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

Abstract

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.

Figure 1

Missed and diagnosed clinical presentations as percentage of total cohort.

Figure 2

Risk of missed presentation by time period stratified by clinical and epidemiological risk factors. * Breslow-Day test of homogeneity of variance: P < 0.05 suggesting significant heterogeneity within the strata. ^† Not calculable due to small numbers. Transmission risks of IVDU, partner HIV positive, recipients of blood products/organs or dialysis patients were not calculated due to small numbers.

Figure 3

Kaplan-Meier curves of time to diagnosis from first presentation by cohort. (Log-rank test, P = 0.005).