Late Presentation HIV/AIDS Is Still a Challenge in Brazil and Worldwide

According to the Collaboration of Observational HIV Epidemiological Research Europe Study (COHERE), late presentation (LP) is defined as CD4 count <350/mm³ or AIDS when first presenting to care. ¹ The “spectrum of engagement in HIV care” (referred to as the “cascade”) takes into account the CD4 count that describes the level of disease progression. However, it is not enough to specify the nature of delays in testing and diagnosis. Timing between testing and access to care critically affects the individual's awareness of the disease and the HIV transmission risk. ² According to the Brazilian Ministry of Health (BMoH), LP includes AIDS and/or CD4 count <200/mm³ or AIDS development during the first year of diagnosis. ³

Those who present late have a higher risk of death and poor antiretroviral response. ² LP includes marginalized groups, people without access to testing, and those stigmatized for presenting themselves for testing. LP is prominent among heterosexuals or people with an unknown mode of transmission. ³ With the latter, it is especially due to a low perception of the risk involved in supposedly monogamous relationships by female individuals. Furthermore, a significant proportion of adults worldwide appear for care for the first time with advanced HIV infection. ⁴

The COHERE consortium, analyzing nine cohorts from Austria, France, Greece, Italy, Spain, and Switzerland, verified that LP was related to socioeconomic inequalities. ⁴ A study performed in six American cities showed that LP due to infrequent or lack of HIV testing was common among black homosexual men. ⁵ The Gap Report, published by UNAIDS in 2014, reports that in half of Latin American countries, 38% of individuals had CD4 count <200 when first tested. ⁶

In 1996, Brazil was the first developing country to offer free and universal access to antiretrovirals, ⁷ HIV testing, and care. Nonetheless, LP in Brazil is still a major challenge.

One study analyzing all the CD4 data from the Brazilian Public System (n = 63,107), using the first CD4 count for each individual from 2000 to 2009, showed that half of patients presented with CD4 count <350/mm³ (48.36% in 2001; 52.33% in 2009). One-third of patients presented with CD4 count <200/mm³ (29.01% in 2001; 33.81% in 2009). Baseline CD4 count was higher among women and lower in older patients as well as in less developed regions. ⁸

According to a study carried out by Grangeiro et al., of a total of 115,369 adults living with HIV (2003–2006), 50,358 patients entered into HIV care late at public healthcare facilities in Brazil and 14,457 died within the first 20 days of care. Of these, 3,408 (67.7%) presented at a more advanced stage with CD4 count <100 cells/mm³. The authors of this study have shown that the risk of death from AIDS in the first 12 months after initiation of care is associated with late entry into HIV care. ⁹

Another Brazilian analysis in Divinópolis, Minas Gerais State (403 individuals), showed that 40.2% were late presenters; women with low education presenting higher risk for being late presenters. ¹⁰ One study in Belo Horizonte (Southeast Brazil) revealed that 44.8% of individuals had their HIV diagnosis during their first hospitalization, also with a lower survival rate. ¹¹ Mortality was higher among late presenters because of delaying antiretrovirals in Rio de Janeiro (Southeast Brazil). In Santarém (North Brazil), LP related to the low number of anonymous testing centers in the region, which contributes to the delay in diagnosis. ¹²

Although the BMoH has improved and optimized HIV testing, in 2015 the North and Northeast regions had the highest proportions of late presenters, whereas the South and Southeast, known as the richest areas of the country, had the lowest. ^13,14 The State of Maranhão (Northeast region) had a ratio of late presenters at diagnosis of 43%, which is above the national rate. Even in Roraima, Amapá, and Mato Grosso, states that had the lowest LP ratios in the analyzed period, about one-fifth of people living with HIV/AIDS came to the health service late. In Alagoas (Northeast region), the average CD4 count at diagnosis was 276, the fourth lowest among Brazilian states. ¹³

In fact, late presenters are usually diagnosed with a very low CD4 count that impairs adequate response to treatment as well as recovery of the immune system. This can lead to death. ¹

Brazil is a country of continental dimensions and this contributes to disparities between its regions and cities (8,516,000 km² of extension; 26 states and a Federal District divided into 5 regions; 200.4 million inhabitants). According to UNAIDS, because of its continental dimensions, Brazil has 40% of new infections, whereas Argentina, Venezuela, Colombia, Cuba, Guatemala, Mexico, and Peru together account for 41% of these cases. ¹⁵ The Brazilian government has tried to solve these difficulties by decentralizing treatment and increasing the coverage of care and testing. There is still much to be done in making early HIV infection diagnosis more accessible, allowing better antiretroviral response and immune recovery, and mitigating HIV transmission. The BMoH published a document in 2014 indicating that rapid HIV tests should be performed outside laboratories, using blood or oral fluid. It also states that self-tests are acquired in drugstores, along with the policy of offering treatment as prevention as well as linkage to care. ⁴ Noninvasive rapid HIV tests became available at drugstores in 2016 in Brazil. However, there still are people who fear family repression, rejection by society, and exposure as illegal immigrants once tested.

Finally, insistence on creating awareness of the need for condoms use is essential. In Brazil, condom distribution is free of charge. However, many people, especially younger individuals, feel ashamed and afraid of exposing themselves by visiting the distribution centers. We must surmount these barriers so that the 90-90-90 goals proposed by UNAIDS may be reached for ending AIDS epidemic by 2030.