Comparison between patients who interrupted ART and those with late HIV diagnosis.

Early diagnosis of human immunodeficiency virus (HIV) and retention in care are cornerstones of better prognosis of people living with HIV (PLWH). The purpose of this study was to compare patients who discontinued antiretroviral treatment (ART) with those who were diagnosed late with HIV. In this retrospective analysis of PLWH under the care of one of the Infectious Diseases Clinics in Poland between 2020 and 2021, two sub-analyses were carried out. One comparing patients who relinked to care after treatment interruption ("Group A") with those who had late HIV diagnosis ("Group B"), another comparing group A to those who were adherent to ART ("Group C"). 215 patients were included in this study (Group A = 47, Group B = 53, Group C = 115). Those who discontinued ART more often used actively drugs (p = 0.001) in comparison to those with late HIV diagnosis. In both bivariate and multivariable analysis migrants were more often diagnosed late with HIV than interrupted ART (p = 0.004 and 0.015, respectively). In the second analysis, in the multivariable analysis female sex was not associated with treatment interruption, whereas active drug usage was. People using drugs have a higher risk of ART interruption. Migrants are more at risk of late HIV diagnosis. Adequate interventions should be made towards both groups.

Early HIV diagnosis enhances quality-adjusted life expectancy of men who have sex with men living with HIV: A population-based cohort study in Taiwan.

BACKGROUND: Whether early HIV diagnosis is beneficial for HIV patients themselves remains uncertain, given the stigma and social discrimination associated with an HIV diagnosis. This study aimed to measure the impact of early HIV diagnosis on quality-adjusted life expectancy (QALE) in comparison with late HIV diagnosis, from real-world data in Taiwan under universal access to antiretroviral therapy (ART). METHODS: This population-based cohort study included 14,570 men who have sex with men (MSM) in the national HIV registry and a quasi-random sample (n = 127) of MSM patients to measure quality of life using the EQ-5D health utility instrument. We integrated quality of life data into the extrapolated cohort survival curve to estimate the QALE in patients with early versus late HIV diagnosis (≤30 days before AIDS diagnosis). Loss-of-QALE were estimated by comparing the cohort with age-, sex-, and calendar-year-matched referents simulated from vital statistics. Difference-in-differences was estimated to quantify the effect of early HIV diagnosis. RESULTS: Early HIV diagnosis is associated with a loss-of-life expectancy of 3.11 years, with an average health utility of 0.95, in contrast to those diagnosed late (loss-of-life expectancy 8.47 years, with an average health utility of 0.86). After integration of survival and life quality, early HIV diagnosis results in a reduction of loss-of-QALE by 8.28 quality-adjusted life years among MSM living with HIV. CONCLUSIONS: Under universal access to ART, early HIV diagnosis is highly beneficial for people living with HIV themselves, with a net gain of 8.28 healthy life years compared with those diagnosed late.

Evaluación de las visitas a urgencias previas a un diagnóstico de VIH: oportunidades perdidas / Evaluation of emergency department visits prior to an HIV diagnosis: Missed opportunities

Objetivo: Existe una elevada tasa de infección oculta y diagnóstico tardío en el VIH. Los servicios de urgencias hospitalarios (SUH) son un punto importante de atención sanitaria. El presente trabajo tiene el objetivo conocer el número de oportunidades perdidas para el diagnóstico de VIH que ocurren en los SUH. Método: Estudio multicéntrico de cohortes retrospectivo que incluyó a todos los pacientes diagnosticados de infección por el VIH en el año 2019 en 27 hospitales españoles de 7 comunidades autónomas diferentes. Se revisaron todos los episodios de consulta en los SUH en los 5años previos al diagnóstico para conocer el motivo de consulta y si este representaba una oportunidad perdida para el diagnóstico de VIH. Resultado: Se incluyeron 723 pacientes, y 352 de ellos (48,7%; IC95%: 45,1-52,3%) presentaron al menos una visita a un SUH durante los 5años anteriores al diagnóstico (mediana2; p25-p75: 1-4). Ciento dieciocho pacientes (16,3%; IC95%: 13,8-19,2%) presentaron oportunidad perdida de diagnóstico. Las principales consultas fueron consumo de drogas (145 [15%]), infecciones de transmisión sexual (91 [9,4%]) y solicitud de profilaxis de VIH postexposición (39 [4%]). Ciento cincuenta y cinco (42,9%) de los 352 tenían menos de 350CD4/mm3 cuando se estableció el diagnóstico de VIH. En los pacientes con visitas previas a urgencias, el tiempo medio hasta el diagnóstico desde esta visita fue de 580 (DE647) días. Conclusiones: El 16% de los pacientes diagnosticados de VIH perdieron la oportunidad de ser diagnosticados en los 5años previos al diagnóstico, lo que pone de manifiesto la necesidad de implementar medidas de cribado en los SUH diferentes a las actuales para mejorar estos resultados.(AU)

