Indicative Conditionals Research Articles

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

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%. 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). 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. 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. 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).

Late presentations and missed opportunities among newly diagnosed HIV patients presenting to a specialty clinic in Lebanon

Late presentation to medical care of individuals infected with the human immunodeficiency virus (HIV) is linked to poor outcomes and increased morbidity and mortality. Missed opportunities for a prompt diagnosis are frequently reported among late presenters. We aimed to estimate the proportion of late presenters and missed opportunities in diagnosis among newly diagnosed HIV-positive subjects presenting to a specialty clinic in Lebanon. This is a retrospective chart review of all newly diagnosed adult HIV-positive subjects presenting to clinic from 2012 to 2022. Demographic, laboratory, and clinical data were collected at initial HIV diagnosis or presentation to medical care. We defined late presentation as having a CD4 count < 350 or AIDS-defining event regardless of CD4 count. Advanced disease is defined as having a CD4 count below 200 cells/μL or the presence of an AIDS-defining illness, regardless of the CD4 count. A missed opportunity was defined as the presence of an indicator condition (IC) that suggests infection with HIV/AIDS during 3 years preceding the actual HIV diagnosis and not followed by a recommendation for HIV testing. The proportions for demographic, epidemiological, and clinical characteristics are calculated by excluding cases with missing information from the denominator. Our cohort included 150 subjects (92.7% males; 63.6% men who have sex with men (MSM); 33.3% heterosexuals; median age 30.5 years at diagnosis). 77 (51.3%) were late presenters and 53 (35.3% of all subjects, 68.8% of late presenters) had advanced HIV on presentation. Up to 76.5% of late presenters had a presentation with an HIV-related condition at a healthcare provider without getting HIV test within the previous 3 years. The most frequent ICs were weight loss, generalized lymphadenopathy, constitutional symptoms, and chronic idiopathic diarrhea. Overall mortality rate was 4% (6/150 individuals). All-cause mortality among those who presented with AIDS was 15.4% (6/39 subjects). In our setting, late presentations and missed opportunities for HIV diagnosis are common. In the Middle East, AIDS mortality remains high with a large gap in HIV testing. To effectively influence policies, comprehensive analyses should focus on estimating the preventable health and financial burdens of late HIV presentations. Another concern pertains to healthcare providers’ attitudes and competencies.

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

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

Opportunities for improved indicator-based HIV testing in the hospital setting: a structural equation model analysis

ABSTRACT Indicator condition (IC)-guided HIV testing, i.e., testing when diagnosing a condition associated with HIV, is a feasible and cost-effective testing strategy to identify undiagnosed individuals. Assessing determinants for IC-guided testing may identify opportunities for improvement. A survey study based on the Theory of Planned Behaviour (TPB) was conducted among 163 hospital physicians from five specialties in Amsterdam, the Netherlands. Structural equation models were used to determine the association between the TPB domains (i.e., attitude, belief, norms, self-efficacy and behavioural control) and (1) the intention to test as a mediator for HIV testing behaviour (intentional model) and (2) actual HIV testing behaviour (direct model). Both models accounted for the effect of guideline recommendations. Behaviour scored lower than intention on a five-point scale (mean score of 2.8, SD = 1.6 versus 3.8, SD = 1.1; p<0.0001). The direct model had a better fit than the intentional model based on fit statistics. Discrepancies between the determinants most important for intention versus those for behaviour led to the following recommendations: interventions to improve IC-guided testing in hospitals should primarily focus on implementation of guideline recommendations, followed by improving physicians’ attitude towards IC-guided HIV testing and self-efficacy, as these were the most important correlates of actual HIV testing behaviour.

Object Shape and Depth of Word Representations in Preschoolers.

This study examined the effect of a shape cue (i.e., co-speech gesture) on word depth. We taught 23 preschoolers (M = 3;5 years, SD = 5.82) novel objects with either shape (SHP) or indicator (IND) gestures. SHP gestures mimicked object form, but IND gestures were not semantically related to the object (e.g., an upward-facing palm, extended toward the object). Each object had a unique IND or SHP gesture. Outcome measures reflected richer semantic and phonological learning in the SHP than in the IND condition. In the SHP condition, preschoolers (a) expressed more semantic knowledge, (b) said more sounds in names, and (c) generalized more names to untaught objects. There were also fewer disruptions to prime picture names in the SHP condition; we discuss the benefit of a co-speech shape gesture to capitalize on well-established statistical word learning patterns.

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.

Improving indicator-condition guided testing for HIV in the hospital setting (PROTEST 2·0): A multicenter, interrupted time-series analysis.

