Abstract
BackgroundLate diagnosis is an important cause of HIV-related morbidity, mortality and healthcare costs in the UK and undiagnosed infection limits efforts to reduce transmission. National guidelines provide recommendations to increase HIV testing in all healthcare settings. We evaluated progress towards these recommendations by comparing missed opportunities for HIV testing and late diagnosis in two six year cohorts from North East Scotland.MethodsWe reviewed diagnostic pathways of all patients newly diagnosed with HIV referred to infectious diseases and genito-urinary medicine services between 1995 and 2000 (n = 48) and 2004 to 2009 (n = 117). Missed presentations (failure to diagnose ≤ 1 month of a clinical or non-clinical indicator for testing), late diagnosis (CD4 < 350 cells/mm3), and time to diagnosis (months from first presentation to diagnosis) were compared between cohorts using χ2 and log-rank tests. Determinants of missed presentation were explored by multivariate logistic regression. Breslow-Day tests assessed change in diagnostic performance by patient subgroup.ResultsThere were significant decreases in missed presentations (33% to 17%; P = 0.02) and time to diagnosis (mean 17 months to 4 months; P = 0.005) but not in late diagnosis (56% vs. 60%; P = 0.57) between earlier and later cohorts. In the later cohort patients were significantly more likely to have acquired HIV abroad and presented with early HIV disease, and testing was more likely to be indicated by transmission risk or contact with GUM services than by clinical presentation. Missed presentation remained significantly less likely in the later cohort (OR = 0.28, 95% CI 0.11 to 0.72; P = 0.008) after adjustment for age, transmission risks and number of clinical indicators. Reductions in missed presentation were greater in patients < 40 years, of non-UK origin, living in least deprived neighbourhoods and with early disease at presentation (P < 0.05). 27% of missed presentations occurred in primary care and 46% in general secondary care.ConclusionsWhile early diagnosis has improved in epidemiological risk groups, clinical indications for HIV testing continue to be missed, particularly in patients who are older, of UK origin and from more deprived communities. Increasing testing in non-specialist services is a priority.
Highlights
Late diagnosis is an important cause of HIV-related morbidity, mortality and healthcare costs in the UK and undiagnosed infection limits efforts to reduce transmission
Indicators for testing at first presentation Patients in the later cohort were less likely to present with a clinical indicator disease (63% vs. 88%; P = 0.005) and more likely to present with epidemiological risk factors or via a service applying universal testing (Table 2)
This study looked for evidence of improvements in early HIV diagnosis in response to national strategies to increase testing in all healthcare settings
Summary
Late diagnosis is an important cause of HIV-related morbidity, mortality and healthcare costs in the UK and undiagnosed infection limits efforts to reduce transmission. National guidelines provide recommendations to increase HIV testing in all healthcare settings. Up to 90% of people living with HIV may be unaware of their status [1]: with estimates ranging from 21% to 30% in have recommended universal ‘opt-out’ testing in all general healthcare settings. In the UK 25% of HIV infections are undiagnosed, undermining efforts to reduce transmission [5], and late diagnosis is an important cause of HIV-related morbidity [6], mortality [7] and healthcare costs [8]. A national audit of deaths among HIV infected adults found that late diagnosis was the leading remediable cause of HIVrelated death [7]. Instead, testing is to be offered universally in selected services, to those with epidemiologic risk-factors and to children or adults presenting with one or more prescribed clinical indicator diseases
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