Objective: There is a high rate of occult infection and late diagnosis in HIV. Hospital emergency departments (ED) are an important point of health care. The present work aims to know the number of missed opportunities for HIV diagnosis occurring in the ED. Method: Retrospective multicenter cohort study that included all patients diagnosed with HIV infection in 2019 in 27 Spanish hospitals in 7 different autonomous communities. All ED consultation episodes in the 5years prior to diagnosis were reviewed to find out the reason for consultation and whether this represented a missed opportunity for HIV diagnosis. Result: Seven hundred twenty-three patients were included, and 352 (48.7%; 95%CI: 45.1%-52.3%) had at least one ED visit during the 5years prior to diagnosis (median2; p25-p75: 1-4). One hundred and eighteen patients (16.3%; 95%CI: 13.8%-19.2%) had a missed diagnostic opportunity. The main consultations were drug use (145 [15%]), sexually transmitted infections (91 [9.4%]) and request for post-exposure HIV prophylaxis (39 [4%]). One hundred and fifty-five (42.9%) of the 352 had less than 350CD4/mm3 when the HIV diagnosis was established. In patients with previous ED visits, the mean time to diagnosis from this visit was 580 (SD647) days. Conclusions: Sixteen percent of patients diagnosed with HIV missed the opportunity to be diagnosed in the 5years prior to diagnosis, highlighting the need to implement ED screening measures different from current ones to improve these outcomes.(AU)

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.

Evaluation of emergency department visits prior to an HIV diagnosis: Missed opportunities.

OBJECTIVE: There is a high rate of occult infection and late diagnosis in HIV. Hospital emergency departments (ED) are an important point of health care. The present work aims to know the number of missed opportunities for HIV diagnosis occurring in the ED. METHOD: Retrospective multicenter cohort study that included all patients diagnosed with HIV infection in 2019 in 27 Spanish hospitals in 7 different autonomous communities. All ED consultation episodes in the 5 years prior to diagnosis were reviewed to find out the reason for consultation and whether this represented a missed opportunity for HIV diagnosis. RESULT: Seven hundred twenty-three patients were included, and 352 (48.7%, 95%CI: 45.1%-52.3%) had at least one ED visit during the 5 years prior to diagnosis (median 2, p25-p75: 1-4). One hundred and eighteen patients (16.3%, 95%CI: 13.8%-19.2%) had a missed diagnostic opportunity. The main consultations were drug use [145 (15%)], sexually transmitted infections [91 (9.4%)] and request for post-exposure HIV prophylaxis [39 (4%)]. One hundred and fifty-five (42.9%) of the 352 had less than 350 CD4/mm3 when the HIV diagnosis was established. In patients with previous ED visits, the mean time to diagnosis from this visit was 580 (SD 647) days. CONCLUSIONS: Sixteen percent of patients diagnosed with HIV missed the opportunity to be diagnosed in the 5 years prior to diagnosis, highlighting the need to implement ED screening measures different from current ones to improve these outcomes.

Late diagnosis of HIV in 2022: Why so little change?

