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Coukan F, Sullivan A, Mitchell H, Jaffer S, Williams A, Saunders J, Atchison C, Ward H. Impact of national commissioning of pre-exposure prophylaxis (PrEP) on equity of access in England: a PrEP-to-need ratio investigation. Sex Transm Infect 2024; 100:166-172. [PMID: 38508708 DOI: 10.1136/sextrans-2023-055989] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2023] [Accepted: 01/13/2024] [Indexed: 03/22/2024] Open
Abstract
OBJECTIVES HIV pre-exposure prophylaxis (PrEP) is highly effective in preventing HIV acquisition. In England, NHS availability was limited to participants of the PrEP Impact Trial until late 2020. Some key populations at greater risk of HIV were under-represented in the trial suggesting inequities in trial PrEP access. We used the PrEP-to-need ratio (PnR; number of PrEP users divided by new HIV diagnoses) to investigate whether PrEP access improved following routine commissioning in October 2020 and identify populations most underserved by PrEP. METHODS Aggregated numbers of people receiving ≥1 PrEP prescription and non-late new HIV diagnoses (epidemiological proxy for PrEP need) were taken from national surveillance data sets. We calculated the PnR across socio-demographics during Impact (October 2017 to February 2020; pre-COVID-19 pandemic) and post-commissioning PrEP era (2021) in England. RESULTS PnR increased >11 fold, from 4.2 precommissioning to 48.9 in 2021, due to a fourfold reduction in non-late new HIV diagnoses and near threefold increase in PrEP users. PnR increased across genders, however, the men's PnR increased 12-fold (from 5.4 precommissioning to 63.9 postcommissioning) while the women's increased sevenfold (0.5 to 3.5). This increasing gender-based inequity was observed across age, ethnicity and region of residence: white men had the highest PnR, increasing >13 fold (7.1 to 96.0), while Black African women consistently had the lowest PnR, only increasing slightly (0.1 to 0.3) postcommissioning, suggesting they were the most underserved group. Precommissioning, the PnR was 78-fold higher among white men than Black women, increasing to 278-fold postcommissioning. CONCLUSIONS Despite the overall increase in PrEP use, substantial PrEP Impact trial inequities widened postcommissioning in England, particularly across gender, ethnicity and region of residence. This study emphasises the need to guide HIV combination prevention based on equity metrics relative to the HIV epidemic. The PnR could support the optimisation of combination prevention to achieve zero new HIV infections in England by 2030.
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Affiliation(s)
- Flavien Coukan
- National Institute for Health Research Applied Research Collaboration North West London, Chelsea and Westminster Hospital, London, UK
- Patient Experience Research Centre, School of Public Health, Imperial College London, London, UK
| | - Ann Sullivan
- Chelsea and Westminster Hospital NHS Foundation Trust, London, UK
- Imperial College London, London, UK
| | - Holly Mitchell
- Blood Safety, Hepatitis, Sexually Transmitted Infections (STI) and HIV Division, UK Health Security Agency, London, UK
| | | | | | - John Saunders
- Blood Safety, Hepatitis, Sexually Transmitted Infections (STI) and HIV Division, UK Health Security Agency, London, UK
- UCL Centre for Clinical Research in Infection and Sexual Health, Institute for Global Health, University College London, London, UK
| | - Christina Atchison
- Patient Experience Research Centre, School of Public Health, Imperial College London, London, UK
