Factors associated with presenting late or with advanced HIV disease in the Netherlands, 1996-2014 Eline Op de Coul, Ard van Sighem, Kees Brinkman, Birgit van Benthem, Ineke van der Ende, Suzanne Geerlings, Peter Reiss on behalf of the ATHENA national observational HIV cohort 1 NCHIV, 18 November 2014
Background HIV in the Netherlands > 1,000 diagnoses every year Transmission groups 2013: - Sex between men (71%) - Heterosexual contact (23%) HIV diagnoses: 1/3 STI clinic, 1/3 GP, 1/3 hospital Estimate 2012 (poster 41): - 24,350 (20,420-31,280) PLWHA - 34% (22-48%) undiagnosed - MSM: 31% - migrants: 44-48% Risk factors for late presentation 18 Nov 2014
Objective: Study trends in late presentation & advanced HIV disease Identify factors associated with late presentation & advanced disease in HIV-infected patients in the Netherlands Relevance Test-and-Treat (TT) is emerging as global prevention strategy Early testing and referral into care are needed to optimize treatment outcomes and to prevent spread of HIV To inform current efforts to improve HIV testing practices to prevent late presentation and reduce the proportions of undiagnosed. Risk factors for late presentation 18 Nov 2014
Methods Data: HIV-infected patients registered between January 1996 and June 2014, ATHENA observational HIV cohort Trend analyses GIS (Geographical Information System) -analyses Multivariable logistic regression to identify risk factors for: late presentation (CD4 <350/mm 3 or AIDS-defining illness) advanced disease (CD4 <200/mm 3 or AIDS-defining illness) Covariates: gender, age, transmission group, region of origin, probable country infection, residence area, SES, degree of urbanization, location HIV diagnosis Risk factors for late presentation 18 Nov 2014
Results: Characteristics study population HIV patients in care, total (n=20,965, 100%) Late presentation (n=11,182, 53%) Advanced disease (n=7,331, 35%) Transmission category MSM 12,314 (59) 5,717 (51) 3,535 (48) Heterosexual, male 2,940 (14) 1,984 (18) 1,425 (19) Heterosexual, female 3,636 (17) 2,043 (18) 1,300 (18) IDU 701 (3) 475 (4) 336 (5) Median age (IQR) 36 (29 44) 37 (30-45) 38 (31-46) Region of origin The Netherlands 11,913 (57) 5,866 (52) 3,808 (52) SSA 3,201 (15) 2,156 (19) 1,424 (19) Europe, else 2,006 (10) 962 (9) 627 (9) Surinam/Antilles/Car 1,749 (8) 1,011 (9) 668 (9) Location HIV diagnosis STI clinic 2,782 (13) 845 (8) 322 (4) General practitioner 6,468 (31) 3,081 (28) 1,777 (24) Hospital 5,342 (25) 3,592 (32) 2,797 (38) Antenatal screening 346 (2) 175 (2) 85 (1) 5 Median CD4 count Risk factors for late presentation 18 Nov 2014 (cells/mms, IQR) 336 (140-540) 150 (50-270) 80 (30-155)
Results: trends Late presentation declined from 62% in 1996 to 43% in 2013 Risk factors for late presentation 18 Nov 2014
Proportions of late presentation, 2012-2014 Overall MSM