BACKGROUND: The proportion of people who are diagnosed late is a key metric to measure the public health response to HIV. But this percentage remains stubbornly high in nearly every country. Delays in accessing antiretroviral therapy affects both (i) individual health, due to a higher risk of mortality, and (ii) population-based health, due to continued risk of transmission. Despite huge efforts to increase testing, late diagnosis continues to be an indication of a public health failure. OUTLINE: This short review includes community perspectives on why late diagnosis continues and how it may be reduced. We discuss both structural barriers that prevent people from testing earlier and personal reasons why some people still refuse testing when offered. We note that late diagnosis is reported in all countries and in all demographic groups and that sex, gender, age, and sexuality all affect these rates. However, even in groups with high HIV awareness, such as in gay and bisexual men in the UK, more than one in three people with HIV continue to be diagnosed late. Fears and prejudice about HIV based on outdated information are still common among both health workers and people using health services. For example, testing is still not offered in primary or emergency care settings, and even free testing might not be accepted if someone fears the outcome might jeopardize their resident status, employment, relationship, or health. SUMMARY: In addition to developing targeted projects to reach the highest-risk groups, a positive mainstream public campaign could make testing more acceptable at a broad population level across all demographics. This could challenge and repair the media campaigns from the 1980s that still contribute to the stigma that frightens people away from testing now. We hope that an effective approach in one country might also help others.

Efficiency of screening for human immunodeficiency virus infection in emergency departments: a systematic review and meta-analysis. / Eficiencia del cribado de VIH en urgencias: revisión sistemática y metanálisis.

OBJECTIVES: The rates of undiagnosed and late-diagnosed human immunodeficiency virus (HIV) infection are high. Screening for HIV infection in hospital emergency departments (EDs) could offer a way to increase the number of diagnoses. Our aim was to analyze whether universal hospital ED screening for HIV is efficient. MATERIAL AND METHODS: We followed the guidelines for Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). PubMed, the Cochrane Library, LILACS, Scopus, EMBASE, and the Web of Science were searched using the following terms: "HIV infections/epidemiology," "AIDS serodiagnosis," "emergency service, hospital," "prevalence," and "mass screening/methods." The searches were limited to a 5-year time frame (2016-2020); only publications in English or Spanish were collected. We included studies of universal HIV screening among hospital ED patients and evaluated them using the Quality Assessment Tool for Quantitative Studies. RESULTS: A total of 273 articles were identified. Twelve met the inclusion criteria. The studies analyzed 103 731 patient samples and yielded 652 new HIV diagnoses. A random effects model estimated an overall new-diagnosis prevalence of 0.60% (95% CI, 0.39%-0.84%). The heterogeneity statistic I2 was high, at 90.02% (P .001). Estimates of prevalence based on studies carried out in Europe, the United States, and Africa were, respectively, 0.48% (95% CI, 0.13%-1.03%), 0.54% (95% CI, 0.33%-0.40%), and 5.6% (95% CI, 3.37%-9.2%). The studies received quality ratings of moderate or strong. CONCLUSION: Although the reviewed studies applied various screening strategies to identify new HIV diagnoses, our findings support the conclusion that universal screening is efficient.

