Improving the evidence for indicator condition guided HIV testing in Europe: Results from the HIDES II Study - 2012 - 2015

High acceptability of point-of-care HIV testing at the colposcopy outpatient clinic in hospitals in the Netherlands

OBJECTIVE

Cervical cancer and its precursor are labeled as HIV indicator conditions, justifying the recommendation of HIV testing for all patients. This study aimed to assess the acceptance and patients' and gynecologists' perceptions on HIV testing in patients with cervical dysplasia at the colposcopy outpatient clinic in hospitals in the Netherlands.

METHODS

A cross-sectional study was conducted between May 2021 and February 2023 to implement point-of-care HIV testing in five hospitals in the Rotterdam region, the Netherlands. We included patients aged 18 years and older, without documented HIV, presenting with cervical dysplasia. The primary outcome was the HIV test acceptance rate. Secondary outcomes were the HIV positivity rate and the association between dysplasia severity and test acceptance. We also assessed patients' and gynecologists' perspectives on this testing strategy with a questionnaire.

RESULTS

Of 563 patients, 523 accepted HIV testing, resulting in a test acceptance rate of 92.9% (95% confidence interval, 90.45%-94.88%). Testing rates were consistent among participating hospitals (91.6%-100.0%) None of the patients tested positive for HIV. Severity of dysplasia was not associated with test acceptance (P = 0.768). Most patients (n = 500, 96.0%) reported good or higher experience with this testing strategy. The main barriers for gynecologists to offer HIV testing were lack of time (n = 22, 33.9%) and fear to offend a patient (n = 7, 12.5%). Less than half (n = 19, 39.3%) of gynecologists believed an HIV test should be offered to all patients with cervical dysplasia.

CONCLUSION

Point-of-care HIV testing at colposcopy outpatient clinics was well accepted by patients. The data indicate that the primary barrier lies with the physicians to offer such testing.

Analysis of the reasons for requesting HIV serology in the emergency department other than those defined in the targeted screening strategy of the "Urgències VIHgila" program and its potential inclusion in a future consensus document

OBJECTIVE

To describe other reasons for requesting HIV serology in emergency departments (ED) other than the 6 defined in the SEMES-GESIDA consensus document (DC-SEMES-GESIDA) and to analyze whether it would be efficient to include any of them in the future.

METHODS

Review of all HIV serologies performed during 2 years in 20 Catalan EDs. Serologies requested for reasons not defined by the DC-SEMES-GESIDA were grouped by common conditions, the prevalence (IC95%) of seropositivity for each condition was calculated, and those whose 95% confidence lower limit was >0.1% were considered efficient. Sensitivity analysis considered that serology would have been performed on 20% of cases attended and the remaining 80% would have been seronegative.

RESULTS

There were 8044 serologies performed for 248 conditions not recommended by DC-SEMES-GESIDA, in 17 there were seropositive, and in 12 the performance of HIV serology would be efficient. The highest prevalence of detection corresponded to patients from endemic countries (7.41%, 0.91-24.3), lymphopenia (4.76%, 0.12-23.8), plateletopenia (4.37%, 1.20-10.9), adenopathy (3.45%, 0.42-11.9), meningoencephalitis (3.12%, 0.38-10.8) and drug use (2.50%, 0.68-6.28). Sensitivity analysis confirmed efficiency in 6 of them: endemic country origin, plateletopenia, drug abuse, toxic syndrome, behavioral-confusional disorder-agitation and fever of unknown origin.

CONCLUSION

The DC-SEMES-GESIDA targeted HIV screening strategy in the ED could efficiently include other circumstances not previously considered; the most cost-effective would be origin from an endemic country, plateletopenia, drug abuse, toxic syndrome, behavioral-confusional-agitation disorder and fever of unknown origin.

Missed opportunities for early HIV diagnosis in Greece: The MORFEAS study, 2019 to 2021

BackgroundLate HIV diagnosis (CD4+ T-cell count < 350 cells/μL, or with an AIDS-defining event) remains a persistent challenge in Greece, indicating potential missed opportunities (MOs) for earlier testing.AimTo determine the frequency of HIV indicator conditions (ICs) preceding diagnosis and to quantify MOs for earlier testing at a nationwide level in Greece.MethodsThis multicentre retrospective study analysed data on 823 antiretroviral therapy-naive adults (≥ 18 years) diagnosed with HIV during 2019-21. Medical records were reviewed to identify pre-diagnosis healthcare contacts (HCCs) and ICs justifying HIV testing. Univariable and multivariable logistic regression identified factors associated with ≥ 1 MO. A Bayesian model estimated the time from seroconversion to diagnosis.ResultsAmong 517 participants with HCC data, 249 had ≥ 1 HCC. Of these, 59.0% (147/249) were late presenters. These cases had 365 HCCs, and 191 (52.3%) were MOs for testing. The most common ICs were sexually transmitted infections (39.8%; 76/191) and fever (11.0%; 21/191). Non-Greek origin was associated with lower odds of experiencing ≥ 1 MO (adjusted odds ratio: 0.48; 95% CI: 0.22─1.02), while higher education increased odds of MOs for early HIV diagnosis. Median time from seroconversion to diagnosis was 3.2 years for the full sample and 3.7 years for those with HCC, with about half of the latter reporting MOs post-estimated seroconversion. Recognising MOs would have potentially spared approximately 1 year of delay in diagnosis.ConclusionMOs for earlier HIV diagnosis were prevalent in Greece. Leveraging IC-guided testing and addressing barriers could support earlier diagnosis and treatment, limiting adverse health outcomes and preventing transmission.

