CAPE TOWN, South Africa — There are significant differences in the demographics of patients who have late presentation of HIV infection and those diagnosed earlier in the disease process, doctors reported here.

• In areas of low prevalence, where HIV may not be the first diagnosis that comes to mind, doctors should remember that older individuals and women may have HIV infection especially if they are from a country where HIV is endemic.
• Note that this study was published as an abstract and presented at a conference. These data and conclusions should be considered to be preliminary until published in a peer-reviewed journal.

Of 54 late-presenters, 13 (24%) were women compared with 26 of 251, or about 10% of the non-late group (P<0.01), according to Jurgen van Lunzen, MD, of the Universitatskilinkum Eppendorf in Hamburg, Germany.

“Late presenters tend to be older, they are more often women, and they are from high prevalence countries,” Dr. van Lunzen said in his poster presentation at the 5th International AIDS Society Conference on HIV Pathogenesis, Treatment and Prevention.

“Prevention and testing strategies should try to take this into account,” Dr. van Lunzen said.

He and his colleagues compared 54 late-presenting cases with 251 patients who were diagnosed earlier in the disease process. Most late presenters had an AIDS-defining illness as their first diagnosis, Dr. Van Lunzen said, but also included in the definition were patients with CD4 counts below 100 cells/mm³ and those who had two months or less between diagnosis and start of HAART.

The researchers also discovered that 10 (19%) of the late presenters were from countries where more than 1% of the population is infected with HIV, compared with 18 (7%) of non-late presenters (P<0.01).

The late-presenters also were older — mean age 40.9 compared with 38.1 years (P=0.034).

“We basically found almost the same experience among late presenters,” said Gerrit Schreij, MD, of the University of Maastricht in the Netherlands.

“When we see women and older individuals in our area — which is much the same as western Germany — we just don’t think immediately about HIV or AIDS,” he said. “Consequently our diagnosis of the illness in these people is delayed.”

Dr. Schreij said that often older people in their 50s, 60s and 70s present late in the disease process because HIV infection is not foremost in clinicians’ minds. “Neither the doctor nor the patient is thinking in terms of HIV,” he said.

The researchers reviewed data collected among patients in the extended German Truvada cohort — patients receiving fixed dose combination of emtricitabine and tenofovir.

Despite the late presentation, Dr. van Lunzen said that treatment with combination therapy that included the combination pill plus either a non-nucleoside reverse transcriptase or a protease inhibitor succeeded in reducing HIV to undetectable levels similarly to that achieved among non-late presenters.

In fact, in his study 70% of the late presenters were able to achieve undetectable levels of virus using the assay with 50 copies/ml as the lower limits of detectability compared with 67% of the non-late presenters.

However, at 48 weeks mean CD4-postitive cell counts lagged in the late presenters. The baseline CD4-positive cell count was 64 in the late presenters compared with 237 in the non-late presenters.

By week 48, the late presenters registered a 271 CD4-positive cell count compared with 408 for the non-late presenters.

In addition, during the 48-week treatment period, 12 (22%) of the late presenters experienced an AIDS-defining event compared with 19 or 7.6% of the non-late presenters (P<0.05).

Dr. van Lunzen noted that late presenters were more likely to receive a protease inhibitor-based treatment (96%) than non-late presenters (50%).

Primary source: Conference Progamme 5^th IAS Conference on HIV Pathogenesis, Treatment and Prevention, 19-22 July 2009

Source reference:
Van Lunzen J, et al “Late presentation is frequent in the elderly, in female and in patients from high prevalence countries in a German outpatient cohort,” Conference Progamme 5^th IAS Conference on HIV Pathogenesis, Treatment and Prevention, 19-22 July 2009. P. 49.

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