OBJETIVO: Existe una elevada tasa de infección oculta y diagnóstico tardío en el virus de la inmunodeficiencia hu mana (VIH). La realización de pruebas diagnósticas de infección por VIH en los servicios de urgencias hospitalarios (SUH) puede representar una oportunidad para aumentar el número de diagnósticos. El objetivo de este trabajo es analizar si el cribado universal para el VIH realizado en los SUH es eficiente. METODO: Se realiza una revisión sistemática y metanálisis siguiendo la normativa PRISMA en la base de datos de Pubmed, Cochrane, LILACS, Scopus, EMBASE y WOS utilizando una combinación de términos MESH: "HIV Infections/ epidemiology", "AIDS Serodiagnosis", "Emergency Service, Hospital", "Prevalence", "Mass screening/methods". Los criterios de la búsqueda se centraron en los últimos 5 años (2016-2020) y en los artículos publicados en inglés y en español. Se incluyeron los estudios de pruebas de cribado universal mediante test de cribado de VIH realizadas en los SUH. Para evaluar la calidad de los artículos se utilizó el cuestionario "Quality assessment tool for quantitative studies". RESULTADOS: Se identificaron un total de 273 artículos de los cuales se analizaron finalmente 12 que cumplían los criterios de inclusión. Los estudios incluidos representan un total de 103.731 muestras analizadas obteniéndose un total de 652 nuevos diagnósticos de VIH. La prevalencia conjunta obtenida a través del modelo de efectos aleatorios fue de 0,60% (IC 95%: 0,39-0,84) y el valor del I2 revela una presencia elevada de heterogeneidad (I2 90,02%; p 0,001). La prevalencia conjunta en los estudios incluidos realizados en Europa, América y África fue de 0,48% (IC 95%: 0,13-1,03), 0,54% (IC 95%: 0,33-0,40) y 5,6% (IC 95%: 3,37-9,2), respectivamente. La evaluación de la calidad de los estudios fue de moderada a fuerte. CONCLUSIONES: Aunque las pruebas del VIH pueden realizarse utilizando diferentes estrategias, nuestros datos avalan que una estrategia de cribado universal es eficiente.

Eficiencia del cribado de VIH en urgencias: revisión sistemática y metanálisis / Efficiency of screening for human immunodeficiency virus infection in emergency departments: a systematic review and meta-analysis

Objetivo. Existe una elevada tasa de infección oculta y diagnóstico tardío en el virus de la inmunodeficiencia humana (VIH). La realización de pruebas diagnósticas de infección por VIH en los servicios de urgencias hospitalarios (SUH) puede representar una oportunidad para aumentar el número de diagnósticos. El objetivo de este trabajo es analizar si el cribado universal para el VIH realizado en los SUH es eficiente. Método. Se realiza una revisión sistemática y metanálisis siguiendo la normativa PRISMA en la base de datos de Pubmed, Cochrane, LILACS, Scopus, EMBASE y WOS utilizando una combinación de términos MESH: “HIV Infections/ epidemiology”, “AIDS Serodiagnosis”, “Emergency Service, Hospital”, “Prevalence”, “Mass screening/methods”. Los criterios de la búsqueda se centraron en los últimos 5 años (2016-2020) y en los artículos publicados en inglés y en español. Se incluyeron los estudios de pruebas de cribado universal mediante test de cribado de VIH realizadas en los SUH. Para evaluar la calidad de los artículos se utilizó el cuestionario “Quality assessment tool for quantitative studies”. Resultado. Se identificaron un total de 273 artículos de los cuales se analizaron finalmente 12 que cumplían los criterios de inclusión. Los estudios incluidos representan un total de 103.731 muestras analizadas obteniéndose un total de 652 nuevos diagnósticos de VIH. La prevalencia conjunta obtenida a través del modelo de efectos aleatorios fue de 0,60% (IC 95%: 0,39-0,84) y el valor del I2 revela una presencia elevada de heterogeneidad (I2 90,02%; p < 0,001). La prevalencia conjunta en los estudios incluidos realizados en Europa, América y África fue de 0,48% (IC 95%: 0,13- 1,03), 0,54% (IC 95%: 0,33-0,40) y 5,6% (IC 95%: 3,37-9,2), respectivamente. La evaluación de la calidad de los estudios fue de moderada a fuerte. [...]

