Late presenters, repeated testing, and missed opportunities in a Danish nationwide HIV cohort

Abstract

Background: We aimed to estimate the incidence and predictors of late presentation among human immunodeficiency virus (HIV)-infected individuals in Denmark. Methods: Incidence rates (IR) of presentation with advanced HIV (CD4 < 200 cells/μl and/or acquired immune deficiency syndrome (AIDS)) and late presentation (CD4 < 350 cells/μl and/or AIDS) were calculated per 100,000 population aged 16–60 y. Mortality rate ratios (MRR) were estimated using Poisson regression analysis. Results: Three thousand and twenty-seven individuals were diagnosed with HIV in 1995–2009; 34.7% presented with advanced HIV and 51.2% were late presenters. The IR of HIV was stable (6.2/100,000 population), but IR of presentation with advanced HIV declined during the study period from 2.2 (95% confidence interval (CI) 1.8–2.8) to 1.1 (95% CI 0.8–1.5). Age >50 y, heterosexuals of non-Danish origin, ‘other’ route of transmission, and diagnosis before 2002 were associated with an increased risk of presenting with advanced HIV, whereas a negative HIV test prior to diagnosis was associated with a significantly reduced risk. A total of 414 individuals (40.0%) had attended a hospital 1–3 y before presenting with advanced HIV. After 2002 the proportion of men who have sex with men with a negative HIV test prior to diagnosis increased (incidence rate ratio (IRR) 1.3, 95% CI 1.1–1.6), coinciding with a reduction in IR of presentation with advanced HIV. Mortality rates were increased the first 2 y following presentation with advanced HIV (MRR 5.9, 95% CI 3.6–9.4 and MRR 2.5, 95% CI 1.4–4.1, respectively). Conclusion: In a setting with a low HIV prevalence, the rate of presentation with advanced HIV can potentially be reduced by repeated HIV testing of individuals with a continuous high risk of transmission and by adhering to guidelines for targeted HIV testing.

Keywords::

• HIV
• late presentation
• presentation with advanced HIV
• HIV testing
• mortality

Declaration of interest: NO has received research funding from Roche, Bristol-Myers Squibb, Merck Sharp & Dohme, GlaxoSmithKline, Abbott, Boehringer Ingelheim, Janssen-Cilag, and Swedish Orphan. JG has received research funding from Abbott, Roche, Bristol-Myers Squibb, Merck Sharp & Dohme, ViiV, Swedish Orphan, and Gilead. ALL is on advisory boards for Prasidio, BMS, Gilead, and GlaxoSmithKline. MH, FNE, GK, LN, OL, JJ, and GP report no conflicts of interest. No funding sources were involved in the study design, data collection, analysis, report writing, or decision to submit the paper.