SummaryBackgroundIndicator-condition (IC) guided HIV testing is a feasible and cost-effective strategy to identify undiagnosed people living with HIV (PLHIV), but remains insufficiently implemented. We aimed to promote IC-guided HIV testing in seven ICs.MethodsRelevant departments in five hospitals of the Amsterdam region participated. HIV testing among adult patients without known HIV infection but with an IC was assessed using electronic health records during pre-intervention (January 2015–June 2020) and intervention (July 2020–June 2021) periods. The multifaceted intervention included audit and feedback. The primary endpoint was HIV testing ≤3 months before or after IC diagnosis and the effect of the intervention was evaluated using segmented Poisson regression.FindingsData from 7986 patients were included, of whom 6730 (84·3%) were diagnosed with an IC in the pre-intervention period and 1256 (15·7%) in the intervention period. The proportion HIV tested ≤3 months before or after IC diagnosis increased from 36.8% to 47.0% (adjusted risk ratio [RR]= 1.16, 95% CI=1.03–1.30, p=0.02). For individual ICs, we observed significant increases in HIV testing among patients with cervical cancer or intraepithelial neoplasia grade 3 (adjusted RR=3.62, 95% CI=1.93–6.79) and peripheral neuropathy (adjusted RR=2.27 95% CI=1.48–3.49), but not the other ICs. Eighteen of 3068 tested patients were HIV positive (0.6%).InterpretationOverall IC-guided testing improved after the intervention, but not for all ICs. Variations in effect by IC may have been due to variations in implemented developments, but the effect of separate elements could not be assessed.FundingHIV Transmission Elimination Amsterdam (H-TEAM) initiative, Aidsfonds (grant number: P-42702).

Efficacy of an electronic reminder for HIV screening in primary healthcare based on indicator conditions in Catalonia (Spain).

The aim of this study was to assess the efficacy of an electronic reminder in primary healthcare in patients diagnosed with an indicator condition (IC) to improve HIV screening. We developed a prospective interventional study in 51 primary healthcare centres in Barcelona randomly assigned into one of two study groups: control and alert. Between June 2018 and May 2019, an electronic reminder appeared in the electronic medical record each time a diagnosis of an IC in patients aged 16-65 years was registered in the alert group. We assessed HIV testing rates within 4months following the diagnosis of an IC. In all, 13000 patients were diagnosed with at least one IC. HIV testing was more likely in the alert group than in the control group. The electronic reminder multiplied the odds of being tested in men by 1.26 [95% confidence interval (CI): 1.04-1.52, p=0.019], by 1.77 (95% CI: 1.33-2.38, p<0.001) among patients aged <50years , and by 1.51 (95% CI: 1.20-1.92, p<0.001) in diagnoses of IC other than a sexually transmitted infection (STI) or an AIDS-defining illness. Five (0.08%) cases of HIV were detected in the control group and 10 (0.17%) in the alert group. Implementing an electronic reminder had a positive impact on HIV screening rates in patients diagnosed with an IC. The alert was more effective among older patients, those living in less socioeconomically deprived neighbourhoods, and those with an IC other than an STI or an AIDS-defining illness.

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

PurposeThe 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...

Targeting fast-track goals: Missed opportunities for HIV testing in the Community of Madrid

IntroductionIn Spain HIV testing is recommended to people with risk behaviors for HIV and with indicator conditions (IC) related to HIV infection. Missed diagnostic opportunities (MO) are defining as situations where these recommendations are not followed. ObjectiveTo characterize MO due to risk behaviors (directed) and due to IC (indicated) among people diagnosed with HIV in the Region of Madrid. MethodsA total of 109 participants newly diagnosed with HIV were recruited from 7 health centers (April 2018-March 2019) by a telephone survey. Diagnostic opportunities were defined as any contact with the healthcare system in which an HIV test should have been carried out. Frequency of MO was calculated within the previous 2 years from HIV diagnosis. ResultsOf the 32 directed and indicated diagnostic opportunities, 96.9% and 57.8% respectively resulted in MO. Overall, 83.8% of diagnostic opportunities resulted in MO. ConclusionMO, both directed and indicated, are an important area for improvement to reduce late diagnosis.