Background and objective. The rates of undiagnosed and late-diagnosed human immunodeficiency virus (HIV) infection are high. Screening for HIV infection in hospital emergency departments (EDs) could offer a way to increase the number of diagnoses. Our aim was to analyze whether universal hospital ED screening for HIV is efficient. Methods. We followed the guidelines for Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). PubMed, the Cochrane Library, LILACS, Scopus, EMBASE, and the Web of Science were searched using the following terms: “HIV infections/epidemiology,” “AIDS serodiagnosis,” “emergency service, hospital,” “prevalence,” and “mass screening/methods.” The searches were limited to a 5-year time frame (2016–2020); only publications in English or Spanish were collected. We included studies of universal HIV screening among hospital ED patients and evaluated them using the Quality Assessment Tool for Quantitative Studies. Results. A total of 273 articles were identified. Twelve met the inclusion criteria. The studies analyzed 103731 patient samples and yielded 652 new HIV diagnoses. A random effects model estimated an overall new-diagnosis prevalence of 0.60% (95% CI, 0.39%–0.84%). The heterogeneity statistic I2 was high, at 90.02% (P < .001). Estimates of prevalence based on studies carried out in Europe, the United States, and Africa were, respectively, 0.48% (95% CI, 0.13%–1.03%), 0.54% (95% CI, 0.33%–0.40%), and 5.6% (95% CI, 3.37%–9.2%). The studies received quality ratings of moderate or strong. Conclusion. Although the reviewed studies applied various screening strategies to identify new HIV diagnoses, our findings support the conclusion that universal screening is efficient.

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.

The Epidemiology of HIV in Oman, 1984-2018: A Nationwide Study from the Middle East.

We used population-based data on all diagnosed people living with Human Immunodeficiency (HIV) reported to the National AIDS Programme in 1984-2018 to describe the HIV epidemiology in Oman. A total of 3060 Omanis were diagnosed with HIV from 1984 to 2018. The proportions of new infections attributed to sexual contact accounted for 56.3% (376/668) in 1984-1996 compared with 80.7% (630/780) in 2013-2018. Of 1417 patients with a documented CD4 count at the entry of care, 45.3% had a baseline CD4 count of <200 cells/mm3. Compared with heterosexuals, homosexuals had higher rates of advanced HIV disease [42.7% (388/908) vs 50.4% (136/270), respectively]. Rates of advanced disease and death within a year of HIV diagnosis rose consistently with age at diagnosis. Approximately half (48.8%) of the patients diagnosed in 1984-2018 had died by December 2018. The majority (85.6%; 572/668) of people who were diagnosed in 1984-1997 had died compared with 12.7% (99/780) of those diagnosed in 2013-2018. However, people died more recently had a higher proportion of death within a year of HIV diagnosis [74.7% (74/99) in 2013-2018 compared with 13.8% (79/572) in 1984-1996]. This study shows that the HIV epidemic in Oman is a low-prevalence one. Of concern, a large proportion of new HIV diagnoses continued to present late, which has resulted in a substantial increase in short-term mortality over the past 20 years. Nevertheless, we observed a remarkable decline in overall mortality over time, which may be explained by the improvement in the quality of HIV care in Oman.

Evaluating a pilot process for reviewing late HIV diagnoses in England and Wales.

Late HIV diagnosis is associated with significant mortality in people living with HIV (PLWH) and high numbers of missed opportunities (MO) for earlier testing have been identified. A pilot of a national late diagnosis review process (LDRP) was undertaken in 15 HIV services evaluating the feasibility of LDRP implementation, as a patient safety initiative. All newly diagnosed PLWH with CD4 counts <200 cells/mm3 were included, and healthcare episodes within 5 years of presentation reviewed. Of 127 patients identified, 40 (31.5%) had MO and were more often white, UK-born and suffered more serious harm around diagnosis. Of these, four were designated serious incidents (undergoing root cause analysis) and eight were serious learning events. Engagement with services where MO occurred was challenging, however 75% of services found the LDRP sustainable. Widespread implementation of the LDRP should enable progress with training and policy changes within external services, enabling earlier HIV diagnosis and preventing deaths.

The relationship between higher social trust and lower late HIV diagnosis and mortality differs by race/ethnicity: results from a state-level analysis.

