Leading HIV Experts Convene to Tackle the Challenge of Late Presentation in Europe

LONDON - A third of HIV-infected persons in UK do not present for screening and
treatment until late in infection increasing morbidity and decreasing their
quality of life.(1,2,3)

Almost three decades after the discovery of HIV/AIDS, and despite big
medical advances, there are still a significant number of HIV-infected
persons who present late in the disease course and with severe
immunosuppression. This often results in less than optimal outcomes, with
increased mortality, morbidity and decreased quality of life.(2,3) In Europe
15 to 38 % of those infected with HIV do not present for testing until late
in infection, with the UK sitting at the higher end of that bracket with 33%
of all patients receiving their diagnosis when their CD4 cell count was less
than 200/mm3, and/or disease progressed to clinical AIDS during the year of
diagnosis.(1,4) To address this issue, leading HIV experts from across Europe
convened today at a meeting titled “Late Presentation for HIV Treatment in
Europe” sponsored by Bristol-Myers Squibb Company. Topics that were covered
include research on late presentation, its public health implications in
Western Europe, early HIV testing, and the management of late presenters.

“Late presentation can have negative consequences for both the individual
and the larger population. Late HIV presenters typically have a poor disease
outcome, are less likely to respond to treatment once initiated, and are more
likely to transmit the disease to others,” said conference co-chair Margaret
Johnson, MD, clinical director and consultant physician of general medicine,
HIV/AIDS and thoracic medicine at the Royal Free Hospital in London. “This
meeting is extremely timely given the gravity of the issue in Western Europe.
As clinicians and concerned citizens, we must act now to encourage earlier
HIV testing and treatment, and help reduce the stigma of HIV diagnosis in all
communities.”

Although the rates of late presentation vary based on countries and
definitions used,(4) some studies indicate that:

- Between 15 to 38% of those infected with HIV in Europe do not present
for testing until late in infection, when their CD4 cell counts are low,
viral load high, and the immune system has been significantly
compromised.(4)
- 28 percent of patients in Spain had a first positive HIV test in the
month of or immediately before AIDS diagnosis(5)
- 33 percent of patients in the United Kingdom,(1) 38 percent in
France,(6) and 39 percent in Italy(7) received their diagnosis when
their CD4 cell count was less than 200/mm3, and/or disease progressed
to clinical AIDS during the year of diagnosis
- In Sweden, 45 percent of patients were diagnosed with HIV less than
three months before AIDS diagnosis(8)
- In Germany, 30% percent of patients were diagnosed with a CD4 cell
count less than 200/mm3 (4)

These patients are more likely to acquire opportunistic infections, and
to present with multiple illnesses within a short time period.(3) Delayed
presenters may also have a poorer treatment response when they do start
highly active antiretroviral therapy (HAART).(3) Antiretroviral drug
resistance is also an issue in this population.(3)

It has been shown that earlier HIV diagnosis results in more favourable
outcomes in short-term mortality (56% overall improvement) and
heterosexually-acquired AIDS mortality (32% improvement).(4) Earlier HIV
diagnosis may also help control the spread of the epidemic.(9) Recent changes
to HIV treatment guidelines confirm the need for patients and physicians to
consider treatment as early as CD4 cell count of 350-500 cells/mm3.(9,10) The
2008 International AIDS Society (IAS) treatment supports new data and
considerations for initiating therapy before CD4 cell count falls below 350
cells/mm3,(10) an update to the 2006 version of the IAS guidelines, which
recommended antiretroviral therapy for asymptomatic patients whose CD4 cell
count is equal to or less than 200 cells/mm3.(11) Additionally, the 2008
guidelines state that, in patients with a count of 350 CD4 cells/mm3 or more,
the decision to begin therapy should be individualized based on the presence
of comorbidities, risk factors for progression to AIDS and non-AIDS diseases,
and patient readiness for treatment.(10)

“Early treatment allows for greater immunological recovery, a reduction
of AIDS progression, a reduced risk of related illnesses, and lower
mortality,” said conference co-chair Jurgen Rockstroh, MD, director of the
Bonn University Clinic and professor in the department of medicine at
University of Bonn, Germany. “Thanks to advances in medical research, there
are a number of HIV treatment options available for low CD4 cell count
patients, including the late presentation population. Antiretroviral therapy
now makes it possible for many HIV-infected persons to live long, and fairly
normal, lives.”