Knowledge and Awareness of Risk Factors for HIV Infection and about HIV Testing among Medical Students in Warsaw

BACKGROUND

The number of late diagnoses of HIV remains very high in Poland, leading to a high proportion of patients developing and dying of HIV-related diseases. The main reason for this is the very low utilization of HIV testing. Our analyses aimed to investigate knowledge about the indications for HIV testing among medical university students, as well as identify their own HIV testing experiences.

MATERIAL AND METHODS

A cross-sectional survey study was designed to collect information on the students' demographics and their experiences of HIV testing, as well as their knowledge of virus transmission and the indications for testing. Data were collected as part of the HIV_week@WUM project conducted at the Medical University of Warsaw in parallel with the 18th European AIDS Conference, which took place in Warsaw between 18 and 21 October 2023.

RESULTS

In total, 545 questionnaires were collected. The median age of the study participants was 20 (interquartile range (IQR): 19-22 years). The majority of respondents were as follows: women (67.5%), born in Poland (97.8%), and were attending the medical faculty (56.7%). Only 114 (21.43%) participants had ever been tested for HIV. For all modes of HIV transmission, most of the respondents overestimated the risk of acquiring HIV, but, at the same time, they had never been tested for HIV.

CONCLUSIONS

Only one in five health sciences students has ever had a test for HIV, which is less than estimates for the general population of Warsaw. There is an ongoing need to popularize testing among future health care providers in order to address both the indications for testing for individuals and the better use of HIV testing in clinical practice.

Early diagnosis of HIV cases by means of text mining and machine learning models on clinical notes

Undiagnosed and untreated human immunodeficiency virus (HIV) infection increases morbidity in the HIV-positive person and allows onward transmission of the virus. Minimizing missed opportunities for HIV diagnosis when a patient visits a healthcare facility is essential in restraining the epidemic and working toward its eventual elimination. Most state-of-the-art proposals employ machine learning (ML) methods and structured data to enhance HIV diagnoses, however, there is a dearth of recent proposals utilizing unstructured textual data from Electronic Health Records (EHRs). In this work, we propose to use only the unstructured text of the clinical notes as evidence for the classification of patients as suspected or not suspected. For this purpose, we first compile a dataset of real clinical notes from a hospital with patients classified as suspects and non-suspects of having HIV. Then, we evaluate the effectiveness of two types of classification models to identify patients suspected of being infected with the virus: classical ML algorithms and two Large Language Models (LLMs) from the biomedical domain in Spanish. The results show that both LLMs outperform classical ML algorithms in the two settings we explore: one dataset version is balanced, containing an equal number of suspicious and non-suspicious patients, while the other reflects the real distribution of patients in the hospital, being unbalanced. We obtain F1 score figures of 94.7 with both LLMs in the unbalanced setting, while in the balance one, RoBERTaBio model outperforms the other one with a F1 score of 95.7. The findings indicate that leveraging unstructured text with LLMs in the biomedical domain yields promising outcomes in diminishing missed opportunities for HIV diagnosis. A tool based on our system could assist a doctor in deciding whether a patient in consultation should undergo a serological test.

Missed Opportunities for HIV Diagnosis and Their Clinical Repercussions in the Portuguese Population-A Cohort Study

Late human immunodeficiency virus (HIV) diagnosis has been associated with missed opportunities for earlier diagnosis. We conducted a retrospective, longitudinal, single-centre cohort study evaluating these missed opportunities and their clinical repercussions in adults with a new HIV diagnosis or who were drug-naïve, who attended our Infectious Diseases Department between 2018 and 2023. We assessed missed opportunities in the two years prior to diagnosis or after the last negative HIV test. We compared clinical and laboratorial data from individuals with and without missed opportunities. The primary outcome considered was AIDS-defining conditions at diagnosis. Among the 436 included individuals, 27.1% experienced at least one missed opportunity. Those with missed opportunities were more likely to be female (p = 0.007), older at their first consultation (p < 0.001), born in Africa (p < 0.001) and in countries with a high HIV prevalence (p < 0.001), and have heterosexual transmission (p < 0.001). The adjusted analysis showed that missed opportunities were significantly associated with AIDS-defining conditions at diagnosis (OR 3.23, CI 95% [1.62-6.46], p < 0.001). These findings highlight the impact of missed opportunities on HIV severity, underscoring the need for more targeted interventions to reduce them.

Prevalence of HIV in people with potential HIV-indicator conditions in Germany: an analysis of data from statutory health insurances

Background

In care of people living with human immunodeficiency virus (HIV), early diagnosis of infection is one of the greatest challenges remaining. A promising approach to increase early diagnosis could be optimized HIV testing in persons with indicator conditions (ICs). ICs are conditions which are AIDS-defining in people living with HIV, conditions that may have significant adverse consequences for the individual's clinical management if the presence of HIV infection is not detected, and conditions with an (undiagnosed) HIV prevalence of ≥0.1%.

Methods

In this cohort study, anonymous routine healthcare data of German statutory health insurances from 07/01/2016 to 06/30/2021 based on insured persons with an ICD-10-based diagnosis of selected ICs were analyzed. In a primary analysis, two stratifications (gender and age), and four sensitivity analyses HIV prevalence/incidence were calculated for persons with at least one of 26 IC described in international literature. This study is registered in the German Clinical Trials Register (identifier: DRKS0002874).