INTRODUCTION: Black men who have sex with men (MSM) continue to suffer a disproportionate burden of new HIV diagnoses and mortality. To better understand some of the reasons for these profound disparities, we examined whether the association between social trust and late HIV diagnosis and mortality differed by race/ethnicity, and investigated potential indirect effects of any observed differences. METHODS: We performed generalized structural equation modelling to assess main and interaction associations between trust among one's neighbours in 2009 (i.e. social trust) and race/ethnicity (Black, White, and Hispanic) predicting late HIV diagnosis (a CD4 count ≤200 cell/µL within three months of a new HIV diagnosis) rates and all-cause mortality rates of persons ever diagnosed late with HIV, across 47 American states for the years 2009-2013. We examined potential indirect effects of state-level HIV testing between social trust and late HIV diagnosis. Social trust data were from the Gallup Healthways Survey, HIV data from the Centers for Disease Control and Prevention, and HIV testing from the Behavioral Risk Factor Surveillance System. Covariates included state-level structural, healthcare, and socio-demographic factors including income inequality, healthcare access, and population density. We stratified analysis by transmission group (male-to-male, heterosexual, and injection drug use (IDU)). RESULTS: States with higher levels of social trust had lower late HIV diagnosis rates: Adjusted Rate Ratio [aRR] were consistent across risk groups (0.57; 95%CI 0.53-0.62, male-to-male), (aRR 0.58; 95%CI 0.54-0.62, heterosexual) and (aRR 0.64; 95%CI 0.60-0.69, IDU). Those associations differed by race/ethnicity (all p < 0.001). The associations were most protective for Blacks followed by Hispanics, and least protective for Whites. HIV testing mediated between 18 and 32% of the association between social trust and late HIV diagnosis across transmission group but for Blacks relative to Whites only. Social trust was associated with lower all-cause mortality rates and that association varied by race/ethnicity within the male-to-male and IDU transmission groups only. CONCLUSION: Social trust may promote timely HIV testing, which can facilitate earlier HIV diagnosis, thus it can be a useful determinant to monitor the relationship with HIV care continuum outcomes especially for racial/ethnic minority groups disproportionately infected by HIV.

Neighborhood Social Capital in Relation to Late HIV Diagnosis, Linkage to HIV Care, and HIV Care Engagement.

High neighborhood social capital could facilitate earlier diagnosis of HIV and higher rates of linkage and HIV care engagement. Multivariate analysis was used to examine whether social capital (social cohesion, social participation, and collective engagement) in 2004/2006 was associated with lower 5-year average (2007-2011) prevalence of (a) late HIV diagnosis, (b) linked to HIV care, and (c) engaged in HIV care within Philadelphia, PA, United States. Census tracts (N = 332). Higher average neighborhood social participation was associated with higher prevalence of late HIV diagnosis (b = 1.37, se = 0.32, p < 0.001), linked to HIV care (b = 1.13, se = 0.20, p < 0.001) and lower prevalence of engaged in HIV care (b = -1.16, se = 0.30, p < 0.001). Higher collective engagement was associated with lower prevalence of linked to HIV care (b = -0.62, se = 0.32, p < 0.05).The findings of different directions of associations among social capital indicators and HIV-related outcomes underscore the need for more nuanced research on the topic that include longitudinal assessment across key populations.

Structural inequalities drive late HIV diagnosis: The role of black racial concentration, income inequality, socioeconomic deprivation, and HIV testing.

In the United States, research is limited on the mechanisms that link socioeconomic and structural factors to HIV diagnosis outcomes. We tested whether neighborhood income inequality, socioeconomic deprivation, and black racial concentration were associated with gender-specific rates of HIV in the advanced stages of AIDS (i.e., late HIV diagnosis). We then examined whether HIV testing prevalence and accessibility mediated any of the associations above. Neighborhoods with highest (relative to lowest) black racial concentration had higher relative risk of late HIV diagnosis among men (RR=1.86; 95%CI=1.15, 3.00) and women (RR=5.37; 95%CI=3.16, 10.43) independent of income inequality and socioeconomic deprivation. HIV testing prevalence and accessibility did not significantly mediate the associations above. Research should focus on mechanisms that link black racial concentration to HIV diagnosis outcomes.

Factors associated with late Human Immunodeficiency Virus (HIV) diagnosis among peoples living with it, Northwest Ethiopia: hospital based unmatched case-control study.

