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      Missed opportunities for earlier diagnosis of HIV in British Columbia, Canada: A retrospective cohort study

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          Abstract

          Background

          Late HIV diagnosis is associated with increased AIDS-related morbidity and mortality as well as an increased risk of HIV transmission. In this study, we quantified and characterized missed opportunities for earlier HIV diagnosis in British Columbia (BC), Canada.

          Design

          Retrospective cohort.

          Methods

          A missed opportunity was defined as a healthcare encounter due to a clinical manifestation which may be caused by HIV infection, or is frequently present among those with HIV infection, but no HIV diagnosis followed within 30 days. We developed an algorithm to identify missed opportunities within one, three, and five years prior to diagnosis. The algorithm was applied to the BC STOP HIV/AIDS population-based cohort. Eligible individuals were ≥18 years old, and diagnosed from 2001–2014. Multivariable logistic regression identified factors associated with missed opportunities.

          Results

          Of 2119 individuals, 7%, 12% and 14% had ≥1 missed opportunity during one, three and five years prior to HIV diagnosis, respectively. In all analyses, individuals aged ≥40 years, heterosexuals or people who ever injected drugs, and those residing in Northern health authority had increased odds of experiencing ≥1 missed opportunity. In the three and five-year analysis, individuals with a CD4 count <350 cells/mm 3 were at higher odds of experiencing ≥1 missed opportunity. Prominent missed opportunities were related to recurrent pneumonia, herpes zoster/shingles among younger individuals, and anemia related to nutritional deficiencies or unspecified cause.

          Conclusions

          Based on our newly-developed algorithm, this study demonstrated that HIV-diagnosed individuals in BC have experienced several missed opportunities for earlier diagnosis. Specific clinical indicator conditions and population sub-groups at increased risk of experiencing these missed opportunities were identified. Further work is required in order to validate the utility of this proposed algorithm by establishing the sensitivity, specificity, positive and negative predictive values corresponding to the incidence of the clinical indicator conditions among both HIV-diagnosed and HIV-negative populations.

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          Most cited references26

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          Late diagnosis of HIV infection: epidemiological features, consequences and strategies to encourage earlier testing.

          A substantial proportion of HIV-infected individuals do not present for HIV testing until late in infection; these individuals are often ill, have a high mortality risk, and are less likely to respond to treatment when initiated. Furthermore, late presentation means that opportunities to reduce onward transmission, either by reducing high-risk behaviours or by reducing an individual's infectivity, are missed. The proportion of HIV-infected individuals who present late has remained relatively stable over the past decade, despite several attempts to encourage earlier diagnosis. Late presenters tend to be those at lower perceived risk of infection, those who are not routinely offered HIV testing, and are often from marginalized groups. Strategies that encourage earlier testing, including routine HIV testing in healthcare settings where high-risk individuals attend frequently, the availability of HIV testing services in non-medical settings, and partner notification schemes or peer-led projects to encourage high-risk individuals to attend for testing, may all increase the proportion of HIV-infected individuals who are aware of their HIV status, thus helping to control the spread of the epidemic. This review summarizes recent evidence on the epidemiology of late presentation and its impact on clinical progression, and describes several key strategies that may encourage earlier diagnosis.
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            Global epidemiology of HIV.

            The number of persons living with HIV worldwide reached approximately 35.3 million in 2012. Meanwhile, AIDS-related deaths and new HIV infections have declined. Much of the increase in HIV prevalence is from rapidly increasing numbers of people on antiretroviral treatment who are now living longer. There is regional variation in epidemiologic patterns, major modes of HIV transmission, and HIV program response. It is important to focus on HIV incidence, rather than prevalence, to provide information about HIV transmission patterns and populations at risk. Expanding HIV treatment will function as a preventive measure through decreasing horizontal and vertical transmission of HIV.
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              Risk of viral failure declines with duration of suppression on highly active antiretroviral therapy irrespective of adherence level.

              To model the effect of adherence and duration of viral suppression on the risk of viral rebound. Viral rebound was defined as the first of at least two consecutive viral loads greater than 400 copies/mL after initial viral suppression. The main exposures were adherence, presence of antiretroviral class resistance before rebound or censoring date, and the percentage of follow-up time with viral suppression. A total of 274 (N = 1305 [21%]) individuals experienced viral rebound. Median time of suppression before rebound was 2 years. Viral rebound was less likely to occur among those with longer duration of continuous viral suppression (odds ratio, 0.37; 95% confidence interval, 0.32 to 0.42). Among individuals with moderate levels of adherence (80% to less than 95%), the probability of virologic failure was 0.85 after being suppressed for 12 months and it was 0.08 after 72 months being suppressed (P < 0.01). Individuals with drug resistance were at a higher risk of viral rebound. The risk of viral rebound decreased with longer duration of viral suppression within each of adherence strata studied. Although perfect adherence remains an important goal of therapy to prevent disease progression, individuals with long-term viral suppression may be able to miss more doses without experiencing viral rebound.
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                Author and article information

