Background:  Often in the United States, HIV is not detected until the infection is relatively advanced. The CDC now recommends expanded screening for HIV as a method to detect HIV infection at earlier stages. We have previously shown that patients do not present for care in Maryland until their CD4 level, on average, is 250 cells/mm³. This analysis assesses the effect of late presentation on person-years of life lost. As of October 2007, Maryland had not yet adopted the CDC recommendations.

Methods:  We determined the CD4 level at first presentation for HIV care from 2000 to 2004 in the Johns Hopkins HIV Clinical Cohort, a large cohort of patients receiving care in Baltimore and at 6 other sites throughout Maryland. Comprehensive demographic and clinical data are collected on patients longitudinally beginning at clinic enrollment. We determined survival by Kaplan-Meier methods from first presentation for late (CD4 <200) vs earlier presentation (CD4 201 to 350, >350). Person-time computations were applied to the number of patients newly presenting with HIV in Maryland during this time period to compute person-years of life lost.

Results:  A total of 1617 patients newly presented for HIV care from 2000 to 2004. Of these, 687 (42.5%) had CD4 <200, 368 (22.8%) had CD4 201 to 350, and 562 (34.7%) had CD4 >350. The number of deaths and Kaplan-Meier computed mortality rate (in parentheses) are shown in the table. Comparing those patients presenting for care at CD4 <200 vs those presenting at CD4 > 350, person-years lost (per 100 patients) by late presentation for HIV care were 11.0 at 1 year, 15.9 at 2 years, 20.5 at 3 years, and 24.3 at 4 years. Extrapolating the 4-year estimates to the 11,000 patients newly diagnosed with HIV infection in Maryland from 2000 to 2004, a total of 2673 person-years of life were potentially lost due to late presentation to care.

Conclusions:  In this era of HAART, these results are a reminder that HIV-infected patients who first present in later HIV stages are at higher risk for early mortality. These data provide strong support for the CDC recommendations for expanded screening.