Missed opportunities for HIV testing in people diagnosed with HIV, Estonia, 2014 to 2015

Epidemiological factors associated with the absence of previous HIV testing among HIV-positive persons in Singapore, 2012-2017

OBJECTIVE

To assess the temporal trend and identify risk factors associated with the absence of previous HIV testing prior to their diagnosis among HIV-positive persons in Singapore.

STUDY DESIGN

Cross-sectional.

SETTING AND PARTICIPANTS

We analysed data of HIV-positive persons infected via sexual transmission, who were notified to the National HIV Registry in 2012-2017.

OUTCOMES

Epidemiological factors associated with the absence of HIV testing prior to diagnosis were determined separately for two groups of HIV-positive persons: early and late stages of HIV infection at diagnosis.

RESULTS

2188 HIV-positive persons with information on HIV testing history and CD4 cell count were included in the study. The median age at HIV diagnosis was 40 years (IQR 30-51). Nearly half (45.1%) had never been tested for HIV prior to their diagnosis. The most common reason cited for no previous HIV testing was 'not necessary to test' (73.7%). The proportion diagnosed at late-stage HIV infection was significantly higher among HIV-positive persons who had never been tested for HIV (63.9%) compared with those who had undergone previous HIV tests (29.0%). Common risk factors associated with no previous HIV testing in multivariable logistic regression analysis stratified by stage of HIV infection were: older age at HIV diagnosis, lower educational level, detection via medical care and HIV infection via heterosexual transmission. In the stratified analysis for persons diagnosed at early-stage of HIV infection, in addition to the four risk factors, women and those of Malay ethnicity were also less likely to have previous HIV testing prior to their diagnosis.

CONCLUSION

Targeted prevention efforts and strategies are needed to raise the level of awareness of HIV/AIDS and to encourage early and regular screening among the at-risk groups by making HIV testing more accessible.

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.