. < 25) 25-34 2.8 (1.0, 7.6) 2.2 (1.2, 4.1) 35-44 3.7 (1.4, 10.3) 2.1 (1.1, 3.9) [greater than or equal to] 45 4.9 (1.7, 14.1) 1.1 (0.5, 2.1) Time since HIV diagnosis (vs. 7-60 mos) 0-6 months 1.8 (1.1, 3.0) 1.1 (0.7, 1.8) > 5 years 1.8 (1.0, 3.3) 1.2 (0.7, 2.1) Unspecified 0.6 (0.3, 1.2) 0.8 (0.4, 1.4) (a) Model adjusted for variables listed and insurance status and history of diabetes. PR, prevalence ratio; CI, CI, confidence interval; mos, months. Table 4. Adjusted associations of delayed presentation to initial HIV medical care, stratified by sex: Birmingham, AL, 1996-2005 (a) Male (n = 904) Female (n = 301) Characteristic PR 95% CI PR 95% CI Age [greater than or equal to] 25 2.0 (1.1, 3.5) 3.6 (1.3, 9.9) (vs. < 25) Time since HIV diagnosis (vs. 7-60 mos) 0-6 months 1.4 (0.9, 2.0) 1.4 (0.7, 2.8) > 5 years 1.2 (0.8, 1.8) 2.8 (1.2, 6.7) Unspecified 0.8 (0.5, 1.2) 0.6 (0.2, 1.8) History of diabetes (vs. no) 2.8 (1.1, 7.6) 0.9 (0.2, 3.0) History of mental illness (vs. no) 0.8 (0.5, 1.3) 0.4 (0.2, 0.8) (a) Model adjusted for variables listed and year presented to HIV care, insurance status, and distance to clinic. PR, prevalence ratio; CI, confidence interval; mos, months Table 5. Adjusted associations of delayed presentation to initial HIV medical care, stratified by age: Birmingham, AL, 1996-2005 (a) < 25 years of age [greater than or equal to] (n = 102) 25 years of age (n = 1107) Characteristic PR 95% CI PR 95% CI Year (vs. 1996-1998) 1999-2001 0.6 (0.1, 3.0) 1.0 (0.7,1.3) 2002-2005 3.5 (1.0,12.8) 1.2 (0.9,1.6) Race/ethnicity (vs. white/non-Hispanic) Black/non-Hispanic 4.3 (1.1,16.4) 1.1 (0.9,1.5) Other or unspecified 0.0 (0.0, 0.9 (0.5,1.7) [infinity]) Male sex (vs. female) 4.5 (1.2,16.0) 1.7 (1.2,2.3) History of mental 2.5 (0.4,13.9) 0.7 (0.5,1.0) illness (vs. no) (a) Model adjusted for variables listed and insurance status, time since HIV diagnosis, and history of diabetes. PR, prevalence ratio; CI, confidence interval.