BACKGROUND: Early HIV diagnosis and access to treatment is one of the most effective ways to prevent its further spread and to protect the health of those living with the virus. However, delay in diagnosis is the major risk factor for uptake of and response to antiretroviral therapy. METHODS: Institution-based unmatched case-control study design was used in the study. The study was conducted in Debre-Markos and Finote-Selam Hospitals, Northwest Ethiopia. Cases were people living with HIV who had CD4 count <350cells/mm3 or WHO clinical stage III and IV regardless of the CD4 count at first presentation and controls were those who had CD4 count ≥350cells/mm3 or WHO clinical stage I and II. If both criteria were available, the CD4 count was used in the study as World Health Organization recommended. A total of 392 respondents (196 cases and 196 controls) were recruited and selected systematically. The data were collected by trained nurses using chart review and interviewer administered structured questionnaire. Binary Logistic Regression Model was used to identify the factors associated with late HIV diagnosis. RESULTS: About 95.9 % of study participants provided complete response. Having no understanding, compared to having understanding, about HIV/AIDS (AOR = 1.7, 95 %CI = 1.08-2.79) and ART (AOR = 2.1, 95 %CI: 1.25-3.72), being tested as a result of symptoms/ illness, compared to being tested for risk exposure (inverted AOR =2.5, 95 %CI: 1.64-4.76), and acquiring HIV through sexual contact, compared to acquiring it through other modes (AOR = 2.5, 95 %CI = 1.52-4.76) were positively and independently associated with late HIV diagnosis. CONCLUSIONS: Unlike perceived HIV stigma, having no understanding about HIV and ART, being tested for presence of symptoms/illness, and acquiring HIV through sexual contact were independent and significant factors for late HIV diagnosis.

Late presentation for diagnosis of HIV infection among HIV positive patients in South Tigray Zone, Ethiopia.

BACKGROUND: In spite of the availability and accessibility of HIV testing opportunities and efforts, people are being late to test in the course of HIV infection. Late diagnosis leads to late anti-retroviral therapy initiation which in turn results in poor treatment outcome and prognosis of the disease. The aim of this study was to determine the prevalence and predictors of late HIV diagnosis among HIV-infected patients in South Tigray Zone, Ethiopia. METHODS: A facility based cross sectional study was conducted among HIV positive patients from February 1-30, 2014 in Southern Tigray, Ethiopia. Multistage sampling technique was employed to select the study participants. Data were collected by reviewing patient medical card and interviewing using structured questionnaire. Data were entered using Epi-Data version 3.1 and analyzed using SPSS version 20.0. Both bivariate and multivariate logistic regressions were modeled to evaluate the association of predictors with late diagnosis of HIV infection. RESULTS: Out of 789 study participants, 68.8 % of them were late for HIV diagnosis. Feeling healthy (65.7 %), fear of stigma and discrimination (32.4 %) and using traditional treatment (1.5 %) were reported as the main reasons for late HIV diagnosis. Use of Khat [AOR = 3.27, 95 % CI (1.75, 6.13)], bed ridden functional status [AOR = 2.66, 95 % CI (1.60, 4.42)], ambulatory functional status [AOR = 1.56, 95 % CI (1.03, 2.35)] and Muslim religion [AOR = 2.26, 95 % CI (1.13, 4.49)] were significantly associated with late presentation for HIV diagnosis. CONCLUSIONS: High prevalence of late HIV diagnosis was recorded in Southern Tigray Zone, Ethiopia. Public health educations and campaigns targeted at improving early diagnosis and prognosis of people living with HIV/AIDS in Southern Tigray, Northern Ethiopia should be underway.

Late HIV Testing in a Cohort of HIV-Infected Patients in Puerto Rico.

