Background:  HIV prevention initiatives and innovative care models to improve access to HIV services have evolved over time. Despite these efforts, it is estimated that >250,000 HIV-infected persons in the United States are undiagnosed, and many do not present until their HIV infection is advanced. Late presentation may increase risk of HIV transmission and make HIV more difficult to effectively treat. With easier tolerated and more effective HIV therapies, it is hoped that patients might present earlier in their disease course. To assess this, we analyzed the immune status of patients who newly presented for care over the past 16 years in a large urban academic center. 

Methods:   We analyzed data from 1990 through 2006 from patients who were ART- naïve at presentation to the Johns Hopkins HIV Clinic in Baltimore, Maryland. Patients were stratified by year of presentation as 1990-1994, 1995-1998, 1999-2002, and 2003-2006. We compared CD4 count at presentation by demographic characteristics at enrollment. Multivariate logistic regression was used to assess the association of CD4 count and demographic characteristics by year of enrollment.   

Results:  Since 1990, 3172 ART-naïve patients presented for care. Over time, the proportion of patients by gender and race remained stable, however, the proportion of patients with heterosexual transmission increased relative to injecting drug users (IDU) and men who have sex with men (MSM), and the age of the patients increased.  Presenting median CD4 declined over time overall, and by individual demographic groups (see the table). In multivariate analysis, CD4 at presentation significantly declined from 1990-1994 to 2003-2006 (p <0.0001). Male sex was independently associated with lower CD4 (–97 cells) as was black race (–76 cells) and older age (–17 cells/10 years).  IDU was associated with higher CD4 (+58 cells). No demographic group had an increase in CD4 over time.    

Conclusions:  There has been no change in the extent of immunosuppression at presentation to care in the last 16 years. Males and those of black race/ethnicity are significantly more likely to present with lower CD4 counts. IDU presented with somewhat higher CD4 counts relative to other risk groups, although all were low. New strategies to provide earlier HIV testing and referral into care are urgently needed.