[Viva] FW: CATIE News - Routine HIV testing urged to speed entry to care in Canada and the U.S.

Thu Apr 29 13:18:01 PDT 2010

From: mailing at mercury.catie.ca [mailto:mailing at mercury.catie.ca] 
Sent: April-29-10 11:47 AM
To: cosmictami at shaw.ca
Subject: CATIE News - Routine HIV testing urged to speed entry to care in
Canada and the U.S.

CATIE News - Routine HIV testing urged to speed entry to care in Canada and
the U.S.

In North America, researchers estimate that about 21% of HIV-positive people
are unaware that they have this infection. This is likely because rates of
testing for HIV are generally low. People who are not aware that they are
HIV positive can miss the benefits of early access to treatment. Indeed,
receiving highly active antiretroviral therapy (HAART) relatively late in
the course of HIV disease may be too late for some people.

A giant grouping of many databases, called the North American Cohort
Collaboration on Research and Design (NA-ACCORD), has been analyzing
health-related information collected from HIV-positive people. Its most
recent report focused on nearly 45,000 people and suggests that HIV-positive
people are delaying the initiation of HAART until relatively late in the
course of HIV infection. This has implications not only for the health and
survival of HIV-positive people but also for costs to the health care
system.

Study design

Researchers recruited adult participants from clinics in three Canadian
provinces—Alberta, Ontario and Quebec—and from states across the U.S. The
NA-ACCORD team focused on people who first sought care for HIV infection
between January 1997 and December 2007. The average profile of these
participants was as follows:

*	19% female, 81% males
*	age – 41 years
*	HIV risk group – gay and bisexual men 29%; injection drug users 19%;
heterosexual 23%; other/unknown risk 28%
*	CD4+ count – 288 cells

Results—changes in CD4+ counts

In 1997, the average CD4+ cell count of people who began HAART was 256
cells. By the end of 2007 this figure rose to 317 cells. Although this
change appears promising, multiple treatment guidelines in the present era
suggest the initiation of HAART when the CD4+ count has fallen below 350
cells, and in some cases at even higher cell counts, depending on
co-infections and other complications.

Demographic changes

The HIV epidemic in North America has changed over time, having an impact on
different communities. Although gay and bisexual men remain the largest
group affected, other communities who have injection drug use or
heterosexual sex as their main risk factor have become increasingly at risk
for HIV infection. These latter categories include increasing numbers of
women and people of colour.

According to the NA-ACCORD researchers, the results of their latest analysis
have implications for HIV-positive people and the health care system as
follows:

*	Survival

Delaying entry to care and treatment increases the risk of death from
HIV-related complications. Results from several other large data sets
suggest that when treatment begins at a CD4+ count of 350 cells or more, the
risk of death is decreased. Modern anti-HIV treatments can greatly prolong
survival, and early initiation of treatment would help take advantage of
this.

*	HIV transmission

HAART can reduce HIV levels in the blood and sometimes in the genital
fluids, potentially reducing the sexual infectiousness of some HIV-positive
people at the level of the community (thousands of people). For more
information about HAART and its potential impact on the spread of HIV in
men, see CATIE News stories from March 25 and March 31, 2010, at
<http://www.catie.ca/catienews.nsf/CATIE-NEWS>
www.catie.ca/catienews.nsf/CATIE-NEWS.

*	Costs

Alberta-based researchers have documented that the average costs of care for
HIV-positive people in the year following a late diagnosis (particularly
when CD4+ counts are less than 200 cells) are more than double that of
people who seek care when their immune systems are less damaged. As many
provinces and states will be grappling with budget deficits in the years
ahead, cost concerns are likely to play an increasing role in the rationing
of health care.

What to do?

Research is needed to assess the reasons that some people at risk for HIV
infection choose to not get tested and enter care later than they should.

One way to help more people become aware of their HIV status is to implement
routine HIV testing in health care settings. The U.S. Centers for Disease
Control and Prevention (CDC) has released guidelines recommending that all
people between the ages of 13 and 64 years get routinely tested for HIV. The
CDC has said that such testing should take place as long as patients are
told in advance of testing and are given the option of refusing such
testing.

This call for more extensive HIV testing in health care settings by the CDC
and other health authorities is likely possible in urban areas, but because
of concerns around confidentiality, not everyone in small communities or
rural areas is likely to welcome routine testing.

In the pre-HAART era, when the benefit of treatment was very limited and
drug toxicity was a major problem, the news of a positive HIV test result
could be particularly devastating because of a very short life expectancy.
Now that more effective, safer and simpler regimens are available and
HIV-positive people are generally expected to live near-normal life spans,
the NA-ACCORD report calls for the elimination of the following in health
care settings:

*	legal requirements for informed consent for HIV testing
*	need for counseling before an HIV test is done

The NA-ACCORD’s report will hopefully spur discussion and debate about the
benefits of more extensive HIV testing and early treatment. In the years to
come, such a debate will hopefully help overcome barriers to testing and
accessing treatment.

—Sean R. Hosein

REFERENCES:

1.     Althoff KN, Gange SJ, Klein MB, et al. Late presentation for human
immunodeficiency virus care in the United States and Canada. Clinical
Infectious Diseases. 2010; in press.

2.     Gay L. The gap between human immunodeficiency virus (HIV) infection
and advances in HIV treatment. Clinical Infectious Diseases. 2010; in press.

3.     Wilson DP, Law MG, Grulich AE, et al. Relation between HIV viral load
and infectiousness: a model-based analysis. Lancet. 2008 Jul
26;372(9635):314-20.

4.     International Monetary Fund. World Economic Outlook: rebalancing
growth. April 2010. Available at:
www.imf.org/external/pubs/ft/weo/2010/01/index.htm.

5.     Schneider H. For nations living the good life, the party’s over, IMF
says. Washington Post. Saturday 24 April 2010. Available at:
www.washingtonpost.com/wp-dyn/content/article/2010/04/23/AR2010042305258.htm
l.

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CATIE-News is written by Sean Hosein, with the collaboration of other
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