Findings

Routine healthcare data from 513,509 insured persons were selected for analysis. In the primary analysis, only in malignant neoplasm of bronchus and lung a HIV prevalence was observed with a 95%-CI < 0.1%. ICs with particularly high HIV prevalence were pneumocystosis (40.33%), oral hairy leukoplakia (36.71%), and Kaposi's sarcoma (29.86%). When stratified by gender, it was observed that in female patients, the 95%-CI of HIV prevalence fell below 0.1% for seven ICs. No such effect was observed in male patients. Stratified by age, among patients aged 30 to <60 years, the 95%-CI of HIV prevalence were always ≥0.1%, while in the other groups the 95%-CI fell below 0.1% for several ICs.

Interpretation

In samples of patients with ICs in Germany, HIV prevalences/incidences were found to be ≥0.1% for all ICs except malignant neoplasm of bronchus and lung. This confirms the classification of these conditions as ICs for the German context and emphasizes the importance of HIV testing in these populations.

Funding

This analysis is part of the HIV testing recommendations in guidelines and practice study (German title of the study: "HIV-Testempfehlungen in Leitlinien und Praxis"; acronym: HeLP), which is funded by the German Federal Joint Committee as part of the Innovationsfonds program to further develop the German healthcare system (funding number 01VSF21050).

Missed Opportunities in HIV Testing in Turkiye: Implications for Late Diagnoses

BACKGROUND

Late diagnosis of HIV infection is a major global problem. In Turkiye, only 41%-50% of people living with HIV are diagnosed, suggesting that many opportunities for HIV testing might be missed.

SETTING

The aim of this study was to determine the missed testing opportunities for HIV in healthcare settings in Turkiye and the predictors for missed opportunities (MOs).

METHODS

The study included patients with a new HIV diagnosis, presenting to care between January 2018 and December 2020. They were given a verbal questionnaire face to face, by a telephone call or an online meeting for visits to a health care setting within the year before their diagnosis. Electronic medical records were also examined.

RESULTS

The sample included 198 patients with at least 1 visit to any health care setting, with a total of 1677 visits. Patients had an indication for HIV testing in 51.3% (861/1677) of the visits; an HIV test was not offered in 77.9% (671/861) and was considered a MO. The highest number of MOs was in emergency departments (59.8%) (180/301). The most common reason for visiting was constitutional symptoms and indicator conditions (55.4%) (929/1677). University graduates and those with a CD4+ T-cell count <200/mm 3 were more likely to have a MO.

CONCLUSIONS

Many opportunities to diagnose HIV at an early stage are missed in health care settings in Turkiye. Considering the rapidly increasing number of new diagnoses in the last decade, urgent action needs to be taken.

Enhancing indicator condition-guided HIV testing in Taiwan: a nationwide case-control study from 2009 to 2015

BACKGROUND

Although indicator condition (IC)-guided HIV testing (IC-HIVT) is effective at facilitating timely HIV diagnosis, research on IC categories and the related HIV risk in Taiwan is limited. To improve the adoption and spread of IC-HIVT in Taiwan, this study compared the IC categories of people living with HIV (PLWH) and non-HIV controls and investigated delays in the diagnosis of HIV infection.

METHODS

This nationwide, retrospective, 1:10-matched case-control study analyzed data from the Notifiable Diseases Surveillance System and National Health Insurance Research Database to evaluate 42 ICs for the 5-year period preceding a matched HIV diagnostic date from 2009 to 2015. The ICs were divided into category 1 ICs (AIDS-defining opportunistic illnesses [AOIs]), category 2 ICs (diseases associated with impaired immunity or malignancy but not AOIs), category 3 ICs (ICs associated with sexual behaviors), and category 4 ICs (mononucleosis or mononucleosis-like syndrome). Logistic regression was used to evaluate the HIV risk associated with each IC category (at the overall and annual levels) before the index date. Wilcoxon rank-sum test was performed to assess changes in diagnostic delays following an incident IC category by HIV transmission routes.

RESULTS

Fourteen thousand three hundred forty-seven PLWH were matched with 143,470 non-HIV controls. The prevalence results for all ICs and category 1-4 ICs were, respectively, 42.59%, 11.16%, 15.68%, 26.48%, and 0.97% among PLWH and 8.73%, 1.05%, 4.53%, 3.69%, and 0.02% among non-HIV controls (all P < 0.001). Each IC category posed a significantly higher risk of HIV infection overall and annually. The median (interquartile range) potential delay in HIV diagnosis was 15 (7-44), 324.5 (36-947), 234 (13-976), and 74 (33-476) days for category 1-4 ICs, respectively. Except for category 1 for men who have sex with men, these values remained stable across 2009-2015, regardless of the HIV transmission route.

CONCLUSIONS

Given the ongoing HIV diagnostic delay, IC-HIVT should be upgraded and adapted to each IC category to enhance early HIV diagnosis.

HIV: Inflammatory dermatoses

Patients living with HIV may experience a variety of inflammatory dermatoses, ranging from exacerbations of underlying conditions to those triggered by HIV infection itself. This article presents a current literature review on the etiology, diagnosis and management of atopic dermatitis, psoriasis, pityriasis rubra pilaris, lichen planus, seborrheic dermatitis, eosinophilic folliculitis, pruritic papular eruption and pruritus, in patients living with HIV.

Missed opportunities in the early detection of HIV infection in patients with sexually transmitted infections: A real-life study

INTRODUCTION

Sexually transmitted diseases such as cervicitis, proctitis and urethritis are associated with high rates of HIV infection. When these pathologies are suspected, HIV serology should be requested.

