Delayed presentation of HIV among older individuals: a growing problem

Abstract

Late presentation for care is a major impediment to the prevention and effective treatment of HIV infection. Older individuals are at increased risk of late presentation, represent a growing proportion of people with late presentation, and might require interventions tailored to their age group. We provide a summary of the literature published globally between 2016-21 (reporting data from 1984-2018) and quantify the association of age with delayed presentation. Using the most common definitions of late presentation and older age from these earlier studies, we update this work with data from the International Epidemiology Databases to Evaluate AIDS (IeDEA) consortium, focusing on data from 2000-19, encompassing four continents. Finally, we consider how late presentation among older individuals might be more effectively addressed as electronic medical records become widely adopted.

Figure 1.

Age at presentation for HIV care and age among all those in HIV care in IeDEA regions (A) North America region (2018). (B) Central America, South America, and the Caribbean region (2019). (C) Central Africa region (2019). (D) East Africa region (2019). (E) West Africa region (2017). (F) Asia-Pacific region (2019). (G) Asia-Pacific region Australia subcohort (2016). (H) Southern Africa region (2017). In the IeDEA Southern Africa regional cohort, participants were observed from ART initiation (not from presentation for HIV care); age at ART initiation is believed to be reflective of age at presentation for HIV care as of 2017 when the Treat All guidelines were adopted in Southern Africa. The age at presentation for HIV care in the Australia subcohort of IeDEA Asia-Pacific in 2016 is not presented because the median age at presentation for HIV care was based on a relatively small subpopulation (<20 participants) of those presenting for HIV care. Participants were recruited to replenish the Australian subcohort in 2016. ART=antiretroviral therapy. IeDEA=International epidemiology Databases to Evaluate AIDS.

Figure 2.

Median CD4 cell count per year by age group at presentation for HIV care and at ART initiation in IeDEA regions (A) North America region (2018). (B) Central America, South America, and the Caribbean region (2019). (C) Central Africa region (2018). (D) East Africa region (2019). (E) West Africa region (2017). (F) Asia-Pacific region (2019). (G) Asia-Pacific region Australia subcohort (2016). (H) Southern Africa region (2017). The total number of people contributing to the estimates in each year, by age (18–49 years and ≥50 years) are noted for the calendar years labelled on the x axis. The plots for Central Africa end in 2018 due to the decrease in CD4 cell count measured in 2019 (the last complete calendar year of data available from the Central Africa region). Estimates of CD4 cell count at presentation for HIV care are not available for Southern Africa. The Southern Africa regional cohort observes participants starting from ART initiation; age at ART initiation is believed to be reflective of age at presentation for HIV care as of 2017, when the Treat All guidelines were adopted in Southern Africa. In the Australia subcohort of the IeDEA Asia-Pacific region, participants were recruited into the clinical cohort to replenish the cohort; the median age at presentation for HIV care was based on a subpopulation (<20 participants) of those presenting for HIV care at participating IeDEA clinics between 2000 and 2016. Breaks in the line representing CD4 cell count at ART initiation among those older than 50 years old shows that no individuals older than 50 years initiated ART in that year. The y axis for CD4 count is different for the Australian subcohort compared with the other regions. ART=antiretroviral therapy. IeDEA=International epidemiology Databases to Evaluate AIDS.

Figure 2.

Median CD4 cell count per year by age group at presentation for HIV care and at ART initiation in IeDEA regions (A) North America region (2018). (B) Central America, South America, and the Caribbean region (2019). (C) Central Africa region (2018). (D) East Africa region (2019). (E) West Africa region (2017). (F) Asia-Pacific region (2019). (G) Asia-Pacific region Australia subcohort (2016). (H) Southern Africa region (2017). The total number of people contributing to the estimates in each year, by age (18–49 years and ≥50 years) are noted for the calendar years labelled on the x axis. The plots for Central Africa end in 2018 due to the decrease in CD4 cell count measured in 2019 (the last complete calendar year of data available from the Central Africa region). Estimates of CD4 cell count at presentation for HIV care are not available for Southern Africa. The Southern Africa regional cohort observes participants starting from ART initiation; age at ART initiation is believed to be reflective of age at presentation for HIV care as of 2017, when the Treat All guidelines were adopted in Southern Africa. In the Australia subcohort of the IeDEA Asia-Pacific region, participants were recruited into the clinical cohort to replenish the cohort; the median age at presentation for HIV care was based on a subpopulation (<20 participants) of those presenting for HIV care at participating IeDEA clinics between 2000 and 2016. Breaks in the line representing CD4 cell count at ART initiation among those older than 50 years old shows that no individuals older than 50 years initiated ART in that year. The y axis for CD4 count is different for the Australian subcohort compared with the other regions. ART=antiretroviral therapy. IeDEA=International epidemiology Databases to Evaluate AIDS.