Trends in missed presentations and late HIV diagnosis in a UK teaching hospital: a retrospective comparative cohort study

BMC Infectious Diseases

Robert BS Laing¹  Timothy Lawes¹  Jared Wohlgemut² 

[1] Infection Unit, Aberdeen Royal Infirmary, Aberdeen, UK;School of Medicine and Dentistry, University of Aberdeen, Aberdeen, UK

关键词: Adult;    Delayed diagnosis;    Cohort studies;    HIV;   

Others  :  1175418
DOI  :  10.1186/1471-2334-12-72

 received in 2011-08-17, accepted in 2012-03-28,  发布年份 2012

【 摘 要 】

Background

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. 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.

Methods

We 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.

Results

There 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.

Conclusions

While 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.

【 授权许可】

   
2012 Wohlgemut et al; licensee BioMed Central Ltd.

【 图 表 】

Figure 1.

Figure 2.

Figure 3.

【 参考文献 】

• [1]UNAIDS/WHO: Guidance on Provider-Initiated HIV testing and counselling in health facilities. Geneva: World Health Organisation and Joint United Nations Programme on HIV/AIDS; 2006.
• [2]Centers for Disease Control and Prevention: HIV prevalence estimates--United States, 2006. Morb Mortal Wkly Rep 2008, 57(39):1073-1076.
• [3]European Center for the Epidemiological Monitoring of AIDS: End-Year Report 2006. [http://www.eurohiv.org/reports/report_75/pdf/report_eurohiv_75.pdf] webciteEuroHIV 2007.
• [4]De Cock KM, Johnson AM: From exceptionalism to normalisation: a reappraisal of attitudes and practice around HIV testing. BMJ 1998, 316(7127):290-293.
• [5]Marks G, Crepaz N, Janssen RS: Estimating sexual transmission of HIV from persons aware and unaware that they are infected with the virus in the USA. AIDS 2006, 20:1447-1450.
• [6]Sabin CA, Smith CJ, Gumley H, Murphy G, Lampe FC, Phillips AN, Prinz B, Youle M, Johnson MA: Late presenters in the era of highly active antiretroviral therapy: uptake of and responses to antiretroviral therapy. AIDS 2004, 18(16):2145-2151.
• [7]Lucas SB, Curtis H, Johnson MA: National review of deaths among HIV-infected adults. Clin Med 2008, 8(3):250-252.
• [8]Fleishman JA, Yehia BR, Moore RD, Gebo KA: The economic burden of late entry into medical care for patients with HIV infection. Med Care 2010, 48(12):1071-1079.
• [9]Sir Liam Donaldson, CMO & Christine Beasley, CNO: Improving the detection and diagnosis of HIV in non- HIV specialties including primary care. [http:/ / www.info.doh.gov.uk/ doh/ embroadcast.nsf/ vwDiscussionAII/ / EEOFA479BAA64A1B80257355003DFB47] webcite
• [10]British HIV Association, British Association of Sexual Health and HIV, British Infection Society: UK National Guidelines for HIV Testing 2008. London: BHIVA/BASHH/BIS; 2008.
• [11]Sanders GD, Bayoumi AM, Sundaram V, Bilir SP, Neukermans CP, Rydzak CE, Douglass LR, Lazzeroni LC, Holodniy M, Owens DK: Cost-effectiveness of screening for HIV in the era of highly active antiretroviral therapy. New Engl J Med 2005, 352:570-585.
• [12]Sullivan AK, Curtis H, Sabin CA, Johnson MA: Newly diagnosed HIV infections: review in UK and Ireland. BMJ 2005, 330(7503):1301-1302.
• [13]Ratcliffe L, Thomas S, Beeching NJ, Phillips-Howard PA, Taegtmeyer M: Acute presentations of HIV are still missed in low prevalence areas. Postgrad Med J 2011, 87(1025):170-174.
• [14]McDaid LM, Hart GJ: Increased HIV testing and reduced undiagnosed infection among gay men in Scotland, 2005-8: support for the opt-out testing policy? Sex Transm Infect 2011, 87(3):221-224.
• [15]World Health Organisation: Interim WHO clinical staging of HIV/AIDS and HIV/AIDS case definitions for surveillance. Geneva 2005.
• [16]Scottish Neighbourhood Statistics [http://www.sns.gov.uk/] webcite The Scottish Government
• [17]Spencer N, Bambang S, Logan S, Gill L: Socioeconomic status and birth weight: comparison of an area based measure with the registrar general's social class. J Epidemiol Community Health 1999, 53:495-498.
• [18]Smith GD, Hart C, Watt G, Hole D, Hawthorne V: Individual social class, area-based deprivation, cardiovascular disease risk factors, and mortality: the Renfrew and Paisley Study. J Epidemiol Community Health 1998, 52:399-405.