MATERIAL AND METHODS

A retrospective study was performed during 2018 at the Hospital Costa del Sol (Marbella, Málaga, Spain). HIV serologies requested in patients who were asked for PCR for Chlamydia trachomatis and Neisseria gonorrhoeae were reviewed.

RESULTS

A total of 1818 patients were evaluated, in which HIV serology was performed in 44.7%, of which 14 (1.7%) were positive. The remaining 55.3% were missed diagnostic opportunities.

CONCLUSIONS

C. trachomatis and N. gonorrhoeae infections are associated with a high rate of occult HIV infection. The degree of suspicion of HIV in this population remains low and it is essential that it be reinforced in the presence of the possibility of infection by these pathologies.

Feasibility of a selective targeted strategy of HIV testing in emergency departments: a before-after study

BACKGROUND AND IMPORTANCE

The rates of hidden infection and late diagnosis of HIV still remain high in Western countries. Missed diagnostic opportunities represent the key point in changing the course of the epidemic.

OBJECTIVE

To evaluate the feasibility and results of implementation of a selective strategy to test for HIV in the emergency department (ED) in patients with six pre-defined medical situations: sexually transmitted infections, herpes zoster, community-acquired pneumonia, mononucleosis syndrome, practice of chemsex (CS) or request of post-exposure prophylaxis.

DESIGN

This quasi-experimental longitudinal study evaluated the pre- and post-implementation results of HIV testing in the six aforementioned clinical scenarios.

SETTINGS AND PARTICIPANTS

Patients attended 34 Spanish EDs.

INTERVENTION OR EXPOSURE

The intervention was an intensive educational program and pathways to facilitate and track orders and results were designed. We collected and compared pre- and post-implementation ED census and diagnoses, and HIV tests requested and results.

OUTCOME MEASURES AND ANALYSIS

The main outcome was adherence to the recommendations. Secondary outcomes were to evaluate the effectiveness of the program by the rate of positive test and the new HIV diagnoses. Differences between first and second periods were assessed. The magnitude of changes (absolute and relative) was expressed with the 95% confidence interval (CI).

MAIN RESULTS

HIV tests increasing from 7080 (0.42% of ED visits) to 13 436 (relative increase of 75%, 95% CI from 70 to 80%). The six conditions were diagnosed in 15 879 and 16 618 patients, and HIV testing was ordered in 3393 (21%) and 7002 (42%) patients (increase: 97%; 95% CI: 90-104%). HIV testing significantly increased for all conditions except for CS. The positive HIV test rates increased from 0.92 to 1.67%. Detection of persons with undiagnosed HIV increased from 65 to 224, which implied a 220% (95% CI: 143-322%) increase of HIV diagnosis among all ED comers and a 71% (95% CI: 30-125%) increase of positive HIV tests.

CONCLUSION

Implementation of a strategy to test for HIV in selective clinical situations in the ED is feasible and may lead to a substantial increase in HIV testing and diagnoses.

Systematic Review: Strategies for Improving HIV Testing and Detection Rates in European Hospitals

Undiagnosed HIV infection is a prominent clinical issue throughout Europe that requires the continuous attention of all healthcare professionals and policymakers to prevent missed testing opportunities and late diagnosis. This systematic review aimed to evaluate interventions to increase HIV testing rates and case detection in European hospitals. Out of 4598 articles identified, 29 studies fulfilled the selection criteria. Most of the studies were conducted in single Western European capital cities, and only one study was from Eastern Europe. The main interventions investigated were test-all and indicator-condition-based testing strategies. Overall, the prevalence of undiagnosed HIV was well above 0.1%. The studied interventions increased the HIV testing rate and the case detection rate. The highest prevalence of undiagnosed HIV was found with the indicator-condition-driven testing strategy, whereas the test-all strategy had the most profound impact on the proportion of late diagnoses. Nevertheless, the HIV testing rates and case-finding varied considerably across studies. In conclusion, effective strategies to promote HIV testing in European hospitals are available, but relevant knowledge gaps regarding generalizability and sustainability remain. These gaps require the promotion of adherence to HIV testing guidelines, as well as additional larger studies representing all European regions.

The use and impact of European Testing Week regional awareness campaigns to increase HIV and viral hepatitis testing coverage

INTRODUCTION

Since 2013, the European Testing Week (ETW) awareness campaign has become a key regional event influencing testing efforts for HIV, viral hepatitis, and sexually transmitted infections (STIs) through participation of 720 organizations. Here, we report on a survey from May to June 2022 aimed at assessing the participant-reported impact of the campaign.

METHODS

All past and current participating organizations were asked to complete an online questionnaire between 12 May and 17 June 2022. Multiple choice and open-text questions included organization information, usage of ETW to engage in local testing-related activities, and the effect of a regional campaign to reach a wider audience and generate impact.

RESULTS

Of the 52 respondents, 34 (65%) stated first participating in ETW 5-10 years ago. ETW was used for awareness raising by 40 respondents (83%), new testing activities by 37 (77%), advocacy initiatives by 15 (31%), and training/capacity building by 18 (38%). For awareness raising, 95% used ETW to highlight the importance of and to encourage testing; for new testing activities, 74% used ETW to reach new groups. In total, 44 (85%) reported added benefits of a Europe-wide campaign compared with national/local campaigns, particularly the increased visibility and collaboration opportunities. Impact at the local level was observed by 24 (51%), and impact at a national level was observed by 20 (43%). A total of 28 (79%) reported increases in the number of tests performed and 25 (75%) reported increases in clients accessing services.

