Objective: A recent consensus defines “late presentation” (LP) during the course of HIV infection as presentation with AIDS whatever the CD4 cell count or with CD4 <350 cells per cubic millimeter. Here, using this new definition, we examined the frequency and predictors of LP and its impact on mortality.
Methods: In antiretroviral-naive patients enrolled in the French Hospital Database on HIV between 2003 and 2009, we studied risk factors for LP by multivariable logistic regression. The impact of LP on mortality was analyzed according to the level of immunodeficiency by using Cox multivariable models adjusted for potential confounders, with follow-up categorized into 0–6, 6–12, and 12–48 months.
Results: There were 11,038 (53.9%) late presenters among the 20,496 patients included in the study. Compared with patients presenting for care with CD4 ≥350 cells per cubic millimeter, patients presenting with AIDS had a very high risk of death with crude hazard ratio ranging from 48.3 during the first 6 months of follow-up to 4.8 during months 12–48; the corresponding values among AIDS-free patients with CD4 ≤200 cells per cubic millimeter were 8.1 and 2.3. Importantly, patients presenting with CD4 between 200 and 350 cells per cubic millimeter also had a significantly increased risk of death beyond 6 months of follow-up (hazard ratio: 3.0 and 1.8 for months 6–12 and 12–48, respectively). Results were similar after adjustment.
Conclusions: LP with HIV infection is still very frequent in France and is associated with higher mortality, even among patients with only moderate immunodeficiency. Encouraging early testing and access to care is still urgently needed.
*INSERM U943, Paris, France;
†UPMC Paris Univ 06 UMR S 943, Paris, France;
‡Assistance Publique Hôpitaux de Paris (AP-HP), Hôpital Avicenne, Service de maladies infectieuses et tropicales, Bobigny, France;
§Centre Hospitalier de Nanterre, Service de médecine interne, maladies infectieuses et rhumatologie, Nanterre, France;
‖Centre Hospitalo-Universitaire de Nice, Hôpital de l’Archet, Service des Maladies Infectieuses et Tropicales, Nice, France;
¶Université Paris Descartes, Paris, France;
#Assistance Publique Hôpitaux de Paris (AP-HP), Hôpital Cochin, Pôle de Médecine, Paris, France;
**Assistance Publique-Hôpitaux de Paris, Hôpital Antoine Béclère, Service de Médecine Interne et Immunologie Clinique, Clamart, France;
††INSERM, UMR_S 996, Clamart, France;
‡‡Université Paris Sud, UMR_S 996, Clamart, France;
§§Hôpitaux Universitaires de Strasbourg, Le trait d’Union, Strasbourg, France;
‖‖Centre Hospitalo-Universitaire de Nice, Hôpital de l’Archet, Département de santé publique, Nice, France;
¶¶Assistance Publique Hôpitaux de Paris (AP-HP), Hôpital Ambroise-Paré, Service de médecine, Boulogne, France;
##Assistance Publique Hôpitaux de Paris (AP-HP), Hôpital Saint-Antoine, Service de maladies infectieuses et tropicales, Paris, France; and
***Assistance Publique-Hôpitaux de Paris, Groupe Hospitalier Cochin Broca Hôtel-Dieu, Unité de Biostatistique et Epidémiologie, Paris, F-75004 France (C. Montlahuc is now with the Observatoire régional de Santé d’Ile de France, Paris, France).
Correspondence to: Dominique Costagliola, PhD, INSERM U943, 56 Bd V Auriol, BP 335, 75625 Paris Cedex 13, France (e-mail: firstname.lastname@example.org).
Supported by ANRS, INSERM, and the French Health Ministry.
The authors have no conflicts of interest to disclose.
Author contributions: D.C. and M.G. conceived and designed the study. S.A., V.D., F.d.S., O.L., V.M., M.P., C.P., E.R., and N.V. were responsible for the provision of study materials or patients. D.C., M.G., and C.M. performed the statistical analysis. All authors interpreted the data. D.C. and C.M. drafted the article. All authors provided critical review of the article for important intellectual content and approved the final article.
The full list of French Hospital Database ANRS CO4 investigators can be found at http://www.ccde.fr.
Received December 27, 2012
Accepted May 21, 2013