- National Institute for Health Research Imperial Biomedical Research Centre, London, UK
| | - Helen Ward
- National Institute for Health Research Applied Research Collaboration North West London, Chelsea and Westminster Hospital, London, UK
- Patient Experience Research Centre, School of Public Health, Imperial College London, London, UK
- National Institute for Health Research Imperial Biomedical Research Centre, London, UK
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Gagliardini R, Tavelli A, Rusconi S, Lo Caputo S, Spagnuolo V, Santoro MM, Costantini A, Vergori A, Maggiolo F, Giacomelli A, Burastero G, Madeddu G, Quiros Roldan E, d'Arminio Monforte A, Antinori A, Cozzi-Lepri A. Characterization and outcomes of difficult-to-treat patients starting modern first-line ART regimens: Data from the ICONA cohort. Int J Antimicrob Agents 2024; 63:107018. [PMID: 38214244 DOI: 10.1016/j.ijantimicag.2023.107018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2023] [Revised: 10/13/2023] [Accepted: 10/23/2023] [Indexed: 01/13/2024]
Abstract
OBJECTIVES Treatment failures to modern antiretroviral therapy (ART) raise concerns, as they could reduce future options. Evaluations of occurrence of multiple failures to modern ART are missing and their significance in the long run is unclear. METHODS People with HIV (PWH) in the ICONA cohort who started a modern first-line ART were defined as 'difficult to treat' (DTT) if they experienced ≥1 among: i) ≥2 VF (2 viral loads, VL>200 copies/mL or 1 VL>1000 copies/mL) with or without ART change; ii) ≥2 treatment discontinuations (TD) due to toxicity/intolerance/failure; iii) ≥1 VF followed by ART change plus ≥1 TD due to toxicity/intolerance/failure. A subgroup of the DTT participants were matched to PWH that, after the same time, were non-DTT. Treatment response, analysing VF, TD, treatment failure, AIDS/death, and SNAE (Serious non-AIDS event)/death, were compared. Survival analysis by KM curves and Cox regression models were employed. RESULTS Among 8061 PWH, 320 (4%) became DTT. Estimates of becoming DTT was 6.5% (95% CI: 5.8-7.4%) by 6 years. DTT PWH were significantly older, with a higher prevalence of AIDS and lower CD4+ at nadir than the non-DTT. In the prospective analysis, DTT demonstrated a higher unadjusted risk for all the outcomes. Once controlled for confounders, significant associations were confirmed for VF (aHR 2.23, 1.33-3.73), treatment failure (aHR 1.70, 1.03-2.78), and SNAE/death (aHR 2.79, 1.18-6.61). CONCLUSION A total of 6.5% of PWH satisfied our definition of DTT by 6 years from ART starting. This appears to be a more fragile group who may have higher risk of failure.
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Affiliation(s)
- Roberta Gagliardini
- INMI L Spallanzani IRCCS, Clinical Department of Infectious Diseases and Research, Roma, Italy.
| | | | - Stefano Rusconi
- Ospedale di Legnano, Struttura Complessa Malattie Infettive, Legnano, Italy and DIBIC, University of Milan, Italy
| | | | - Vincenzo Spagnuolo
- IRCCS San Raffaele Scientific Institute, Infectious Diseases Unit, Milan, Italy
| | | | - Andrea Costantini
- Clinical Immunology Unit, Azienda Ospedaliero Universitaria delle Marche and Marche Polytechnic University, Ancona, Italy
| | - Alessandra Vergori
- INMI L Spallanzani IRCCS, Clinical Department of Infectious Diseases and Research, Roma, Italy
| | - Franco Maggiolo
- ASST Papa Giovanni XXIII, Infectious Diseases Unit, Bergamo, Italy
| | - Andrea Giacomelli
- ASST Fatebenefratelli Sacco, Ospedale Luigi Sacco, III Infectious Diseases Unit, Milano, Italy