CONCLUSIONS

Regional awareness campaigns reach wider audiences, boost local and national efforts to increase testing, and sensitize key populations about the critical value of testing compared with local/national campaigns.

Prevalence, characteristics and challenges of late HIV diagnosis in Germany: an expert narrative review

PURPOSE

We aimed to review the landscape of late HIV diagnosis in Germany and discuss persisting and emerging barriers to earlier diagnosis alongside potential solutions.

METHODS

We searched PubMed for studies informing the prevalence, trends, and factors associated with late HIV diagnosis in Germany. Author opinions were considered alongside relevant data.

RESULTS

In Germany, older individuals, heterosexuals, and migrants living with HIV are more likely to be diagnosed late. The rate of late diagnosis in men who have sex with men (MSM), however, continues to decrease. Indicator conditions less often prompt HIV testing in women and non-MSM. During the COVID-19 pandemic, the absolute number of late diagnoses fell in Germany, but the overall proportion increased, probably reflecting lower HIV testing rates. The Ukraine war and subsequent influx of Ukrainians living with HIV may have substantially increased undiagnosed HIV cases in Germany. Improved indicator testing (based on unbiased assessments of patient risk) and universal testing could help reduce late diagnoses. In patients who receive a late HIV diagnosis, rapid treatment initiation with robust ART regimens, and management and prevention of opportunistic infections, are recommended owing to severely compromised immunity and increased risks of morbidity and mortality.

CONCLUSION

Joint efforts are needed to ensure that UNAIDS 95-95-95 2030 goals are met in Germany. These include greater political will, increased funding of education and testing campaigns (from government institutions and the pharmaceutical industry), continued education about HIV testing by HIV experts, and broad testing support for physicians not routinely involved in HIV care.

Optimization of HIV testing services in Germany using HIV indicator diseases: study protocol of the HeLP study

BACKGROUND

Despite the potentially accompanying negative clinical, epidemiologic, and health economic effects, a large proportion of persons living with the human immunodeficiency virus (HIV) are diagnosed late. Internationally, numerous diseases are known to be HIV indicator diseases. Adequate HIV testing in the presence of HIV indicator diseases could help to diagnose unknown HIV infections earlier. The objective of the HeLP study is to validate published HIV indicator diseases for the German setting and to identify guidelines in terms of these indicator diseases in order to reduce knowledge gaps and increase HIV testing when HIV indicator diseases are diagnosed.

METHODS

A mixed methods approach is used. In a first step, published HIV indicator diseases will be identified in a systematic literature review and subsequently discussed with clinical experts regarding their relevance for the German setting. For the validation of selected indicator diseases different data sets (two cohort studies, namely HIV-1 seroconverter study & ClinSurv-HIV, and statutory health insurance routine data) will be analyzed. Sensitivity analyses using different time periods will be performed. Guidelines of HIV indicator diseases validated in the HeLP study will be reviewed for mentioning HIV and for HIV testing recommendations. In addition, semi-standardized interviews (followed by a free discussion) with guideline creators will identify reasons why HIV testing recommendations were (not) included. Subsequently, a random sample of physicians in medical practices will be surveyed to identify how familiar physicians are with HIV testing recommendations in guidelines and, if so, which barriers are seen to perform the recommended tests in everyday care.

DISCUSSION

The HeLP-study adopts the challenge to validate published HIV indicator diseases for the German setting and has the potential to close a knowledge gap regarding this objective. This has the potential to improve targeted HIV testing for patients with HIV indicator diseases and consequently lead to earlier HIV diagnosis.

TRIAL REGISTRATION

DRKS00028743.

HIV Late Presenters in Asia: Management and Public Health Challenges

Many individuals are diagnosed with human immunodeficiency virus (HIV) infection at an advanced stage of illness and are considered late presenters. We define late presentation as a CD4 cell count below 350 cells/mm³ at the time of HIV diagnosis, or presenting with an AIDS-defining illness regardless of CD4 count. Across Asia, an estimated 34-72% of people diagnosed with HIV are late presenters. HIV late presenters generally have a higher disease burden and higher comorbidity such as opportunistic infections than those who are diagnosed earlier. They also have a higher mortality rate and generally exhibit poorer immune recovery following combined antiretroviral therapy (cART). As such, late HIV presentation leads to increased resource burden and costs to healthcare systems. HIV late presentation also poses an increased risk of community transmission since the transmission rate from people unaware of their HIV status is approximately 3.5 times higher than that of early presenters. There are several factors which contribute to HIV late presentation. Fear of stigmatisation and discrimination are significant barriers to both testing and accessing treatment. A lack of perceived risk and a lack of knowledge by individuals also contribute to late presentation. Lack of referral for testing by healthcare providers is another identified barrier in China and may extend to other regions across Asia. Effective strategies are still needed to reduce the incidence of late presentation across Asia. Key areas of focus should be increasing community awareness of the risk of HIV, reducing stigma and discrimination in testing, and educating healthcare professionals on the need for early testing and on the most effective ways to engage with people living with HIV. Recent initiatives such as intensified patient adherence support programs and HIV self-testing also have the potential to improve access to testing and reduce late diagnosis.

