| Objectives(1) To understand late HIV diagnosis among people living with HIV/AIDS in Wuhan and explore the risk factors of late HIV diagnosis, providing scientific basis for prevention and control of HIV/AIDS.(2) To compare the predictive ability of the new definitions which were combined with the European consensus definition of late HIV diagnosis and different time periods between initial diagnosis of HIV infection and AIDS diagnosis (CD4<200cell/?L) or CD4<350cell/?L for reliably identifying individuals with high risk of mortality within one year of diagnosis, and further to provide suggestions for the common definitions.(3) To evaluate the gender difference in late HIV diagnosis according to the published literature and to explore the underlying reasons, providing evidence of evidence-based medicine for the formulation of relevant health care and disease prevention policies.Methods(1) Data of people living with HIV/AIDS in Wuhan from 1994 to February 2012 were derived from the national HIV surveillance system. A contingency table was applied to assess the linear trend by year for the proportions of Advanced HIV disease (AHD), Late presentation (LP), Late entry to HIV care and death within 1 year of HIV diagnosis (short-term mortality). Spearman rank correlation coefficients (rs) were used to evaluate the correlation between the two selected variables. Univariate and multivariate non-conditional logistic regression analyses were applied to explore the potential factors associated with AHD, LP, Late entry to HIV care, and AIDS within 1 year of diagnosis.(2) Four time periods (one month, three months, six months, twelve months) between a first-reported CD4 count<200 cells/?L (or<350 cells/?L) or an ADE and HIV diagnosis combined with the European consensus definition of AHD or LP were compared. The predictive ability of each definition for identifying an individual who died within 1 year after HIV diagnosis was assessed using sensitivity, specificity, Youden's index, likelihood ratio, consistency rate, Kappa value, predictive value, receiver operating characteristic curve (ROC) and area under the curve (AUC).(3) The study was conducted in accordance with the Meta-Analysis of Observational Studies in Epidemiology guidelines. Heterogeneity among studies was assessed using the Cochrane Q and the I2 statistic to determine whether the random-effect model or the fixed-effect model was performed to calculate the pooled results. Sensitivity analysis was applied to evaluate the robustness of the pooled result. The subgroup analyses and Meta-regression were also performed according to variables which might explain the potential source of heterogeneity. Begg'test, Egger's test and Funnel plots were used to assess the effect of publication bias.Results(1) A total of 980 cases of HIV were included in the current study. The proportions of AHD, LP, AIDS within 1 year, and Late entry to HIV care were 29.49%,46.02%,39.39%, and 20.84%, respectively. Most of the deaths (74.27%,127/171) occurred within 1 year of diagnosis from 1994 to 2011. The risks of short-term mortality of people with AHD, LP, and Late entry to HIV care were 5.75,1.16,7.91 times higher than those without. Short-term mortality, proportion of AHD, LP and Late entry to HIV care showed a similar downward trend from pre-2003 to 2011 (P<0.001). Short-term mortality decreased as the proportion of AHD (rs=0.668, P<0.01) and Late entry to HIV care decreased (rs=0.817, P=0.007). Age, transmission category, sample source were associated with AHD, LP, Late entry to HIV care, and AIDS within 1 year in the multivariate logistic regression analysis. Gender was also an independent associated factor of LP, and occupation was an independent associated factor of Late entry to HIV care, and AIDS within 1 year.(2) The proportion of individuals defined as AHD or LP according to the definition conbining the European consensus definiton and the four time periods increased as the time period increased. Longer time periods increased the sensitivity and the negative predictive value but decreased the specificity and the positive predictive value. Time period within one month presented the highest consistency rate, positive likelihood ratio, and Kappa value. The highest Youden's index and largest area under the curve were presented in time period within three months, while the difference of area under the curve was not statistically significant.(3) The results of the Meta-Analysis of Observational Studies showed that the pooled adjusted odds ratios (aOR) of males presenting with AHD and LP compared with females were 1.73 (95% confidence interval [CI]:1.59-1.89) and 1.38 (95%CI:1.18-1.62). Sensitivity analysis showed robustness of the results with aOR ranging from 1.68 (95%CI: 1.55-1.82) to 1.76 (95% CI:1.61-1.93) for studies on AHD, and 1.30 (95%CI:1.13-1.51) to 1.43 (95% CI:1.21-1.69) for studies on LP. Subgroup analysis and Meta-regression revealed that time period, study location, number of patients, proportion of females, study design, number of adjusted variables might be potential source of heterogeneity. No publication bias was observed in studies on AHD or LP from the results of Begg'test, Egger's test and Funnel plots.Conclusions(1) Individuals diagnosed with AHD, LP and Late entry to HIV care were associated with an increased incidence of AIDS or death, particularly within 1 year of diagnosis. Age, transmission category, sample source, and occupation were the main associated factors of late HIV diagnosis. More attention should be directed towards patients at high risk of late HIV diagnosis with the corresponding prevention and control measures, so as to promote the early diagnosis of HIV infection, early entry HIV care and treatment, and to further improve the disease process, and ultimately to promote population health.(2) Definitions of AHD and LP with shorter time periods were more reliable to identify an individual at high risk of death within 1 year after HIV diagnosis, to be more specified, a one-month time period could be possibly used in the consensus definition of late HIV diagnosis. Thus, the common definitions of late HIV diagnosis are suggested that "Advanced HIV disease" could be defined as "a first-reported CD4 count<200 cells/?L or an AIDS-defining event within one month after HIV diagnosis". "Late presentation" could be defined as "a first-reported CD4 count<350 cells/?L or an AIDS-defining event within one month after HIV diagnosis".(3) Males are at higher risk of AHD or LP compared with females. Considering the consistent findings of a number of studies, and the reliability and robustness of the current study, we strongly recommend that more attention should be paid to males, and more effort should be made to encourage individuals with high-risk behavior to participate counseling and testing. |
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