Missed opportunities for earlier diagnosis of HIV in patients who presented with advanced HIV disease: a retrospective cohort study

Abstract

ObjectiveTo quantify and characterise missed opportunities for earlier HIV diagnosis in patients diagnosed with advanced HIV.DesignA retrospective observational cohort study.SettingA central tertiary medical centre in Israel.MeasuresThe proportion of patients with advanced HIV, the proportion of missed opportunities to diagnose them earlier, and the rate of clinical indicator diseases (CIDs) in those patients.ResultsBetween 2010 and 2015, 356 patients were diagnosed with HIV, 118 (33.4%) were diagnosed late, 57 (16%) with advanced HIV disease. Old age (OR=1.45 (95% CI 1.16 to 1.74)) and being heterosexual (OR=2.65 (95% CI 1.21 to 5.78)) were significant risk factors for being diagnosed late. All patients with advanced disease had at least one CID that did not lead to an HIV test in the 5 years prior to AIDS diagnosis. The median time between CID and AIDS diagnosis was 24 months (IQR 10–30). 60% of CIDs were missed by a general practitioner and 40% by a specialist.ConclusionsMissed opportunities to early diagnosis of HIV occur in primary and secondary care. Lack of national guidelines, lack of knowledge regarding CIDs and communication barriers with patients may contribute to a late diagnosis of HIV.

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

“…Routine testing for HIV in the presence of IC has been demonstrated to be cost effective . Failure to screen for HIV when patients intersect with the healthcare system with an IC represents a missed opportunity for earlier diagnosis . Other studies have demonstrated that among patients presenting with IC, rates of HIV testing are low .…”

“…Other studies have demonstrated that among patients presenting with IC, rates of HIV testing are low . Multiple barriers to testing have been identified including lack of knowledge of IC, lack of guidelines, low‐risk perception and perceived lack of knowledge around HIV . Studies reviewing non‐HIV specialty guidelines for IC found that many of these guidelines do not consider HIV testing as part of the investigations for IC .…”

“…11 Failure to screen for HIV when patients intersect with the healthcare system with an IC represents a missed opportunity for earlier diagnosis. 10,12,13 Other studies have demonstrated that among patients presenting with IC, rates of HIV testing are low. 10,14,15 Multiple barriers to testing have been identified including lack of knowledge of IC, lack of guidelines, low-risk perception and perceived lack of knowledge around HIV.…”

“…10,14,15 Multiple barriers to testing have been identified including lack of knowledge of IC, lack of guidelines, low-risk perception and perceived lack of knowledge around HIV. 6,13,16 Studies reviewing non-HIV specialty guidelines for IC found that many of these guidelines do not consider HIV testing as part of the investigations for IC. 10,17,18 Thus, specialist clinicians managing IC may not be aware of the prevalence of undiagnosed HIV among their patients with such conditions.…”

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

“…This figure compares to 53% mentioning and 38% recommending HIV testing in comparable UK findings. 16 In our own experience 15 and the experience of others, [19][20][21][22] missed opportunities for diagnosis are likely to be followed by later presentation to hospital with AIDS-defining events. Early diagnosis and screening are likely to reduce morbidity and mortality and be cost effective.…”