Promoting HIV indicator condition-guided testing in hospital settings (PROTEST 2.0): study protocol for a multicentre interventional study

BackgroundLate presentation remains a key barrier towards controlling the HIV epidemic. Indicator conditions (ICs) are those that are AIDS-defining, associated with a prevalence of undiagnosed HIV > 0.1%, or whose clinical management would be impeded if an HIV infection were undiagnosed. IC-guided HIV testing is an effective strategy in identifying undiagnosed HIV, but opportunities for earlier HIV diagnosis through IC-guided testing are being missed. We present a protocol for an interventional study to improve awareness of IC-guided testing and increase HIV testing in patients presenting with ICs in a hospital setting.MethodsWe designed a multicentre interventional study to be implemented at five hospitals in the region of Amsterdam, the Netherlands. Seven ICs were selected for which HIV test ratios (proportion of patients with an IC tested for HIV) will be measured: tuberculosis, cervical/vulvar cancer or high-grade cervical/vulvar dysplasia, malignant lymphoma, hepatitis B and C, and peripheral neuropathy. Prior to the intervention, a baseline assessment of HIV test ratios across ICs will be performed in eligible patients (IC diagnosed January 2015 through May 2020, ≥18 years, not known HIV positive) and an assessment of barriers and facilitators for HIV testing amongst relevant specialties will be conducted using qualitative (interviews) and quantitative methods (questionnaires). The intervention phase will consist of an educational intervention, including presentation of baseline results as competitive graphical audit and feedback combined with discussion on implementation and opportunities for improvement. The effect of the intervention will be assessed by comparing HIV test ratios of the pre-intervention and post-intervention periods. The primary endpoint is the HIV test ratio within ±3 months of IC diagnosis. Secondary endpoints are the HIV test ratio within ±6 months of diagnosis, ratio ever tested for HIV, HIV positivity percentage, proportion of late presenters and proportion with known HIV status prior to initiating treatment for their IC.DiscussionThis protocol presents a strategy aimed at increasing awareness of the benefits of IC-guided testing and increasing HIV testing in patients presenting with ICs in hospital settings to identify undiagnosed HIV in Amsterdam, the Netherlands.Trial registrationDutch trial registry: NL7521. Registered 14 February 2019.

Implementation of indicator condition guided HIV testing still lagging behind the evidence.

Bogers and colleagues report a disappointing but unsurprising low level of HIV testing in people presenting for care with HIV Indicator Conditions (IC) [1]. The authors highlight the ongoing challenges of high levels of undiagnosed HIV infection and late presentation with the attendant morbidity, mortality and transmission potential, and the effectiveness of an IC testing strategy to address these. Their paper presents a systematic review and meta-analysis of current implementation of IC-guided HIV testing.

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

ABSTRACT 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.

Missed opportunities for HIV testing persist despite a single educational intervention: how can we close this evidence-practice gap?

In Australia, one-third of human immunodeficiency virus (HIV) diagnoses occur late, with an estimated 11% of people with HIV unaware of their diagnosis. Undiagnosed and untreated HIV infection increases morbidity in the HIV positive person and allows onward transmission of HIV. To determine the rate of HIV testing in acute general medicine patients with HIV indicator conditions (IC) and evaluate the effectiveness of an educational intervention in improving testing rates. Single-centre, tertiary hospital, before-after study of general medicine inpatients with IC for 12 weeks prior and 10 weeks post an educational intervention focusing on recommendations for HIV testing including IC. The REASON Cohort Discovery Tool was used to search for the IC using ICD-10 codes and laboratory data. The presence of IC was estimated, and HIV testing rates before and after the intervention were compared. Regression analysis was utilised to identify characteristics associated with HIV testing. Of 1414 admissions in the baseline period and 946 in the post-period, 161 (11.4%) and 132 (14.0%) had at least one IC present respectively. There were 18 (11.2%) HIV tests performed for admissions with IC in the pre-period which increased to 27 (20.5%) (P = 0.028) in the post-period. Younger patients were more likely to be tested and regression analysis identified the educational intervention (adjusted odds ratio) 2.2 (1.1, 4.4) to be significantly associated with testing. Although HIV testing rates for IC doubled following the intervention, they remained unacceptably low. The recently introduced electronic medical record presents opportunities to prompt HIV testing.

Review of HIV testing recommendations in Australian specialty guidelines for HIV indicator conditions: a missed opportunity for recommending testing?

