BRIEF REPORT • OFID • 1 Open Forum Infectious Diseases BRIEF REPORT High Prevalence of Late-Stage Disease in Newly Diagnosed Human Immunodefciency Virus Patients in Sierra Leone George A. Yendewa, 1,2,3, Eva Poveda, 4 Sulaiman Lakoh, 5 Sahr A. Yendewa, 5 Darlinda F. Jiba, 5 Angel Salgado-Barreira, 6 Foday Sahr, 5,7 and Robert A. Salata 1,2 1 Department of Medicine, Case Western Reserve University, Cleveland, Ohio; 2 Division of Infectious Diseases and HIV Medicine, University Hospitals Cleveland Medical Center, Ohio; 3 Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland; 4 Group of Virology and Pathogenesis, Galicia Sur Health Research Institute (IIS Galicia Sur)-Complexo Hospitalario Universitario de Vigo, SERGAS-UVigo, Spain; 5 College of Medicine and Allied Health Sciences, University of Sierra Leone, Freetown; 6 Methodology and Statistics Unit, Galicia Sur Health Research Institute (IIS Galicia Sur)-Complexo Hospitalario Universitario de Vigo, SERGAS-UVigo, Spain; 7 34 Military Hospital, Republic of Sierra Leone Armed Forces, Freetown A high prevalence of late-stage disease (75.4%) and severe immunosuppression (23.3%) was observed in 155 newly diag- nosed human immunodefciency virus patients in Freetown, Sierra Leone during August to November 2017. Within the late- stage diagnosis group, a signifcantly high proportion of patients reported fever (84.2% vs 65.2%; P = .01), weight loss (82.2% vs 63.5%; P = .01), and malaise (89.7% vs 71.7%; P = .05). Fever was identifed as the only independent predictor of late-stage disease in this study. Keywords. HIV; late diagnosis; resource-limited settings; Sierra Leone. Late-stage human immunodefciency virus (HIV) diagnosis, defned as CD4 count <350 cells/μL cells and/or the presence of an acquired immune defciency syndrome (AIDS) defn- ing illness (ADI) at diagnosis [1] continues to present a major obstacle to eforts seeking to control the global HIV epidemic. Delayed HIV diagnosis has been associated with a higher inci- dence of adverse clinical events and complications [2], early mortality [3], and infation of treatment-related costs [4]. Furthermore, it is considered a key driver of HIV transmission in the general population by HIV-infected people who are una- ware of their status. Recent studies from East and Southern African countries have revealed that despite the expansion of HIV services across the region in recent years, late-stage diagnosis remains com- monplace, ranging from 33.6% to 65.5% of newly diagnosed HIV patients [5–7]. Tis broad range likely refects the hetero- geneity of the inherent population characteristics, sample sizes, study designs, and the CD4 cutof used. In comparison, data regarding late-stage diagnosis in the West African sub-region where immunological status was accessed by CD4 enumer- ation are scarce. One study from Guinea-Bissau (2005–2013) has reported a late-stage presentation rate of 71.8% [8], whereas another study from Nigeria recorded 85.4% during the period 2005–2010 [9]. Sierra Leone is a low-income country in West Africa where the HIV epidemic has long been regarded as low prevalence and stable, with an estimated countrywide HIV seroprevalence rate of 1.5 to 1.7% [10, 11]. However, the Ebola epidemic of 2014–2016 and other recent developmental challenges have led to considerable disruptions in HIV and other healthcare ser- vices, raising concerns that the HIV epidemic may in fact be escalating in the country [12]. Tis study is the frst to describe the clinical and immunological characteristics of newly diag- nosed HIV patients in Sierra Leone—2 objective parameters that could provide critical insight into the scale and direction of the HIV epidemic in the country. METHODS We conducted a cross-sectional study of 155 newly diagnosed HIV adult patients aged ≥18 years at Connaught Hospital in Freetown—the national referral hospital and site of the largest HIV clinic in Sierra Leone—from August through November 2017. The Institutional Review Board of University Hospitals Cleveland Medical Center granted a waiver and deferred to the Sierra Leone Ethical and Scientific Research Committee, which approved the study. After obtaining patient consent, we collected their demographic, clinical, and immunological data at the time of HIV diagnosis. Human immunodeficiency virus status was determined using the fourth-generation rapid test by SD Bioline HIV-1/2 3.0 (Standard Diagnostics, Inc.). The Alere Pima Analyzer (Abbott) was used for CD4 enumeration. This is a well validated point-of-care CD4 testing platform with proven comparable performance to flow cytometry-based methods, especially in resource-limited settings [13]. The GeneXpert MTB/RIF assay (Cepheid) and sputum AFB smear with/with- out chest radiography was used to determine tuberculosis pos- itive status. Late-stage disease (CD4 <350 cells/μL) was further stratified into AIDS (CD4 <200 cells/μL and/or presence of ADI Open Forum Infectious Diseases ® © The Author(s) 2018. Published by Oxford University Press on behalf of Infectious Diseases Society of America. This is an Open Access article distributed under the terms of the Creative Commons Attribution-NonCommercial-NoDerivs licence (http://creativecommons.org/licenses/ by-nc-nd/4.0/), which permits non-commercial reproduction and distribution of the work, in any medium, provided the original work is not altered or transformed in any way, and that the work is properly cited. For commercial re-use, please contact journals.permissions@oup.com DOI: 10.1093/ofd/ofy208 Received 26 June 2018; editorial decision 20 August 2018; accepted 20 August 2018. Correspondence: G. A. Yendewa, MD, MPH and TM, Division of Infectious Diseases and HIV Medicine, University Hospitals Cleveland Medical Center, 11100 Euclid Ave., Cleveland, OH 44106 (gay7@case.edu). Downloaded from https://academic.oup.com/ofid/article/5/9/ofy208/5078457 by guest on 06 November 2022