Factors Associated with Late Presentation of HIV and Estimation of Antiretroviral Treatment Need according to CD4 Lymphocyte Count in a Resource-Limited Setting: Data from an HIV Cohort Study in India
We describe the CD4 lymphocyte count at HIV presentation in an HIV cohort from a rural district of India. The majority of patients were diagnosed for their HIV-related symptoms, although a sizeable proportion of women were diagnosed because of antenatal screening or for having an HIV-positive partner. Patients diagnosed of HIV for antenatal screening or having an HIV-positive sexual partner had higher CD4 lymphocyte count than patients having tuberculosis or HIV-related symptoms. The proportion of patients diagnosed with CD4 count <200 and <350 cells/mm3 were 46% and 68.7%, respectively, and these figures did not change during the five years of the study. Factors associated with late presentations were male sex, older age, not having a permanent house, and, in women, lower education and being a widow or separated. With the implementation of 2010 WHO guidelines, the number of newly diagnosed patients who will require HIV treatment will increase 13.8%. If the CD4 count threshold for initiating HIV treatment is increased from 350 to 500 cells/mm3, the number of patients in need of treatment would increase 15.7%. Therefore, new strategies for avoiding HIV late presentation are urgently needed in developing countries. 1. Introduction International HIV guidelines for the use of antiretroviral therapy (ART) in adults are shifting towards earlier initiation of HIV treatment [1–3]. Late initiation of ART is associated with higher risk of death and opportunistic infections as well as poorer response to treatment [4, 5]. However, patients who are diagnosed when their CD4 lymphocyte count is low are not able to get the benefits of an early ART initiation. From the public health point of view, these patients have a longer period of undiagnosed HIV infection. Late presentation of HIV delays patients from receiving education for avoiding the infection to others and precludes them from receiving ART, which can reduce their HIV viral load and, therefore, lowering the risk of HIV transmission to others. In Europe and North America, approximately 30 to 35% of patients have CD4 lymphocyte count below 200？cells/mm3 at HIV diagnosis [6, 7]. Despite having more than 90% of the world burden of people living with HIV [8], information about the immunological situation at HIV diagnosis of patients from developing countries is scarce [9]. The aim of this study is to describe the CD4 lymphocyte count at HIV presentation in patients from a rural district of India and to investigate factors associated with late presentation [10]. We have also performed a simulation of how many people
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