Impact of late presentation of HIV infection on short-, mid- and long-term mortality and causes of death in a multicenter national cohort: 2004-2013

Objectives: To analyze the impact of late presentation (LP) on overall mortality and causes of death and describe LP trends and risk factors (2004-2013). Methods: Cox models and logistic regression were used to analyze data from a nation-wide cohort in Spain. LP is defined as being diagnosed when CD4 < 350 cells/ml or AIDS. Results: Of 7165 new HIV diagnoses, 46.9% (CI_95%:45.7-48.0) were LP, 240 patients died.First-year mortality was the highest (aHR_LP.vs.nLP = 10.3[CI_95%:5.5-19.3]); between 1 and 4 years post-diagnosis, aHR_LP.vs.nLP = 1.9(1.2-3.0); and >4 years, aHR_LP.vs.nLP = 1.5(0.7-3.1).First-year's main cause of death was HIV/AIDS (73%); and malignancies among those surviving >4 years (32%). HIV/AIDS-related deaths were more likely in LP (59.2% vs. 25.0%; p < 0.001). LP declined from 55.9% (2004-05) to 39.4% (2012-13), and reduced in 46.1% in men who have sex with men (MSM) and 37.6% in heterosexual men, but increased in 22.6% in heterosexual women.Factors associated with LP: sex (OR_MEN.vs.WOMEN = 1.4[1.2-1.7]); age (OR_31-40.vs.<30 = 1.6[1.4-1.8], OR_41-50.vs.<30 = 2.2[1.8-2.6], OR_>50.vs.<30 = 3.6[2.9-4.4]); behavior (OR_{InjectedDrugUse.vs.MSM} = 2.8[2.0-3.8]; OR_{Heterosexual.vs.MSM} = 2.2[1.7-3.0]); education (OR_{PrimaryEducation.vs.University} = 1.5[1.1-2.0], OR_{LowerSecondary.vs.University} = 1.3[1.1-1.5]); and geographical origin (OR_{Sub - Saharan.vs.Spain} = 1.6[1.3-2.0], OR_{Latin-American.vs.Spain} = 1.4[1.2-1.8]). Conclusions: LP is associated with higher mortality, especially short-term- and HIV/AIDS-related mortality. Mid-term-, but not long-term mortality, remained also higher in LP than nLP. LP decreased in MSM and heterosexual men, not in heterosexual women. The groups most affected by LP are low educated, non-Spanish and heterosexual women.