| | - Giulia Burastero
- Azienda Ospedaliero-Universitaria di Modena, Infectious Disease Clinic, Modena, Italy
| | - Giordano Madeddu
- University of Sassari, Department of Medical, Surgical, and Experimental Sciences, Sassari, Italy
| | - Eugenia Quiros Roldan
- University of Brescia and ASST Spedali Civili of Brescia, Department of Infectious and Tropical Diseases, Brescia, Italy
| | | | - Andrea Antinori
- INMI L Spallanzani IRCCS, Clinical Department of Infectious Diseases and Research, Roma, Italy
| | - Alessandro Cozzi-Lepri
- Institute for Global Health, UCL, Centre for Clinical Research, Epidemiology, Modelling and Evaluation (CREME), London, United Kingdom
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Arantes LMN, Pedroso AO, Menegueti MG, Gir E, Botelho EP, Silva ACDOE, Reis RK. Factors Associated with Late Diagnosis of Human Immunodeficiency Virus/Acquired Immunodeficiency Syndrome (HIV/AIDS) in a University Hospital in Brazil: Challenges to Achieving the 2030 Target. Viruses 2023; 15:2097. [PMID: 37896874 PMCID: PMC10612088 DOI: 10.3390/v15102097] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2023] [Revised: 09/22/2023] [Accepted: 09/26/2023] [Indexed: 10/29/2023] Open
Abstract
INTRODUCTION This study aimed to identify factors associated with late diagnosis and clinically monitor newly diagnosed HIV/AIDS patients. METHOD Retrospective study, based on secondary data from a specialized unit at the Hospital das Clínicas da Faculdade de Medicina de Ribeirão Preto of the University of Sao Paulo. Data collection included sociodemographic, behavioral, clinical, and laboratory data of newly diagnosed HIV patients between 2015 and 2019. Data analysis was undertaken using inferential statistical tests. RESULTS A total of 314 individuals were newly diagnosed with HIV/AIDS, 86.6% (272) had a late diagnosis and 53.8% (169) were diagnosed very late. Using the adjusted odds ratio, we observed that bisexual and MSM patients were less likely to have a late diagnosis compared to straight patients. Individuals who entered through the emergency department and Outpatient Clinic had a lower chance of having a very late diagnosis compared to those diagnosed in the ward/inpatient unit. Having a higher education and university education were protective factors against having a very late diagnosis of HIV infection compared to elementary school education only. In addition, male patients were more likely to have a very late diagnosis compared to female patients. CONCLUSIONS This study evidenced a high prevalence of late and very late diagnoses. Therefore, attention should be directed towards factors related to late and very late presentation.
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Affiliation(s)
- Ligia Maria Nascimento Arantes
- Ribeirão Preto College of Nursing, University of São Paulo, Ribeirão Preto 14040-902, Brazil; (A.O.P.); (M.G.M.); (E.G.); (R.K.R.)
| | - Andrey Oeiras Pedroso
- Ribeirão Preto College of Nursing, University of São Paulo, Ribeirão Preto 14040-902, Brazil; (A.O.P.); (M.G.M.); (E.G.); (R.K.R.)
| | - Mayra Gonçalves Menegueti
- Ribeirão Preto College of Nursing, University of São Paulo, Ribeirão Preto 14040-902, Brazil; (A.O.P.); (M.G.M.); (E.G.); (R.K.R.)
| | - Elucir Gir
- Ribeirão Preto College of Nursing, University of São Paulo, Ribeirão Preto 14040-902, Brazil; (A.O.P.); (M.G.M.); (E.G.); (R.K.R.)
| | | | | | - Renata Karina Reis
- Ribeirão Preto College of Nursing, University of São Paulo, Ribeirão Preto 14040-902, Brazil; (A.O.P.); (M.G.M.); (E.G.); (R.K.R.)
