Understanding delay to medical care for HIV infection: the long-term non-presenter

Objective: To examine delayed presentation for HIV testing and primary care in the second decade of the AIDS epidemic. Design: Cohort study in two urban hospitals in the USA between February 199 4 and April 1996. Methods: A total of 203 consecutive outpatients on initial HIV primary care presentation were interviewed about sociodemographic characteristics, alco hol and drug use, social support, sexual practices, HIV testing, awareness of possible HIV infection, and CD4 cell count. Main outcome measure: Duration of delay to medical presentation in years ba sed on CD4 cell count, factors independently associated with low CD4 cell c ounts, frequency of awareness of HIV risk before testing. Results: The estimated mean duration between acquiring HIV infection and in itial presentation to primary care was 8.1 years (95% CI 7.5, 8.6) based on our cohort's median initial CD4 cell count of 280/mul. Male sex, older age , and no jail time were associated with lower CD4 cell counts; 34% reported not being aware that they were at risk of HIV before testing. Heterosexual intercourse as a risk behavior for HIV was the most statistically signific ant factor for personal unawareness of HIV risk. Of those who acknowledged awareness, the mean time between awareness of HIV risk and testing was 2.5 years (median 1.0 year). Conclusion: In the pre-highly active antiretroviral therapy era, HIV-infect ed patients frequently initiated primary medical care years after initial i nfection, at a time of advanced immunosuppression. Over one-third of HIV-in fected patients were not cognisant of their HIV risk before testing, a cond ition significantly associated with heterosexual intercourse as the only HI V risk behavior. (C) 2001 Lippincott Williams & Wilkins.