HIV-Indicator Condition Guided Testing in a Hospital Setting

Late diagnosis is still a major issue in HIV infection management, leading to important consequences for both patients and community. In this perspective, HIV screening targeted on some clinical conditions (HIV indicator conditions-HIVICs) emerged as a useful strategy, also involving patients not considered at high behavioral risk. We organized an in-hospital HIVICs guided screening campaign named ICEBERG in Milan, Italy, between 2019 and 2021. Among the 520 subjects enrolled, mainly presenting with viral hepatitis or mononucleosis-like syndrome, 20 resulted HIV positive (3.8% prevalence). A significant proportion of them had multiple conditions and advanced immunosuppression, with 40% being AIDS-presenters. As adherence to the screening campaign was modest for non-ID specialists, educational interventions to raise clinicians' sensitivity are urgently needed. HIV-ICs guided testing was confirmed as a useful tool, but a combined approach with other screening strategies seems to be essential for early HIV diagnosis.

Mapping hematologists' HIV testing behavior among lymphoma patients-A mixed-methods study

BACKGROUND

HIV testing among patients with malignant lymphoma (PWML) is variably implemented. We evaluated HIV testing among PWML, and mapped factors influencing hematologists' testing behavior.

MATERIALS

We conducted a mixed-methods study assessing HIV testing among PWML, factors influencing HIV testing and opportunities for improvement in five hospitals in the region of Amsterdam, the Netherlands. The proportion of PWML tested for HIV within 3 months before or after lymphoma diagnosis and percentage positive were assessed from January 2015 through June 2020. Questionnaires on intention, behavior and psychosocial determinants for HIV testing were conducted among hematologists. Through twelve semi-structured interviews among hematologists and authors of hematology guidelines, we further explored influencing factors and opportunities for improvement.

FINDINGS

Overall, 1,612 PWML were included for analysis, including 976 patients newly diagnosed and 636 patients who were referred or with progressive/relapsed lymphoma. Seventy percent (678/976) of patients newly diagnosed and 54% (343/636) of patients with known lymphoma were tested for HIV. Overall, 7/1,021 (0.7%) PWML tested HIV positive, exceeding the 0.1% cost-effectiveness threshold. Questionnaires were completed by 40/77 invited hematologists, and 85% reported intention to test PWML for HIV. In the interviews, hematologists reported varying HIV testing strategies, including testing all PWML or only when lymphoma treatment is required. Recommendations for improved HIV testing included guideline adaptations, providing electronic reminders and monitoring and increasing awareness.

CONCLUSIONS

Missed opportunities for HIV testing among PWML occurred and HIV test strategies varied among hematologists. Efforts to improve HIV testing among PWML should include a combination of approaches.

National medical specialty guidelines of HIV indicator conditions in Europe lack adequate HIV testing recommendations: a systematic guideline review

BackgroundAdequate identification and testing of people at risk for HIV is fundamental for the HIV care continuum. A key strategy to improve timely testing is HIV indicator condition (IC) guided testing.AimTo evaluate the uptake of HIV testing recommendations in HIV IC-specific guidelines in European countries.MethodsBetween 2019 and 2021, European HIV experts reviewed guideline databases to identify all national guidelines of 62 HIV ICs. The proportion of HIV IC guidelines recommending HIV testing was reported, stratified by subgroup (HIV IC, country, eastern/western Europe, achievement of 90-90-90 goals and medical specialty).ResultsOf 30 invited European countries, 15 participated. A total of 791 HIV IC guidelines were identified: median 47 (IQR: 38-68) per country. Association with HIV was reported in 69% (545/791) of the guidelines, and 46% (366/791) recommended HIV testing, while 42% (101/242) of the AIDS-defining conditions recommended HIV testing. HIV testing recommendations were observed more frequently in guidelines in eastern (53%) than western (42%) European countries and in countries yet to achieve the 90-90-90 goals (52%) compared to those that had (38%). The medical specialties internal medicine, neurology/neurosurgery, ophthalmology, pulmonology and gynaecology/obstetrics had an HIV testing recommendation uptake below the 46% average. None of the 62 HIV ICs, countries or medical specialties had 100% accurate testing recommendation coverage in all their available HIV IC guidelines.ConclusionFewer than half the HIV IC guidelines recommended HIV testing. This signals an insufficient adoption of this recommendation in non-HIV specialty guidelines across Europe.

A call to action to reclaim focus on testing and early treatment for HIV, viral hepatitis, sexually transmitted infections and tuberculosis

We present the outcomes of the HepHIV 2021 Lisbon & virtual conference held on 5-7 May 2021, including a Call to Action addressing policy and practice implications in the field of earlier and integrated testing for HIV, viral hepatitis, STI and TB and in light of lessons learned from the COVID-19 pandemic. Conference presentations showed that combination prevention and integrated testing and care models for multiple infectious diseases are necessary and feasible in diverse settings. Successful examples of service and system adaptations developed to mitigate impact of the pandemic were shared. Aiming to ensure greater equity in health in current and future health policies and programmes and address the adverse effects of COVID-19, we must learn from the many innovative approaches to service delivery developed in response to the pandemic, many of which have the potential to reach people whose needs were not met by existing models.

Delayed presentation of HIV among older individuals: a growing problem

Late presentation for care is a major impediment to the prevention and effective treatment of HIV infection. Older individuals are at increased risk of late presentation, represent a growing proportion of people with late presentation, and might require interventions tailored to their age group. We provide a summary of the literature published globally between 2016-21 (reporting data from 1984-2018) and quantify the association of age with delayed presentation. Using the most common definitions of late presentation and older age from these earlier studies, we update this work with data from the International Epidemiology Databases to Evaluate AIDS (IeDEA) consortium, focusing on data from 2000-19, encompassing four continents. Finally, we consider how late presentation among older individuals might be more effectively addressed as electronic medical records become widely adopted.