Late presentation Univariable OR (95% CI) Late presentation Multivariable aor (95% CI) Advanced disease Univariable OR (95% CI) Advanced disease Multivariable aor (95% CI) Period of diagnosis <2001 2002 2007 1 0.67 (0.63-0.72) 1 0.63 (0.59-0.68) 1 0.65 (0.61-0.70) 1 0.62 (0.58-0.67) 2008> 0.49 (0.46-0.53) 0.55 (0.51-0.59) 0.46 (0.43-0.50) 0.51 (0.47-0.55) Age [years] <30 0.70 (0.65-0.74) 0.63 (0.59-0.68) 0.64 (0.60-0.68) 0.59 (0.55-0.64) 30-49 1 1 1 1 >50 1.32 (1.22-1.44) 1.46 (1.33-1.60) 1.36 (1.25-1.48) 1.46 (1.33-1.60) Transmission category MSM 1 1 1 1 Heterosexual, male 2.40 (2.20-2.61) 1.59 (1.44-1.75) 2.34 (2.15-2.54) 1.62 (1.47-1.79) Heterosexual, female 1.48 (1.37-1.59) 0.98 (0.89-1.08) 1.38 (1.28-1.49) 1.03 (0.93-1.14) IDU 2.42 (2.06-2.85) 2.00 (1.69-2.38) 2.29 (1.96-2.67) 1.85 (1.57-2.18) Region of origin The Netherlands 1 1 1 1 Europe, else 0.95 (0.86-1.04) 1.13 (0.96-1.32) 0.97 (0.87-1.07) 0.94 (0.83-1.05) SSA 2.13 (1.96-2.31) 2.11 (1.88-2.36) 1.71 (1.58-1.85) 1.64 (1.46-1.84) Surinam 1.63 (1.42-1.87) 1.59 (1.37-1.84) 1.46 (1.27-1.67) 1.37 (1.18-1.60) N. Antilles/Caribbean 1.21 (1.05-1.39) 1.31 (1.13-1.53) 1.17 (1.01-1.36) 1.27 (1.08-1.50) Latin America 1.00 (0.85-1.18) 1.23 (1.04-1.46) 0.95 (0.80-1.13) 1.23 (1.02-1.49) South East Asia 2.00 (1.71-2.35) 2.14 (1.80-2.54) 1.91 (1.64-2.23) 2.07 (1.75-2.45)
Late presentation Univariable OR (95% CI) Late presentation Multivariable aor (95% CI) Advanced disease Univariable OR (95% CI) Advanced disease Multivariable aor (95% CI) Residence (PH region) Amsterdam 1 1 1 1 Zuidoost-Brabant 0.73 (0.62-0.87) 0.68 (0.78-0.82) 0.77 (0.64-0.94) 0.70 (0.57-0.86) West-Brabant 0.78 (0.65-0.95) 0.78 (0.63-0.97) 0.85 (0.69-1.05) 0.85 (0.67-1.06) The Hague 1.05 (0.93-1.18) 0.89 (0.78-1.02) 1.00 (0.88-1.14) 0.83 (0.72-0.96) Groningen 1.28 (1.07-1.54) 1.23 (1.01-1.51) 1.39 (1.16-1.67) 1.30 (1.06-1.60) Rotterdam-Rijnmond 1.22 (1.10-1.34) 1.12 (1.01-1.25) 1.27 (1.15-1.40) 1.16 (1.04-1.29) Location HIV diagnosis STI clinic 1 1 1 1 General practitioner 2.09 (1.90-2.29) 1.66 (1.50-1.83) 2.89 (2.54-3.29) 2.27 (1.99-2.60) Hospital 4.70 (4.26-5.19) 3.27 (2.94-3.63) 8.40 (7.39-9.54) 5.87 (5.14-6.71) Antenatal screening 2.34 (1.87-2.94) 1.76 (1.38-2.24) 2.49 (1.90-3.26) 2.09 (1.57-2.78) Not associated: SES, population density, country of infection Risk factors for late presentation 18 Nov 2014
Conclusion Substantial proportions of late presenters and advanced disease among newly diagnosed Decline in MSM only, possible explanations: Opting out testing at STI clinics Repeated HIV testing (high risk MSM) HIV testing through the Internet Earlier treatment Enhanced partner notification Targeted programs needed for all risk groups, but should be prioritized for heterosexual males, migrant populations, people of 50 years, and certain regions in the Netherlands More active role of health care provider needed, focus on indicator diseases Risk factors for late presentation 18 Nov 2014
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Results: trends Proportions of late presentation, Amsterdam vs rest Netherlands 70 60 50 40 30 MSM, Amsterdam MSM, rest Netherlands heterosexuals, Amsterdam heterosexuals, rest Netherlands 20 10 0 Risk factors for late presentation 18 Nov 2014 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013