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Candevir A, Kuscu F, Kurtaran B, Kömür S, İnal AS, Ertürk D, Taşova Y. Late Diagnosis in HIV with New and Old Definitions; Data from a Regional Hospital in Turkey. Int J Gen Med 2023; 16:4227-4234. [PMID: 37745135 PMCID: PMC10516126 DOI: 10.2147/ijgm.s424561] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2023] [Accepted: 09/12/2023] [Indexed: 09/26/2023] Open
Abstract
Background Late presentation for HIV care, continues to be a challenge, leading to increased morbidity, mortality, and society costs. The study aimed to determine the rates of late diagnosis (LD) and patient characteristics in Turkey, utilizing the new definition excluding recently infected. Methods The study included patients admitted to the hospital between 1998 and 2023, with at least 1 year of follow-up. Patients without a CD4 count at their initial admission were excluded. Two definitions of presentation were used: LD, (CD4<350 cells/mL or AIDS-defining event) and advanced disease (AD), (CD4<200 cells/mL or AIDS-defining event). Individuals with recent evidence of infection were reclassified as "not late". Results Out of the 914 patients meeting the criteria and the analysis focused on 794 treatment-naïve patients, with 90.6% being male and an average age of 36.0 ± 12.0 years. Using the previous definition, 48.9% were diagnosed as late, while the new definition identified 47.2%. A total of 183 patients (23%) were diagnosed with AD, and 25.9% of the diagnoses occurred during the COVID-19 Pandemic. The rate of LD increased during the pandemic compared to before (55.8% vs 44.2%, p=0.005), as did the rate of AD (30.1% vs 20.6%, p=0.007). There was no significant relationship between gender and LD. Patients with LD were older (median ages were 31 vs 36 in groups, p<0.001), had poorer virological response, higher mortality rates (4.8% vs 1.2%, p=0.003), and shorter survival compared to those without (log rank=0.004). Conclusion HIV patients with LD have poorer prognosis with older age as well as disruption of health services during the pandemic as risk factors. To improve outcomes, multicenter studies should investigate missed opportunities and specific risk factors in our region, and we should screen at-risk populations, promote awareness among underdiagnosed populations, and advocate testing even in disastrous situations.
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Affiliation(s)
| | - Ferit Kuscu
- Infectious Diseases, Çukurova University, Adana, Türkiye
| | | | - Süheyla Kömür
- Infectious Diseases, Çukurova University, Adana, Türkiye
| | - Ayşe Seza İnal
- Infectious Diseases, Çukurova University, Adana, Türkiye
| | - Damla Ertürk
- Infectious Diseases, Health Sciences University Izmir Tepecik Education and Research Hospital, İzmir, Türkiye
| | - Yeşim Taşova
- Infectious Diseases, Çukurova University, Adana, Türkiye
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Sevgi DY, Demirbas ND, Genc Yaman I, Derin O, Oncul A, Atasoy Tahtasakal C, Gul O, Diktas H, Dokmetas I. Evaluation of the late presentation and associated factors of people living with HIV in Turkey. J Med Virol 2023; 95:e28781. [PMID: 37212337 DOI: 10.1002/jmv.28781] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2023] [Revised: 03/31/2023] [Accepted: 04/28/2023] [Indexed: 05/23/2023]
Abstract
To identify the frequency of late presentation and late presentation with advanced disease, and associated factors in people living with HIV (PLHIV). Data from PLHIV diagnosed between 2008 and 2021 were retrospectively analyzed. Time of diagnosis (categorized based on key events affecting HIV care continuum e.g., national strategies, HIV guidelines, COVID-19 pandemic) and characteristics of late presenters (LP: CD4 ≤350 cells/mm³ or an AIDS defining event) and late presenters with advanced disease (LPAD: CD4 <200 cells/mm³) were describe. Associations between dependent (LP, LPAD) and independent variables were assessed using univariate/multivariate regression tests and presented as odds ratios (95% confidential interval). Of 1585 individuals (93.7% men), 42.5% were LPs and 19.3% were LPADs. Most common route of transmission was sex between men (54.3%). Non-LPs were younger (30 vs. 34 and 36 years; p < 0.001) and included more men who have sex with men (60.3% vs. 46.3% and 39.5%; p < 0.001). Factors associated with being LP and LPAD were age >30 years, heterosexual/unknown route of transmission (vs. sex between men), diagnosis in 2008-2013 or 2020-2021, (vs. 2014-2019). With reference to Turkish subjects, migrants from Africa had higher odds of being LPAD. LP is still an important health issue in HIV care. Heterosexuality, older age (>30 years), migration from Africa, and the COVID-19 pandemic are associated with delays in HIV presentation in Turkey. These factors need to be considered when developing and implementing policies to enable earlier diagnosis and treatment of PLHIV to achieve UNAIDS 95-95-95 targets.