Clinical parameters, selected HLA and chemokine gene variants associated with late presentation into care of people living with HIV/AIDS

INTRODUCTION

Late presentation into care remains a significant problem in the diagnosis of HIV infection, and may negatively impact the Joint United Nations Program HIV/AIDS elimination targets. Host genetics affects the tempo of HIV disease progression and therefore may influence clinical status at care entry.

MATERIALS AND METHODS

Longitudinal data were collected for 863 Caucasian patients followed up at Pomeranian Medical University, Szczecin, Poland. Single nucleotide polymorphisms in CCR2 (rs1799864), CX3CR1 (rs3732378), HLAC-35 (rs9264942), CCR5 promoter (rs1799988) as well as 32 base pair CCR5 mutation and HLA-B*5701 genotypes were correlated with the clinical and immunologic patient status at care entry. Late presentation was defined as baseline CD4 lymphocyte count <350 cells/μL or history of AIDS-defining illness, while advanced HIV disease as baseline CD4 lymphocyte count <200 cells/μL or AIDS.

RESULTS

Of the analyzed gene variants, the CCR2 (rs1799864) GG genotype was more frequent among patients presenting for care with a CD4 lymphocyte count <200/μL (82.6% for GG homozygotes vs. 74.5% for allele A carriers, p = 0.01). The presence of the heterozygous wt/Δ32 genotype at the CCR5 gene was associated with a higher frequency of asymptomatic infection (18.9% for wt/Δ32 heterozygotes vs. 12% for wt/wt homozygotes, p = 0.03). As expected, this association was also observed among late presenters compared to patients presenting for care earlier (13.7% vs. 19,7%, respectively, p = 0.04). Finally, HLA-B*5701 was less common among late presenters (5%) compared to patients who entered care early (9.6%, p = 0.01) or patients with advanced HIV disease (8.9% vs. 5.2%, p = 0.02).

CONCLUSIONS

Late presentation was associated with the GG homozygous genotype at the CCR2 rs1799864 SNP, while both the HLA-B*5701 variant and the CCR5 wt/Δ32 were associated with more favorable clinical profile at care entry.

Increased integrated testing for HIV, hepatitis C and sexually transmitted infections in health care facilities: results from the INTEGRATE Joint Action pilots in Lithuania, Romania and Spain

BACKGROUND

Indicator condition guided HIV testing is a proven effective strategy for increasing HIV diagnosis in health care facilities. As part of the INTEGRATE Joint Action, we conducted four pilot studies, aiming to increase integrated testing for HIV/HCV/HBV and sexually transmitted infections, by introducing and expanding existing indicator condition guided HIV testing methods.

METHODS

Pilot interventions included combined HIV/HCV testing in a dermatovenerology clinic and a clinic for addictive disorders in Lithuania; Increasing HIV testing rates in a tuberculosis clinic in Romania by introducing a patient information leaflet and offering testing for HIV/HCV/sexually transmitted infections to chemsex-users in Barcelona. Methods for implementing indicator condition guided HIV testing were adapted to include integrated testing. Testing data were collected retrospectively and prospectively. Staff were trained in all settings, Plan-do-study-act cycles frequently performed and barriers to implementation reported.

RESULTS

In established indicator conditions, HIV absolute testing rates increased from 10.6 to 71% in the dermatovenerology clinic over an 18 months period. HIV testing rates improved from 67.4% at baseline to 94% in the tuberculosis clinic. HCV testing was added to all individuals in the dermatovenerology clinic, eight patients of 1701 tested positive (0.47%). HBV testing was added to individuals with sexually transmitted infections with a 0.44% positivity rate (2/452 tested positive). The Indicator condition guided HIV testing strategy was expanded to offer HIV/HCV testing to people with alcohol dependency and chemsex-users. 52% of chemsex-users tested positive for ≥ 1 sexually transmitted infection and among people with alcohol dependency 0.3 and 3.7% tested positive for HIV and HCV respectively.

CONCLUSIONS

The four pilot studies successfully increased integrated testing in health care settings, by introducing testing for HBV/HCV and sexually transmitted infections along with HIV testing for established indicator conditions and expanding the strategy to include new indicators; alcohol dependency and chemsex. HCV testing of individuals with alcohol abuse showed high positivity rates and calls for further implementation studies. Methods used for implementing indicator condition guided HIV Testing have proven transferable to implementation of integrated testing.

Latent infection screening and prevalence in cancer patients born outside of Australia: a universal versus risk-based approach?

PURPOSE

Contention surrounds how best to screen patients for latent and undiagnosed infection prior to cancer treatment. Early treatment and prophylaxis against reactivation may improve infection-associated morbidity. This study sought to examine rates of screening and prevalence of latent infection in overseas-born patients receiving cancer therapies.

METHODS

A single-centre retrospective audit of 952 overseas-born patients receiving chemotherapy, targeted agents and immunotherapy between January 1 and December 31 2019 was undertaken at Peter MacCallum Cancer Centre. Pre-treatment screening for hepatitis B (HBV), hepatitis C (HCV), human immunodeficiency virus (HIV), latent tuberculosis (LTBI), toxoplasmosis and strongyloidiasis was audited.

RESULTS

Approximately half of our overseas-born patients were screened for HBV (58.9%) and HCV (50.7%). Fewer patients were screened for HIV (30.5%), LTBI (18.3%), strongyloidiasis (8.6%) or toxoplasmosis (8.1%). Although 59.7% of our patients were born in countries with high epidemiological risk for latent infection, according to World Health Organization data, 35% were not screened for any infection prior to commencement of therapy.

