Immune status at presentation to care did not improve among antiretroviral-naive persons from 1990 to 2006. Clin Infect Dis 2007

(See the editorial commentary by Goicoechea and Smith on pages 1375–6) Background. Human immunodeficiency virus (HIV) prevention initiatives to improve access to HIV services have increased over time. Despite this, 1250,000 cases of HIV infection in the United States are undiagnosed, and many infected persons do not present for care until their HIV infection is advanced. Late presentation may increase the risk of HIV transmission and make HIV infection more difficult to treat effectively. With more effective HIV therapy, it was hoped that patients might present earlier in their disease course. Methods. To assess immune status and time of HIV diagnosis in patients who newly presented for care, we analyzed data for the period 1990–2006 from patients who were antiretroviral naive at presentation to the Johns Hopkins HIV Clinic in Baltimore, Maryland. We compared CD4+ cell count and time from HIV diagnosis at presentation by demographic characteristics at enrollment. Results. The median presenting CD4+ cell count decreased from 371 cells/mm3 during 1990–1994 to 276 cells/ mm3 during 2003–2006 ( ) overall and decreased within individual demographic groups. There was also aP!.01 decrease in the median time from HIV diagnosis to presentation for care (271 days in 1990–1994 to 196 days in 2003–2006;). Multivariate analysis revealed that, in addition to CD4+ cell count at presentation, male sexP!.01 was associated with lower CD4+ cell counts (93 cells/mm3), as was black race (71 cells/mm3) and older age (20 cells/mm3 per 10 years). Conclusions. There has been a decrease in time from diagnosis of HIV infection to presentation for care, coupled with an increase in the severity of immunocompromise at time of presentation, over the past 16 years in Maryland. New strategies to provide earlier HIV testing and referral into care are urgently needed. Innovative care models to improve access to HIV ser-vices along with HIV prevention initiatives in the United States have evolved over time to address the medical needs of HIV-infected persons and the public health need to contain the spread of the virus. In 1990