Late Presentation of HIV/AIDS Patients: A Caribbean Problem

Dear Editor:

A substantial proportion of HIV–infected individuals do not present for HIV testing and treatment until late in infection. A number of studies from resource-poor countries have described the frequency of late presentation (CD4 count less than 200 cells/mm³) among antiretroviral-naïve individuals with estimates ranging from 15–43%. ¹ In a study in 2000–2003 carried out in the southeastern United States where there was a disproportional HIV/AIDS burden, the prevalence of late presenters (CD4 count less than 200 cells/mm³) was as high as 50% with 27% presenting with an AIDS-defining illness. ² In a report from the University of Alabama at Birmingham and Duke University, Durham, North Carolina, between October 2003 and August 2004, 49% of recently diagnosed HIV-infected patients had clinical or undiagnosed AIDS (CD4 count less than 200 cells/mm³), ³ and in another study in Tijuana, Mexico, the percentage of late presenters was 43.2%. ⁴ More recently, a bulletin of the International Society of Antiretroviral Research on late presentation of HIV treatment in several countries in Europe reported that 23–45% of patients in Europe had CD4 counts less than 200 cells/ mm³. ⁵

In the Commonwealth Caribbean, the first cases of HIV/AIDS were reported from Trinidad and Tobago in 1983, ⁶ it is estimated that the HIV seroprevalence is about 2–3% and the subtype B HIV-1 viruses are indistinguishable from other subtype B viruses. ⁷ Highly active antiretroviral therapy (HAART) has been available for patients in resource-rich industrialized countries since approximately 1996 but because of its high cost it was only in 2003 that Trinidad and Tobago (like many Third World countries) has been able to provide HAART free of charge to HIV/AIDS patients.

The Medical Research Center of the Ministry of Health in Port of Spain, Trinidad is the largest HIV/AIDS treatment and research center in the Commonwealth Caribbean and since 2002–2003 has had a patient roll of 5500 as of June 2010 with a monthly enrollment of approximately 50 new antiretroviral-naïve patients. CD4 cell counts were assayed by the Becton Dickinson FACSCount system (BD Biosciences, San Jose, CA) and baseline CD4 cell counts were performed at enrollment and at 6 monthly intervals.

This is the first report of a 6-year study (2004–2009) of late presenters from an island in the Caribbean, Trinidad and Tobago. Patients were defined as “late presenters” if they had a CD4 count less than 200 cells/mm³ and were treatment-naïve at first enrollment in the Medical Research Center. Of 3917 newly enrolled patients, 1483 (40%) were late presenters, of whom 634 patients (42.8%) first joined the clinic in very late stage disease with less than 50 cells/ mm³ (Fig. 1). Of these late presenters, 853 (42%) were male and 630 (58%) were female.

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FIG. 1.

Total patients enrolled with CD4 less than 50 January 1, 2004 to December 31, 2009 (3717).

The percentage of HIV-infected individuals who present late has remained stable over this 6-year period (p=0.001). In resource-rich countries the proportion of HIV-infected individuals who present late has also remained relatively stable over the past decade despite several attempts to encourage earlier diagnosis. ¹

In another study of HIV-positive pregnant women who were referred from antenatal clinics to the Medical Research Center in Trinidad and Tobago between January 1, 2004 and June 31, 2010, of 871 HIV-positive pregnant mothers, 173 (21%) had CD4 counts less than 200 cells/ mm³. In similar studies of pregnant women in the United Kingdom, 20% of women diagnosed with HIV as a result of active screening in antenatal clinics had CD4 counts less than 200 cells/mm³. ¹

The number of counseling and rapid-testing centers has been increased throughout the island appealing to people who are at risk of infection to get tested but more emphasis has to be placed on strongly advising patients who test positive to seek treatment as soon as possible. This international problem has to be seriously addressed as late presenters, apart from having a higher risk of clinical events, a higher mortality than those who present earlier even after receipt of antiretroviral therapy and also incurring added costs, are in addition a societal burden because they are associated with an increased risk of HIV transmission to others.