Australian National human immunodeficiency virus (HIV) Testing policy recommends HIV indicator condition-based testing, adapted from the European AIDS Clinical Society (EACS) guidelines. To evaluate the extent that Australian non-HIV specialty guidelines mention and recommend HIV testing in HIV indicator conditions. EACS guidelines were reviewed to produce a list of 24 AIDS-defining conditions (ADC) and 31 indicator conditions (IC) where HIV prevalence >0.1%, and 5 IC where HIV non-diagnosis would have adverse effect on patients' management. Australian guidelines for these conditions were identified from websites of specialty societies, electronic Therapeutic Guidelines, National Health and Medical Research Council (NHMRC), state governments, MEDLINE and Google searches. We identified eight key IC as that were part of the HIDES I study. Overall, 51 ADC and IC had Australian guidelines: 24/51(47%) mention association with HIV and 14/51 (27%) recommend HIV testing. Twenty-five out of 51 (49%) Australian guidelines were for ADC: 18/25(72%) mention association with HIV and 5/25 (20%) recommend testing. Twenty-five out of 51 (49%) were guidelines IC with HIV prevalence of 0.1%: 6/25 (24%) mention HIV association and 8/25 (32%) recommend HIV testing. Two of eight (25%) key IC had no Australian guidelines and 3/8 (38%) do not mention HIV association or recommend HIV testing. Although almost half of HIV non-HIV guidelines for ADC and IC mention HIV association, only 27% specifically recommend HIV testing. This suggests partnership with guideline development and specialist groups may be useful to ensure patients diagnosed with ADC/IC are tested for HIV.

Significant Impact of COVID-19 on the First Pillars of the HIV Care Continuum

Background: After SARS-CoV-2 reached the Netherlands in February 2020, rapid interventions were taken to mitigate viral spread and optimise care for COVID-19 patients. Lockdowns and downscaling of regular healthcare practices were necessary. The effect of these interventions on HIV care are uncertain. We assessed the impact of the nationwide lockdown in March and May during the first COVID-19 wave on HIV diagnosis and linkage to care.Methods: An observational study was conducted at the Erasmus MC, a regional reference tertiary hospital in the Netherlands. All patients ≥ 18 years presenting with HIV ICs were identified in electronic patient records, using an automated identification system for ICD-10 and health insurance codes. Primary outcomes measured were the number of HIV tests performed, number of HIV ICs and corresponding HIV testing rates, and new HIV diagnoses before, during and after lockdown.Findings: From January to April, all newly registered diagnoses decreased by 35%, and in patients referred for HIV ICs by 69%. The proportion of patients presenting with HIV ICs that were adequately tested for HIV remained relatively stable, especially where HIV testing is standardised, even during lockdown in March, April and May when a cumulative 328 proven or suspected COVID-19 patients were admitted. The absolute number of HIV tests performed during the first half year of 2020 was 13% lower than the same period in 2019, and new HIV patient referrals dropped 67%. The number of HIV IC, HIV testing rates and HIV referrals showed recovery after the lockdown.Interpretations: The first two pillars of the HIV care continuum were affected by the lockdown during the COVID-19 pandemic. Standardisation of HIV testing could partially prevent diagnostic delays. Anticipating subsequent COVID-19 waves, this indicates that maintaining focus on adequate identification and testing of patients with undiagnosed HIV is essential to prevent unwanted declines affecting the 95-95-95 goals.Funding Statement: Dutch Federation Medical Specialist SKMS grant nr.: 59825822.Declaration of Interests: CR reports research grants from FMS, AIDSfonds, ZonMW, Health~Holland, Gilead, ViiV, Janssen- Cilag, Merck. The other authors declare no competing interests.Ethics Approval Statement: The study was conducted according to the principles of the Declaration of Helsinki and complied with Dutch privacy laws, WGBO and followed GDPR regulations. The study was IRB approved including a waiver to obtain written informed consent.

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

BackgroundIt is cost-effective to perform an HIV test in people with specific indicator conditions (IC) with an undiagnosed HIV prevalence of at least 0.1%. Our aim was to determine the HIV prevalence for 14 different conditions across 20 European countries.MethodsIndividuals aged 18–65 years presenting for care with one of 14 ICs between January 2012 and June 2014 were included and routinely offered an HIV test. Logistic regression assessed factors associated with testing HIV positive. Patients presenting with infectious mononucleosis-like syndrome (IMS) were recruited up until September 2015.ResultsOf 10,877 patients presenting with an IC and included in the analysis, 303 tested positive (2.8%; 95% CI 2.5–3.1%). People presenting with an IC in Southern and Eastern Europe were more likely to test HIV positive as were people presenting with IMS, lymphadenopathy and leukocytopenia/ thrombocytopenia. One third of people diagnosed with HIV after presenting with IMS reported a negative HIV test in the preceding 12 months. Of patients newly diagnosed with HIV where data was available, 92.6% were promptly linked to care; of these 10.4% were reported lost to follow up or dead 12 months after diagnosis.ConclusionThe study showed that 10 conditions had HIV prevalences > 0.1%. These 10 ICs should be adopted into HIV testing and IC specialty guidelines. As IMS presentation can mimic acute HIV sero-conversion and has the highest positivity rate, this IC in particular affords opportunities for earlier diagnosis and public health benefit.