*About Late Presentation

Although there is no standard definition of late presentation, in
clinical literature late presenters have been most frequently defined as
patients who present with low CD4 cell count (less than 200/mm3) and those
who receive HIV diagnosis within three months of AIDS diagnosis.(4) Some
studies have also defined late presenters as those who present with CD4 cell
count of less than 350.(4) In addition, delayed presenters have been defined
as patients with more than six months between their first HIV positive test
and presentation for HIV care,(12) or simply those who present for HIV care
after it may have been beneficial to begin treatment.(4)

Research shows that as many as 77% of all AIDS-related deaths could be
considered late presenters,(4) and that baseline CD4 cell count is strongly
associated with the probability of progression to death.(13) Among late
presenters, there is significant short-term mortality, at a rate much higher
than those who receive an earlier HIV diagnosis.(3)

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References

(1) Sullivan, A., et al. Newly Diagnosed HIV Infections: Review in UK and
Ireland. BMJ. 2005; 330: 1301-2.

(2) Sanders, GD., et al. Cost-Effectiveness of Screening for HIV in the
Era of Highly Active Antiretroviral Therapy. N Engl J Med; 2005; 352; 6.

(3) Girardi, E., et al. Late Diagnosis of HIV Infection: Epidemiological
Features, Consequences and Strategies to Encourage Earlier Testing. J Acquir
Immune Defic Syndr. 2007; 46: S3-S8.

(4) Adler, A., et al. Late Diagnosis of HIV in Europe: Definitional and
Public Health Challenges. AIDS Care; 2008; 1-10.

(5) Castilla, J., et al. Late Diagnosis of HIV Infection in the Era of
Highly Active Antiretroviral Therapy: Consequences on AIDS Incidence. AIDS.
2002; 16: 1945-51.

(6) Delpierre, C., et al. High-Risk Groups for Late Diagnosis of HIV
Infection: A Need for Rethinking Testing Policy in the General Population.
AIDS Patient Care and STDs. 2006; 20: 838-47.

(7) Borghi, V., et al. Late Presenters in an HIV Surveillance System in
Italy During the Period 1992-2006. J Acquir Immune Defic Syndr. 2008; Nov 1;
49(3): 282-6.

(8) Brannstrom et al. Patients Unaware of their HIV Infection until AIDS
Diagnosis in Sweden 1996-2002 - A Remaining Problem in the Highly Active
Antiretroviral Therapy Era. INT J STD AIDS. 2005; 16: 702-6.

(9) BHIVA Treatment Guidelines Writing Group. British HIV Association
Guidelines for the Treatment of HIV-1-infected Adults with Antiretroviral
Therapy 2008. HIV Medicine. 2008; 9, 563-608.

(10) Hammer, S., et al. Antiretroviral Treatment of Adult HIV Infection -
2008 Recommendations of the International AIDS Society-USA Panel. JAMA. 2008;
300(5): 555-570.

(11) Hammer, SM., et al. Treatment of Adult HIV Infection: 2006
Recommendations of the International AIDS Society - USA. JAMA. 2006; 296(7)
P827-843.

(12) Girardi, E., et al. Delayed Presentation and Late testing for HIV:
Demographic and Behavioural Risk Factors in a Multicenter Study in Italy.
JAIDS. 2004; 36: 951-59.

(13) Egger, M., et al. Prognosis of HIV-1-infected Patients Starting
Highly Active Antiretroviral Therapy: A Collaborative Analysis of Prospective
Studies. Lancet. 2002 Jul 13; 360(9327): 119-29.

Source: Bristol-Myers Squibb

Caroline Almeida, Corporate and Business Communications, Bristol-Myers Squibb, caroline.almeida at bms.com, +44-01895-52-3519; or Jenny Bickett of CPR Worldwide, j.bickett at cprworldwideusa.com, or +44-020-8563-8745