CONCLUSION

The prevalence of latent infections amongst overseas-born patients with cancer, and complexities associated with risk-based screening, likely supports universal latent infection screening amongst this higher-risk cohort.

Assessment of HIV testing recommendations in Greek specialty guidelines: A missed opportunity and room for improvement for recommending testing

HIV testing for individuals presenting with indicator conditions (ICs) including AIDS-defining conditions (ADCs) is explicitly recommended by European guidelines. We aimed to review specialty guidelines in Greece and assess if HIV was discussed and testing recommended. We reviewed European guidelines to produce a list of 25 ADCs and 48 ICs. We identified Greek guidelines for 11 of 25 (44%) ADCs and 30 of 48 (63%) ICs. In total, 47 guidelines were reviewed (range: 1-6 per condition); 11 (23%) for ADCs and 36 (77%) for ICs. Association with HIV was discussed in 7 of 11 (64%) ADC and 8 of 36 IC guidelines (22%), whereas HIV testing was appropriately recommended in two of 11 ADC (18%) and 10 of 36 IC guidelines (28%). Significant differences were found for the distribution of recommendations to test in both types of condition, with ICs having higher percentage of non-recommendation (50%, p < 0.05). No association was found between source of guideline or publication year and testing recommendation. Most guidelines for ICs and ADCs do not recommend testing. Specialists managing most ICs and ADCs may be unaware of the actual prevalence of undiagnosed HIV infection among their patients or the respective recommendations produced by HIV societies.

Tracking missed opportunities for an early HIV diagnosis in a population of people living with HIV with known time of infection

PURPOSE

The goal of 90-90-90 first requires the expansion of access to HIV testing. Our aim was to record frequencies of HIV indicator conditions (ICs) and identify missed opportunities for an early HIV diagnosis.

METHODS

We retrospectively identified ICs in a population of 231 people living with HIV with known infection dates who attended our clinic. The study population was divided into four groups: (1) those self-tested pre-emptively (47/231, 20.3%), (2) those offered targeted testing based on risk factors (67/231, 29%), (3) those tested after an IC (73/231, 31.6%) and (4) those who were not offered testing after an IC (44/231, 19%). HIV acquisition dates were estimated by molecular clock analysis.

RESULTS

A total of 169 healthcare contacts (HCCs) were recorded. The most frequent HCC was mononucleosis-like syndrome (20.1%), unexplained weight loss (10.7%) and STIs (10.1%). AIDS-defining conditions were detected in 11.8%. Only 62.4% (73/117) of those with an IC were offered testing after their first HCC. Patients in group 4 had statistically significant delay in diagnosis compared with group 3 (109.1 weeks (IQR 56.4-238.6) vs 71.6 weeks (IQR 32.3-124.6)). The proportion of patients diagnosed as late presenters in each group was: (1) 16/47 (34%), (2) 37/67 (55.2%), (3) 43/73 (58.9%) and (4) 27/44 (61.4%) (p=0.027).

CONCLUSIONS

Our study uses a combination of molecular and clinical data and shows evidence that late presentation occurs in a high proportion of patients even in the presence of an IC. Given that risk-based targeted testing has low coverage, IC-guided testing provides a reasonable alternative to facilitate earlier HIV diagnosis and to improve late diagnosis across Europe and globally.

Missed opportunities for HIV testing in patients newly diagnosed with HIV in Morocco

Background

In Morocco, of the estimated 29,000 people living with HIV in 2011, only 20% were aware of their HIV status. More than half of diagnoses were at the AIDS stage. We assumed that people who were unaware of their infection had contacts with the healthcare system for HIV indicators that might prompt the healthcare provider to offer a test. The aim was to assess missed opportunities for HIV testing in patients newly diagnosed with HIV who accessed care in Morocco.

Methods

A cross-sectional study was conducted in 2012–2013 in six Moroccan HIV centers. Participants were aged ≥18, and had sought care within 6 months after their HIV diagnosis. A standardized questionnaire administered during a face-to-face interview collected the patient’s characteristics at HIV diagnosis, HIV testing and medical history. Contacts with care and the occurrence of clinical conditions were assessed during the 3 years prior to HIV diagnosis. Over this period, we assessed whether healthcare providers had offered HIV testing to patients with HIV-related clinical or behavioral conditions.

Results

We enrolled 650 newly HIV-diagnosed patients (median age: 35, women: 55%, heterosexuals: 81%, diagnosed with AIDS or CD4 < 200 cells/mm³: 63%). During the 3 years prior to the HIV diagnosis, 71% (n = 463) of participants had ≥1 contact with the healthcare system. Of 323 people with HIV-related clinical conditions, 22% did not seek care for them and 9% sought care and were offered an HIV test by a healthcare provider. The remaining 69% were not offered a test and were considered as missed opportunities for HIV testing. Of men who have sex with men, 83% did not address their sexual behavior with their healthcare provider, 11% were not offered HIV testing, while 6% were offered HIV testing after reporting their sexual behavior to their provider.

Conclusions

Among people who actually sought care during the period of probable infection, many opportunities for HIV testing, based on at-risk behaviors or clinical signs, were missed. This highlights the need to improve the recognition of HIV clinical indicators by physicians, further expand community-based HIV testing by lay providers, and implement self-testing to increase accessibility and privacy.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12879-020-05711-2.