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Affiliation(s)
- Dilek Yildiz Sevgi
- Infectious Diseases and Clinical Microbiology, Sisli Hamidiye Etfal Training and Research Hospital, University of Health Sciences, Istanbul, Turkey
| | - Nazife Duygu Demirbas
- Infectious Diseases and Clinical Microbiology, Sisli Hamidiye Etfal Training and Research Hospital, University of Health Sciences, Istanbul, Turkey
| | - Irem Genc Yaman
- Infectious Diseases and Clinical Microbiology, Sisli Hamidiye Etfal Training and Research Hospital, University of Health Sciences, Istanbul, Turkey
| | - Okan Derin
- Infectious Diseases and Clinical Microbiology, Sisli Hamidiye Etfal Training and Research Hospital, University of Health Sciences, Istanbul, Turkey
| | - Ahsen Oncul
- Infectious Diseases and Clinical Microbiology, Sisli Hamidiye Etfal Training and Research Hospital, University of Health Sciences, Istanbul, Turkey
| | - Ceren Atasoy Tahtasakal
- Infectious Diseases and Clinical Microbiology, Sisli Hamidiye Etfal Training and Research Hospital, University of Health Sciences, Istanbul, Turkey
| | - Ozlem Gul
- Infectious Diseases and Clinical Microbiology, Sisli Hamidiye Etfal Training and Research Hospital, University of Health Sciences, Istanbul, Turkey
| | - Husrev Diktas
- Infectious Diseases and Clinical Microbiology, Sisli Hamidiye Etfal Training and Research Hospital, University of Health Sciences, Istanbul, Turkey
| | - Ilyas Dokmetas
- Infectious Diseases and Clinical Microbiology, Sisli Hamidiye Etfal Training and Research Hospital, University of Health Sciences, Istanbul, Turkey
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Parczewski M, Rockstroh JK. Late HIV diagnosis: Where we stand and the way forward. HIV Med 2022; 23:1115-1117. [PMID: 36453534 DOI: 10.1111/hiv.13443] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2022] [Accepted: 10/21/2022] [Indexed: 12/03/2022]
Affiliation(s)
- Miłosz Parczewski
- Department of Infectious, Tropical Diseases and Immune Deficiency, Pomeranian Medical University in Szczecin, Szczecin, Poland
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Croxford S, Stengaard AR, Brännström J, Combs L, Dedes N, Girardi E, Grabar S, Kirk O, Kuchukhidze G, Lazarus JV, Noori T, Pharris A, Raben D, Rockstroh JK, Simões D, Sullivan AK, Van Beckhoven D, Delpech VC. Late diagnosis of HIV: An updated consensus definition. HIV Med 2022; 23:1202-1208. [PMID: 36347523 PMCID: PMC10100195 DOI: 10.1111/hiv.13425] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2022] [Accepted: 10/04/2022] [Indexed: 11/11/2022]
Abstract
INTRODUCTION In recent years, HIV testing frequency has increased, resulting in more people being diagnosed during seroconversion with a temporarily low CD4 count. Using the current consensus definition of late HIV presentation ('presenting for care with a CD4 count < 350 cells/μL or an AIDS-defining event, regardless of CD4 count') these individuals would be incorrectly assigned as being diagnosed late. METHODS In spring 2022, a European expert group convened to revise the current late HIV presentation consensus definition. A survey on data availability to apply this revised definition was sent to nominated European focal points responsible for HIV surveillance (n = 53). RESULTS Experts agreed that the updated definition should refer to late HIV diagnosis rather than presentation and include the following addition: People with evidence of recent infection should be reclassified as 'not late', with evidence of recent infection considered hierarchically. The individual must have: (i) laboratory evidence of recent infection; (ii) a last negative HIV test within 12 months of diagnosis; or (iii) clinical evidence of acute infection. People with evidence of being previously diagnosed abroad should be excluded. A total of 18 countries responded to the survey; 83% reported capturing CD4 count and/or AIDS at diagnosis through national surveillance, 67% captured last negative test and/or previous HIV diagnosis, 61% captured seroconversion illness at diagnosis and 28% captured incident antibody results. CONCLUSIONS Accurate data on late diagnosis are important to describe the effects of testing programmes. Reclassification of individuals with recent infection will help to better identify populations most at risk of poor HIV outcomes and areas for intervention.
