Despite the availability of effective antiretroviral treatment and optimization of screening programs in Europe and the USA, 15–30% of patients who discover they are infected with HIV have already passed on to the AIDS stage [1–3]. Late diagnosis leads to a lower survival rate, spreading of the disease and increased healthcare costs [4–6]. Because we observed several consecutive cases of AIDS occurring in truck drivers, we hypothesized that being a truck driver could be a risk factor for a late diagnosis of HIV infection. The objective of this work is to study late diagnosis in truck drivers in industrialized countries and its impact on subsequent survival.
We conducted a retrospective study on 5914 men from a population of 8229 patients infected with HIV in four university hospitals in the northwest of France. We identified persons born in Europe and exercising, at the time of diagnosis, the profession of truck driver. Bus drivers and delivery people were excluded from the study. For each participant, we randomly selected three to four controls defined as men born in Europe with HIV infection diagnosed in the same year and in the same center as the truck drivers, who did not report being employed as a truck driver. For all individuals, the following variables were extracted: age, route of transmission, CD4 cell count (cells/μl) at the time of diagnosis, AIDS in the month following HIV diagnosis and survival during follow-up. Institutional Review Board approval was waived because of the retrospective and observational nature of the study. The primary outcome criterion was the occurrence of an AIDS-defining event within the month following the diagnosis of HIV infection. The secondary outcome criterion was survival subsequent to HIV infection diagnosis. Primary and secondary outcome rates were compared between truck drivers and controls by Fisher's exact test and log-rank tests, respectively. To assess the independent role of truck driving on the probability of primary and secondary endpoints, we built multivariate logistic and Cox models, respectively, by using SAS 9.2 (SAS Software, Cary, North Carolina, California, USA). P < 0.05 was considered statistically significant.
Fifty truck drivers were individualized and matched to 191 controls. The median year of diagnosis of HIV infection was 1998 (range = 1987–2008). The numbers of truck drivers and controls, respectively, were 21 and 78 for center 1, 15 and 60 for center 2, eight and 29 for center 3, and six and 24 for center 4. The mean (SD) age was 42.4 (9.8) years for truck drivers and 37.7 (10.9) years for controls (P = 0.007). The mean CD4 cell count (cells/μl, SD) at the time of diagnosis was 217 (205) for truck drivers and 411 (280) for controls (P < 0.0001). The route of transmission was heterosexual for 34 truck drivers (68.0%) and for 65 controls (34.0%) (P < 0.0001). The frequency of diagnosis at AIDS stage was significantly higher for truck drivers than for controls: 18% (36.0%) versus 26% (13.6%) respectively, with an odds ratio (OR) of 3.6 and 95% confidence interval (CI) of 1.8–7.3, P = 0.0003. Using a multivariate logistic regression analysis, the relationship between truck drivers and diagnosis at AIDS stage remained statistically significant [adjusted OR (AOR) = 2.8, 95% CI = 1.3–6.1, P = 0.009] adjusting for age (AOR for a 10-year increase in age = 1.8, 95% CI = 1.3–2.5, P = 0.0006), heterosexual route of transmission (nonsignificant) and center (nonsignificant). Nine truck drivers (18.0%) and 12 controls (6.3%) died during the follow-up. As shown in Fig. 1, survival was also significantly lower among truck drivers than among controls [hazard ratio (HR) = 3.0, 95% CI = 1.3–7.1, P = 0.01 by the log-rank test]. Using a Cox model, truck drivers remained a risk factor for death (HR adjusted = 2.6, 95% CI = 1.1–6.3, P = 0.03), adjustments were made according to age (adjusted HR for a 10-year increase = 1.7, 95% CI = 1.1–2.6, P = 0.001).
To our knowledge, our study is the first to identify a relationship between truck drivers, late diagnosis of HIV infection and lower survival rate in industrialized countries.
There are several limitations to our study. Although we found a statistically significant relationship between truck drivers and late diagnosis, the number of events analyzed was small. Furthermore, causes of death are not known.
Truck driving is a profession known to have a high-risk behavior and a high prevalence of HIV infection in developing countries [7–12]. Its possible role in the propagation of the epidemic has also been pointed out . Recently, in the USA, a qualitative investigation on behavior has revealed the existence of high-risk conduct that exposes truck drivers to potential HIV infection; of note is traveling long distances and being away from home for long periods . There are no data available on prevalence of HIV infection in this group in industrialized countries. However, one must bear in mind that risk factors for late diagnosis of HIV infection cannot be considered as risk factors for HIV infection per se.
Late diagnosis was previously associated with age, sex (discordant data), route of transmission, geographic origin and unemployment [15–17]. Truck drivers are at risk for poor health outcomes and experience significant difficulty to access healthcare services . This lack of regular healthcare could explain the late diagnosis of HIV infection. Moreover, we know that groups with low risk factors for HIV infection are more likely to be diagnosed late, with major consequences on morbidity and mortality . As mentioned before, being a truck driver is not considered as a risk factor for HIV infection in industrialized countries. This could further explain the late diagnosis for these professionals.
Our study also throws light on the problem of the poor prognosis for these patients. The mortality rate for patients with late diagnosis remains higher than that for other patients during the first 4 years of follow-up . In our study, poor prognosis is not only linked to delayed care initiated at the AIDS stage, because the trend continues beyond the first 4 years (Fig. 1). Other factors, such as co-morbidities, tobacco or alcohol use that are associated with the truck driver profession, may also have a role in determining prognosis.
In conclusion, we suggest a link between the profession of truck driving and late diagnosis of HIV infection in industrialized countries, with an associated increase in mortality rate. Our work may have potential public health consequences. Identifying new risk factors is part of the strategy aiming to reduce the number of late diagnoses. The optimization of awareness, prevention and HIV-testing campaigns appears necessary for the truck driver population.
We thank all the members of G4 study group, in particular Pascale Goubin, Chantal Jeanjean, Nathalie Decaux, Sylvie Dargère, François Caron, Françoise Borsa-Lebas, Isabelle Gueit, Anne Martin, Philippe Feret and Philippe Choisy, for their collaboration.
Guillaume Gras designed the study, collected the patient data from the different centers and wrote the article. Loik Geffray and Yazdan Yazdanpanah selected the patients, gathered data and reviewed the article, Jean-Jacques Parienti designed the study, performed the statistical analyses and reviewed the article, Manuel Etienne and Jean-Luc Schmit gathered and selected the data, Renaud Verdon designed, coordinated the study and reviewed the article.
This study was sponsored by an academic research grant from Côte de Nacre University Hospital.
This work had been presented in part at the Journées Nationales d'Infectiologie (abstract K-08) June 2008, Marseille, France.
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