CATIE News

9 April 2019 

Missed opportunities for early HIV diagnosis in British Columbia

  • British Columbia researchers say many cases of HIV are being diagnosed late
  • A new study reviewed health information of 2,119 people diagnosed with HIV
  • 14% had reported HIV-related symptoms up to five years prior to diagnosis

Well-designed clinical trials have found that early initiation of HIV treatment (ART) is associated with a significantly reduced risk of serious health complications, both related and unrelated to AIDS. Furthermore, ART can reduce the amount of HIV in the blood (the viral load) to very low levels commonly called “undetectable.” Continued use of ART exactly as prescribed and directed helps to maintain this very low level of HIV in the blood, which also has another benefit: Clinical trials have found that ART users who maintain an undetectable level of HIV in their blood do not pass on the virus to their sexual partners.

These twin benefits of ART—overall health and prevention of sexual transmission—are so transformative that the Joint United Nations Program on HIV/AIDS (UNAIDS) has set goals for cities, regions and countries to meet by 2020; these goals are commonly shortened to 90-90-90:

  • 90% of people with HIV will be diagnosed
  • 90% of people diagnosed will receive continuous ART
  • 90% of people taking ART will have an undetectable viral load

To achieve the first of these goals, widespread and convenient access to an offer of HIV testing and counselling is necessary. However, some people may not realize that they are at risk for HIV infection and may decline to be tested. Also, some healthcare providers may not be aware that some of their patients who seek medical care may need HIV testing. These missed opportunities for HIV testing within a city, region or country may hamper efforts to diagnose HIV early in the course of infection and to achieve UNAIDS’ 90-90-90 goals.

In 2017, researchers in British Columbia found that “nearly a quarter” of people who had HIV were diagnosed relatively late in the course of HIV disease, when their immune systems were very weak.

Missed opportunities

To gain an understanding of gaps in HIV testing among people with health conditions who had not received an HIV diagnosis within 30 days of seeking medical care, researchers in B.C. conducted an analysis of several databases that collected health-related information. The team was made up of members from the BC Centre for Excellence in HIV/AIDS, the University of British Columbia, the Ministry of Health and Vancouver Coastal Health. They focused on the period between 2001 and 2014, when data were collected from 2,119 people. They found that 298 (14%) of these people who were subsequently diagnosed with HIV (in some cases, between one and five years after they first sought care) initially had one or more of the following problems:

  • recurrent pneumonia
  • anemia
  • shingles (herpes zoster) in young adults
  • oral yeast infections

Furthermore, these health conditions were relatively common among sub-groups of people (detailed later in this bulletin). The B.C. study is important and underscores that much work lies ahead to expand opportunities for HIV testing so that swift referral to care and treatment can occur in cases of positive test results.

Study details

The researchers analysed information from several databases containing health-related data on 2,119 HIV-positive people. Their average profile upon entry to the database was as follows:

  • 82% men, 18% women
  • a majority (53%) were aged 40 or older
  • 75% were gay, bisexual or other men who have sex with men (MSM), or people who injected street drugs, or both categories
  • 75% lived in an urban area

Result

The researchers’ analysis found that the following diagnoses were made in the case of 14% of people:

  • recurrent pneumonia
  • anemia related to a deficiency of iron, vitamin B12 or other nutrients
  • shingles (herpes zoster) in young people
  • disorders of the lymphatic system
  • oral yeast infections

These 298 people were not diagnosed with HIV within 30 days of their initial medical care visit. In some cases, a diagnosis of HIV was not made until five years after that initial visit.

A closer look

Researchers also found that these 298 people were more likely than people who had been diagnosed early to have the following features:

  • age 50 years or more
  • injected street drugs at some point in their past
  • identify as heterosexual
  • reside in the Northern health authority region of B.C.

Bear in mind

The Public Health Agency of Canada (PHAC) estimates that about 14% of people with HIV in Canada are not aware of their infection status. The findings from B.C. underscore that undiagnosed HIV infection remains an issue, even among people who seek medical care because of illness.

The B.C. researchers stated:

“While addressing missed opportunities for earlier diagnosis through increased testing in healthcare settings is a valuable strategy in reducing late diagnosis, individuals who do not present to care (e.g. those without symptoms of HIV disease; those experiencing barriers to care) continue to be overlooked and contribute to late diagnosis in the absence of complementary interventions.”

The B.C. study is retrospective in design; that is, it reviewed data that was collected in the past for one reason and subsequently analysed the data for a different reason. Such retrospective analyses can sometimes cause researchers to inadvertently draw biased conclusions. However, a study of a different design would be expensive and the findings from the B.C. study make intuitive sense.

The results from the B.C. study will hopefully enhance efforts to help that province reach UNAIDS’ 90-90-90 goals.

—Sean R. Hosein

REFERENCE:

Nanditha NGA, St-Jean M, Tafessu H, et al. Missed opportunities for earlier diagnosis of HIV in British Columbia, Canada: A retrospective cohort study. PLoS One. 2019 Mar 21;14(3):e0214012.

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