HIV Late Presenters in Asia: Management and Public Health Challenges

Abstract

Many individuals are diagnosed with human immunodeficiency virus (HIV) infection at an advanced stage of illness and are considered late presenters. We define late presentation as a CD4 cell count below 350 cells/mm3 at the time of HIV diagnosis, or presenting with an AIDS-defining illness regardless of CD4 count. Across Asia, an estimated 34–72% of people diagnosed with HIV are late presenters. HIV late presenters generally have a higher disease burden and higher comorbidity such as opportunistic infections than those who are diagnosed earlier. They also have a higher mortality rate and generally exhibit poorer immune recovery following combined antiretroviral therapy (cART). As such, late HIV presentation leads to increased resource burden and costs to healthcare systems. HIV late presentation also poses an increased risk of community transmission since the transmission rate from people unaware of their HIV status is approximately 3.5 times higher than that of early presenters. There are several factors which contribute to HIV late presentation. Fear of stigmatisation and discrimination are significant barriers to both testing and accessing treatment. A lack of perceived risk and a lack of knowledge by individuals also contribute to late presentation. Lack of referral for testing by healthcare providers is another identified barrier in China and may extend to other regions across Asia. Effective strategies are still needed to reduce the incidence of late presentation across Asia. Key areas of focus should be increasing community awareness of the risk of HIV, reducing stigma and discrimination in testing, and educating healthcare professionals on the need for early testing and on the most effective ways to engage with people living with HIV. Recent initiatives such as intensified patient adherence support programs and HIV self-testing also have the potential to improve access to testing and reduce late diagnosis.

Changing Mortality and Patterns of Death Causes in HIV Infected Patients — China, 2013–2022

“…A primary concern is the continued prevalence of late HIV diagnosis. Within Asia, it is estimated that between 34% and 72% of individuals diagnosed with HIV present late ( 8 ). Late presentation is associated with an elevated risk of treatment failure, higher mortality, and significant economic impacts.…”

“…Indeed, cancer constitutes a significant factor in mortality rates, with NADCs showing increased fatality rates, partly due to the advancing age of the HIV-infected population. One of the foremost challenges for clinicians treating HIV-infected individuals is to devise and apply efficacious strategies for the early detection, treatment, and prevention of cancers in this demographic (7).…”

New sexually transmitted HIV infections from 2016 to 2050 in Guangdong Province, China: a study based on a dynamic compartmental model

“…Another challenge is how to determine a criterion for model calibration for a compartmental model. Given that the problem of late diagnosis is prevalent worldwide [36][37][38][39] and continues to be prevalent [40], model calibration must also consider the proportion in addition to the number of new HIV diagnoses each year, which was often employed to calibrate owing to a lack of other data. The number predicted must be almost higher than the number of new HIV diagnoses each year in most countries due to late diagnoses [37,38,41,42], whose proportion may increase owing to the impacts of the COVID-19 pandemic [43]; otherwise, the predicted number will be underestimated to some extent.…”

The association between HIV-related stigma, HIV knowledge and HIV late presenters among people living with HIV (PLHIV) attending public primary care clinic settings in Selangor

“…Furthermore, HIV related stigma and limited HIV knowledge have been identified as barriers to early testing, treatment, and prevention efforts [ 20 , 21 ]. This pervasive stigma is a pressing concern globally, including in Malaysia.…”