Reduced delays in time to first HIV consultation after diagnosis in France in the antiretroviral therapy era: the possible role of a free care system

In high-income countries, late presentation to care can impair reductions in morbidity and mortality risks, increase the risk of HIV transmission at the population level, and prevent patients from experiencing the full benefits of advances in HIV treatment. Most relevant studies do not distinguish between late HIV diagnosis and delayed entry into care. Factors associated with the latter should be characterized to improve HIV care interventions at individual and public health levels. Estimates of the time from ‘diagnosis to care’ in the payable HIV care context vary considerably. Bamford et al. [1] reported a median time of 8 months in Philadelphia (2005–2006). Hospital in-patient/public clinic diagnosis, age 440 years and injecting drug use (IDU) were associated with delayed access [1]. Torian et al. reported that the first HIV care visits occurred 43 months after diagnosis for 19.1% of patients diagnosed in 2003 in New York City, while 17.2% of patients never initiated care. Factors associated with delayed access were diagnosis at centres without in situ care facilities, non-White race/ethnicity, IDU and non-USA birth [2]. Hamers and Phillips [3] estimated that 30% of HIV-infected individuals in Europe are undiagnosed. In France, HIV testing is routinely performed during pregnancy, following voluntary patient request, and for prisoners and patients with sexually transmitted infections or tuberculosis. Despite free testing and HIV care, two studies (FHDH [4] and VESPA [5]) demonstrated that, between 1996 and 2003, 35.7 and 33.1% of French seropositive patients, respectively, still experienced delayed access to care, which was defined as a CD4 count o200 cells/mL or AIDS-stage disease at presentation. However, neither study addressed the delay between diagnosis and first consultation for primary care. Using data from the VESPA [Agence Nationale de Recherche sur le SIDA (ANRS)-EN12] study, we determined time to first consultation after HIV diagnosis, and identified factors associated with delayed entry to care in the context of free access to diagnosis and care. The VESPA survey was conducted in out-patient hospitals [6]. Our study population consisted of 2932 patients (from 4963 eligible patients). Percentages of patients waiting 6 months for their first post-diagnosis HIV consultation within three specific diagnosis periods were 30.6% for 1982–1989 (n 5 840), 11.9% for 1990–1996 (n 5 1132), and 3.5% for 1997–2003 (n 5 945). Thanks to free and widespread care and antiretroviral therapy (ART) in France, in the most recent period considered, only a minority of HIV-positive people still experienced long delays between diagnosis and their first HIV care consultation. Multivariate analysis helped to determine individual correlates of late entry into care after diagnosis for those diagnosed from 1997 onwards (n 5 945), a key year in terms of widespread availability of protease inhibitors. The model was estimated using rare events logistic regression [7], for which the RELOGIT package in STATA (StataCorp LP, College Station, TX, USA) was employed. Factors associated with reporting a delay of 6 months before first consultation were: HIV diagnosis in a foreign country [odds ratio (OR) 11.8; 95% confidence interval (CI) 4.9–28.9; Po0.001]; history of IDU (OR 5.2; 95% CI 2.1–12.6; Po0.001); being a heterosexual man (OR 3.4; 95% CI 1.2–9.7; P 5 0.02); having a seropositive partner (OR 3.1; 95% CI 1.2–8.5; P 5 0.02); and being younger at the time of diagnosis (OR 0.92; 95% CI 0.87– 0.97; P 5 0.001). These characteristics are similar to those for ‘late testers’ in the VESPA study [5], except for age (associated with late diagnosis only). No significant association was found in terms of diagnosis setting or whether diagnosis was at the patient’s or healthcare provider’s request. In the context of free access to effective HIV care in the ART era, late entry into medical care is mainly attributable Correspondence: Dr Marie Suzan-Monti, INSERM, U912 (SE4S), 23 Rue Stanislas Torrents, Marseille 13006, France. Tel: 1 33 4 96 10 28 76; fax: 1 33 4 10 28 99; e-mail: marie.suzan@inserm.fr DOI: 10.1111/j.1468-1293.2010. 00893.x