OBJECTIVE: Late HIV testing (LT), defined as receiving an AIDS diagnosis within a year of one's first positive HIV test, is associated with higher HIV transmission, lower HAART effectiveness, and worse outcomes. Latinos represent 36% of LT in the US, yet research concerning LT among HIV cases in Puerto Rico is scarce. METHODS: Multivariable logistic regression analysis was used to identify factors associated with LT, and a Cochran‒Armitage test was used to determine LT trends in an HIV-infected cohort followed at a clinic in Puerto Rico specialized in the management and treatment of HIV. RESULTS: From 2000 to 2011, 47% of eligible patients were late testers, with lower median CD4 counts (54 vs. 420 cells/mm3) and higher median HIV viral load counts (253,680 vs. 23,700 copies/mL) than non-LT patients. LT prevalence decreased significantly, from 47% in 2000 to 37% in 2011. In a mutually adjusted logistic regression model, males, older age at enrollment and past history of IDU significantly increased LT odds, whereas having a history of amphetamine use decreased LT odds. When the data were stratified by mode of transmission, it became apparent that only the category men who have sex with men (MSM) saw a significant reduction in the proportion of LT, falling from 67% in 2000 to 33% in 2011. CONCLUSION: These results suggest a gap in early HIV detection in Puerto Rico, a gap that decreased only among MSM. An evaluation of the manner in which current HIV-testing guidelines are implemented on the island is needed.

Deficiencies in the health care system contribute to a high rate of late HIV diagnosis in Sweden.

OBJECTIVES: The aim of the study was to identify factors in HIV-infected patients and the health care system which contribute to late diagnosis. METHODS: All patients who were newly diagnosed with HIV infection at 12 clinics in Sweden over a period of 2.5 years (n = 575) were included in the study, corresponding to three-quarters of newly diagnosed HIV infections in the country. The patients were classified as non-late presenters or late presenters (LPs), defined as those with a CD4 count < 350 cells/µL or AIDS. LPs were subdivided into those without and those with advanced HIV disease, which was defined as a CD4 count < 200 cells/µL or AIDS. Demographics, missed AIDS and HIV-associated symptoms in the preceding 3 years, immigration date, and health examination at immigration were recorded. RESULTS: Fifty-eight per cent of the patients were LPs, of whom 66% had advanced disease. Age > 30 years, origin in sub-Saharan Africa or Eastern Europe/Asia/the Pacific region, and country of transmission being in sub-Saharan Africa or unknown were associated with late presentation. Half of the patients of non-Swedish origin had lived for more than 1 year in Sweden at diagnosis and 66% had a missed HIV testing opportunity at immigration. Twenty-seven per cent of all patients had presented for health care with AIDS- and/or HIV-associated conditions without having an HIV test. Sixteen per cent had a history of symptoms without seeking care. CONCLUSIONS: Deficiencies in the health care system with missed HIV testing opportunities contribute to the high proportion of late presenters in Sweden, especially among migrants. With increased testing at immigration and further incorporation of "indicator-guided" testing in general practice, most patients could be diagnosed earlier.

Late HIV Testing in a Cohort of HIV-Infected Patients in Puerto Rico.

OBJECTIVE: Late HIV testing (LT), defined as receiving an AIDS diagnosis within a year of one's first positive HIV test, is associated with higher HIV transmission, lower HAART effectiveness, and worse outcomes. Latinos represent 36% of LT in the US, yet research concerning LT among HIV cases in Puerto Rico is scarce. METHODS: Multivariable logistic regression analysis was used to identify factors associated with LT, and a Cochran‒Armitage test was used to determine LT trends in an HIV-infected cohort followed at a clinic in Puerto Rico specialized in the management and treatment of HIV. RESULTS: From 2000 to 2011, 47% of eligible patients were late testers, with lower median CD4 counts (54 vs. 420 cells/mm3) and higher median HIV viral load counts (253,680 vs. 23,700 copies/mL) than non-LT patients. LT prevalence decreased significantly, from 47% in 2000 to 37% in 2011. In a mutually adjusted logistic regression model, males, older age at enrollment and past history of IDU significantly increased LT odds, whereas having a history of amphetamine use decreased LT odds. When the data were stratified by mode of transmission, it became apparent that only the category men who have sex with men (MSM) saw a significant reduction in the proportion of LT, falling from 67% in 2000 to 33% in 2011. CONCLUSION: These results suggest a gap in early HIV detection in Puerto Rico, a gap that decreased only among MSM. An evaluation of the manner in which current HIV-testing guidelines are implemented on the island is needed.