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Affiliation(s)
| | - Annemarie Rinder Stengaard
- Centre of Excellence for Health, Immunity and Infections - CHIP, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Johanna Brännström
- Institution of Medicine, Karolinska Institute, Karolinska University Hospital Huddinge, Stockholm, Sweden.,EuroTEST Steering Committee, Copenhagen, Denmark.,Department of Infectious Diseases, Venhälsan, Södersjukhuset, Stockholm, Sweden
| | - Lauren Combs
- Centre of Excellence for Health, Immunity and Infections - CHIP, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Nikos Dedes
- EuroTEST Steering Committee, Copenhagen, Denmark.,European AIDS Treatment Group, Brussels, Belgium
| | - Enrico Girardi
- National Institute for Infectious Diseases "Lazzaro Spallanzani" IRCCS, Rome, Italy
| | - Sophie Grabar
- Sorbonne Université, INSERM, Institut Pierre Louis d'épidémiologie et de Santé Publique, Paris, France
| | - Ole Kirk
- Centre of Excellence for Health, Immunity and Infections - CHIP, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark.,Department of Infectious Diseases, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Giorgi Kuchukhidze
- World Health Organization Regional Office for Europe, Copenhagen, Denmark
| | - Jeffrey V Lazarus
- EuroTEST Steering Committee, Copenhagen, Denmark.,ISGlobal, Barcelona Institute for Global Health, Hospital Clínic - University of Barcelona, Barcelona, Spain
| | - Teymur Noori
- European Centre for Disease Prevention and Control, Stockholm, Sweden
| | - Anastasia Pharris
- European Centre for Disease Prevention and Control, Stockholm, Sweden
| | - Dorthe Raben
- Centre of Excellence for Health, Immunity and Infections - CHIP, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Jürgen K Rockstroh
- EuroTEST Steering Committee, Copenhagen, Denmark.,European AIDS Clinical Society, Brussels, Belgium.,University Hospital Bonn, Bonn, Germany
| | - Daniel Simões
- EuroTEST Steering Committee, Copenhagen, Denmark.,EPIUnit-Instituto de Saúde Pública, Universidade do Porto, Porto, Portugal.,Coalition PLUS, Paris, France
| | - Ann K Sullivan
- UK Health Security Agency, London, UK.,EuroTEST Steering Committee, Copenhagen, Denmark.,European AIDS Clinical Society, Brussels, Belgium.,Directorate of HIV and Sexual Health, Chelsea and Westminster Hospital NHS Foundation Trust, London, UK
| | | | - Valerie C Delpech
- UK Health Security Agency, London, UK.,EuroTEST Steering Committee, Copenhagen, Denmark
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Collins S, Namiba A, Sparrowhawk A, Strachan S, Thompson M, Nakamura H. Late diagnosis of HIV in 2022: Why so little change? HIV Med 2022; 23:1118-1126. [PMID: 36397250 DOI: 10.1111/hiv.13444] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2022] [Accepted: 10/19/2022] [Indexed: 11/21/2022]
Abstract
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.
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Affiliation(s)
| | | | | | | | | | - Hideta Nakamura
- Division of Infectious, Respiratory, and Digestive Medicine, First Department of Internal Medicine, University of the Ryukyus Graduate School of Medicine, Okinawa, Japan
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