Delayed presentation for human immunodeficiency virus (HIV) care among veterans: a problem of access or screening?

BACKGROUND: Despite the effectiveness of antiretroviral therapy, nearly half of patients entering human immunodeficiency virus (HIV) care have advanced disease. Many attribute this delay to poor access to healthcare. Others argue that delays will persist until routine screening is adopted. The Veterans Health Administration (VA) is a unique laboratory to examine whether access to comprehensive health benefits results in earlier entry into HIV care.
METHODS: Retrospective observational study of 4368 HIV-positive patients entering HIV care during 1998-2002 at VA medical centers nationwide. OUTCOMES OF INTEREST: rates of acquired immune deficiency syndrome in year of presentation; duration of VA utilization before HIV presentation; presence of "clinical triggers," signaling greater risk of HIV infection, before presentation.
RESULTS: Fifty-one percent (n = 2211) of all patients presented with CD4 counts of < 200 cells/mm. Thirty-nine percent (n = 1697) of all patients used other VA services before presentation for HIV care, with median duration of 3.6 years (interquartile range 25-75: 2.2-5.1 year) and 6 physician visits [interquartile range (IQR), 25-75: 2-18 visits] between first utilization and HIV presentation. No difference existed in the percentage presenting with CD4 counts <200 cells/mm among those with and without prior VA healthcare (50% vs. 51%, P = 0.76). Only 13% of those with prior VA healthcare demonstrated a clinical trigger before HIV presentation.
CONCLUSIONS: More than half of veterans entered HIV care with an acquired immune deficiency syndrome diagnosis at presentation irrespective of whether they had previously established healthcare in the VA. Access to care does not seem to be the primary cause of delayed HIV presentation. Widespread HIV screening is needed to improve rates of early detection.