• [19]World Medical Association Declaration of Helsinki: Ethical principles for medical research involving human subjects. Adopted 1964, Amended 1975, 1983, 1989, 1996, 2000, 2002, 2004 and 2008: [http://www.wma.net/en/30publications/10policies/b3/17c.pdf webcite]
• [20]Mackenzie AR, Laing RB, Urbaniak SJ, Molyneaux PJ, Douglas JG, Smith CC: Epidemiology and outcome of HIV infection in North-East Scotland (1985-1997). J Infect 1999, 38(2):107-110.
• [21]Mabey D, Mayaud P: Sexually transmitted diseases in mobile populations. Genitourin Med 1997, 73:18-22.
• [22]Burns FM, Johnson AM, Nazroo J, Ainsworth J, Anderson J, Fakoya A, Fakoya I, Hughes A, Jungmann E, Sadiq ST, Sullivan AK, Fenton KA, SONHIA Collaboration Group: Missed opportunities for earlier HIV diagnosis within primary and secondary healthcare settings in the UK. AIDS 2008, 22(1):115-122.
• [23]Delpierre C, Dray-Spira R, Cuzin L, Marchou B, Massip P, Lang T, Lert F, VESPA Study Group: Correlates of late HIV diagnosis: implications for testing policy. Int J STD AIDS 2007, 18(5):312-317.
• [24]Health Protection Agency Centre for Infections, Health Protection Scotland, UCL Institute of Child Health: United Kingdom New HIV Diagnoses to end of December 2010. London; Health Protection Agency; 2011.
• [25]Kaufmann GR, Bloch M, Finlayson R, Zaunders J, Smith D, Cooper DA: The extent of HIV-1-related immunodeficiency and age predict the long-term CD4 T lymphocyte response to potent antiretroviral therapy. AIDS 2002, 16(3):359-367.
• [26]Zenilman JM, Shahmanesh M, Winter AJ: Ethnicity and STIs: more than black and white. Sex Transm Infect 2001, 77(1):2-3.
• [27]Srinivasan R, Menon L, Stevens P, Campbell I, Alfaham M: Ethnic differences in selective neonatal BCG immunisation: white British children miss out. Thorax 2006, 61(3):247-249.
• [28]Gossop M, Powis B, Griffiths P, Strang J: Multiple risks for HIV and hepatitis B infection among heroin users. Drug Alcohol Rev 1994, 13:293-300.
• [29]Rodrigo T, Cayla JA, de Garcia Olalla P, Galdos-Tanguis H, Jansa JM, Miranda P, Brugal T: Characteristics of tuberculosis patients who generate secondary cases. Int J Tuberc Lung Dis 1997, 1(4):352-357.
• [30]Scaradavou A: HIV-related thrombocytopenia. Blood Rev 2002, 16(1):73-76.
• [31]Fox J, Nastouli E, Thomson E, Muir D, McClure M, Weber J, Fidler S: Increasing incidence of acute hepatitis C in individuals diagnosed with primary HIV in the United Kingdom. AIDS 2008, 22(5):666-668.
• [32]Hung CC, Hsiao CF, Wang JL, Chen MY, Hsieh SM, Sheng WH, Chang SC: Herpes zoster in HIV-1-infected patients in the era of highly active antiretroviral therapy: a prospective observational study. Int J STD AIDS 2005, 16(10):673-676.
• [33]Johnson NW: The mouth in HIV/AIDS: markers of disease status and management challenges for the dental profession. Aust Dent J 2010, 55(Suppl 1):85-102.
• [34]Sudarshi D, Pao D, Murphy G, Parry J, Dean G, Fisher M: Missed opportunities for diagnosing primary HIV infection. Sex Transm Infect 2008, 84(1):14-16.
• [35]Lee V, Foley E, Patel R: Evaluation of time for non-GU medicine physicians to diagnose HIV infection in patients presenting with HIV-related illnesses. Int J ST AIDS 2006, 17:97-98.
• [36]Aicken CR, Cassell JA, Estcourt CS, Keane F, Brook G, Rait G, White PJ, Mercer CH: Rationale and development of a survey tool for describing and auditing the composition of, and flows between, specialist and community clinical services for sexually transmitted infections. BMC Health Serv Res 2011, 11:30. BioMed Central Full Text
• [37]Castilla J, Sobrino P, De La Fuente L, Noguer I, Guerra L, Parras F: Late diagnosis of HIV infection in the era of highly active antiretroviral therapy: consequences for AIDS incidence. AIDS 2002, 16(14):1945-1951.
• [38]Hamill M, Burgoine K, Farrell F, Hemelaar J, Patel G, Welchew DE, Jaffe HW: Time to move towards opt out testing for HIV in the UK. BMJ 2007, 334(7608):1352-1354.
• [39]Peck L, Ferenczi E, Burns F, Cosgrove C, Brown M: Barriers to targeted HIV testing on an acute admissions unit: evaluation of the UK guideline. QJM 2010, 103(3):147-151.