Missed opportunities in the diagnosis of human immunodeficiency virus infection in the Region of Aragon. Late diagnosis importance

IntroductionLate diagnosis (LD) of human immunodeficiency virus (HIV) infection (CD4 lymphocytes <350/μl at diagnosis of the disease), deteriorates the condition of those affected and increases the probability of transmission. The objective of the present study was to analyse the prevalence of LD, to identify missed diagnostic opportunities (MDO) and to find out which level of the health care delivery system they took place. MethodsRetrospective, observational and descriptive study of the population diagnosed with infection of HIV/AIDS in the period 2011–2015 in Aragon. MDO were identified during the 3 years prior to diagnosis of the disease in all levels of the health care delivery system as well as frequentation of consultations. The indicator conditions (IC) that generated more MDO were analysed according to the latest recommendations for early diagnosis of HIV in the health care setting. Results435 newly diagnosed HIV/AIDS cases were analysed. 45.1% were diagnosed in Primary Healthcare (PH). 49.4% presented criteria of LD and 61.1% were infected through heterosexual contact. The majority of MDO (68.5%) were given in PH. The IC that generated the most MDO were seborrheic dermatitis/exanthema (19.4%) and fever of unknown origin (10.3%). However, the IC that were associated with higher LD were pneumonia acquired in the community and unjustified weight loss. ConclusionIn Aragon, prevalence of LD is high, the main route of infection is heterosexual and most of MDO go unnoticed in PH. The dissemination of current guidelines for requesting IC guided HIV testing and HIV screening across the preoperative period will result in an effective measure to decrease the LD.

HIV testing in patients presenting with indicator conditions in outpatient settings: offer and uptake rates, and educational and active interventions.

Approximately 13% of people living with HIV in the UK are undiagnosed which has significant implications in terms of onward transmission and late diagnosis. HIV testing guidelines recommend routine screening in anyone presenting to healthcare with an HIV indicator condition (IC); however, this does not occur routinely. This study aimed to assess the feasibility and effectiveness of using case note prompts highlighting the presence of an IC to increase HIV testing. Clinicians in three outpatient departments received case note prompts either before or after a period of clinician-led identification. Test offer and uptake rates were assessed. A parallel anonymous seroprevalence study estimated the prevalence of undiagnosed HIV. A total of 4191 patients had an appointment during the study period; 608 (14.5%) had an IC. HIV test offer was significantly higher when a prompt was inserted into notes (34.3% versus 3.2%, p < 0.001). The prevalence of diagnosed HIV in the cohort was 4.1%. No cases of undiagnosed HIV infection were identified. Despite guidelines, offer of HIV testing is low. Strategies to increase routine screening of patients presenting with an IC are needed. Individual case note prompts significantly increase HIV test offer; however, the effect is lost if the strategy is withdrawn.

Oportunidades perdidas en el diagnóstico de la infección por el virus de inmunodeficiencia humana en la Comunidad de Aragón. Importancia del diagnóstico tardío

IntroductionLate Diagnosis (LD) of Human Immunodeficiency Virus (HIV) infection (CD4 lymphocytes <350/μl at diagnosis of the disease), deteriorates the condition of those affected and increases the probability of transmission. The objective of the present study was to analyse the prevalence of LD, to identify missed diagnostic opportunities (MDO) and to find out which level of the health care delivery system they took place. MethodsRetrospective, observational and descriptive study of the population diagnosed with infection of HIV/AIDS in the period 2011-2015 in Aragon. MDO were identified during the 3 years prior to diagnosis of the disease in all levels of the health care delivery system as well as frequentation of consultations. The indicator conditions (IC) that generated more MDO were analysed according to the latest recommendations for early diagnosis of HIV in the health care setting. Results435 newly diagnosed HIV/AIDS cases were analysed. 45.1% were diagnosed in Primary Healthcare (PH). 49.4% presented criteria of LD and 61.1% were infected through heterosexual contact. The majority of MDO (68.5%) were given in PH. The IC that generated the most MDO were seborrheic dermatitis/exanthema (19.4%) and fever of unknown origin (10.3%). However, the IC that were associated with higher LD were pneumonia acquired in the community and unjustified weight loss. ConclusionIn Aragon, prevalence of LD is high, the main route of infection is heterosexual and most of MDO go unnoticed in PH. The dissemination of current guidelines for requesting IC guided HIV testing and HIV screening across the preoperative period will result in an effective measure to decrease the LD.