                Contributors
                Role: ConceptualizationRole: MethodologyRole: Writing – original draftRole: Writing – review & editing
                Role: ConceptualizationRole: MethodologyRole: Writing – original draftRole: Writing – review & editing
                Role: Formal analysisRole: Writing – original draftRole: Writing – review & editing
                Role: MethodologyRole: Writing – review & editing
                Role: MethodologyRole: Writing – review & editing
                Role: Formal analysisRole: Writing – review & editing
                Role: Writing – review & editing
                Role: Data curationRole: Writing – review & editing
                Role: Data curationRole: Funding acquisitionRole: Writing – review & editing
                Role: ConceptualizationRole: Data curationRole: Formal analysisRole: Funding acquisitionRole: MethodologyRole: SupervisionRole: Writing – original draftRole: Writing – review & editing
                Role: Editor
                Journal
                PLoS One
                PLoS ONE
                plos
                plosone
                PLoS ONE
                Public Library of Science (San Francisco, CA USA )
                1932-6203
                21 March 2019
                2019
                : 14
                : 3
                : e0214012
                Affiliations
                [1 ] British Columbia Centre for Excellence in HIV/AIDS, Vancouver, Canada
                [2 ] Division of Infectious Diseases, Department of Medicine, Faculty of Medicine, University of British Columbia, Vancouver, Canada
                [3 ] Department of Family Practice, Faculty of Medicine, University of British Columbia, Vancouver, Canada
                [4 ] Division of AIDS, Department of Medicine, Faculty of Medicine, University of British Columbia, Vancouver, Canada
                [5 ] British Columbia Ministry of Health, Victoria, Canada
                [6 ] Vancouver Coastal Health, Vancouver, Canada
                ARGENTINA
                Author notes

                Competing Interests: JSGM has received institutional grants from Gilead Sciences, J&J, Merck, ViiV Healthcare, and a Knowledge Translation Award from the Canadian Institutes of Health Research. JSGM has also served as an advisor to Government of Canada and the Government of British Columbia in the last year. All other authors declare no competing interests. This does not alter our adherence to PLOS ONE policies on sharing data and materials. However, the British Columbia Centre for Excellence in HIV/AIDS is prohibited from making individual-level data available publicly due to provisions in our service contracts, institutional policy, and ethical requirements. In order to facilitate research we make such data available via data access requests. Some BC-CfE data is not available externally due to prohibitions in service contracts with our funders or data providers. Institutional policies stipulate that all external data requests require collaboration with a BC-CfE research. For more information or to make a request, please contact Irene Day, Senior Director, Internal and External Relations and Strategic Development: iday@ 123456cfenet.ubc.ca .

                Article
                PONE-D-18-33712
                10.1371/journal.pone.0214012
                6428302
                30897143
                5ac4668f-b05c-4c10-9a07-a929a2c90e8b
                © 2019 Nanditha et al

                This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

                History
                : 23 November 2018
                : 5 March 2019
                Page count
                Figures: 1, Tables: 4, Pages: 17
                Funding
                Funded by: funder-id http://dx.doi.org/10.13039/100000026, National Institute on Drug Abuse;
                Award ID: R01DA036307
                Award Recipient :
                Funded by: Public Health Agency of Canada
                Award ID: CTN 248
                Award Recipient :
                Funded by: funder-id http://dx.doi.org/10.13039/501100000024, Canadian Institutes of Health Research;
                Award ID: PJT-148595
                Award Recipient :
                Funded by: funder-id http://dx.doi.org/10.13039/501100000245, Michael Smith Foundation for Health Research;
                Award ID: Scholar Award
                Award Recipient :
                Funded by: funder-id http://dx.doi.org/10.13039/501100000024, Canadian Institutes of Health Research;
                Award ID: New Investigator Award
                Award Recipient :
                This work was supported by the following sources of funding: JSGM’s Treatment as Prevention (TasP) research, paid to his institution, has received support from the Public Health Agency of Canada, the British Columbia Ministry of Health and the US National Institutes of Health (R01DA036307 and CTN 248). VDL is funded by a grant from the Canadian Institutes of Health Research (PJT-148595), by a Scholar Award from the Michael Smith Foundation for Health Research and a New Investigator award from the Canadian Institutes of Health Research. The sponsors had no role in the design, data collection, data analysis, data interpretation, or writing of the report.
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                Biology and Life Sciences
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                Microbial Pathogens
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                Custom metadata
                The British Columbia Centre for Excellence in HIV/AIDS (BC-CfE) is prohibited from making individual-level data available publicly due to provisions in our service contracts, institutional policy, and ethical requirements. In order to facilitate research, we make such data available via data access requests. Some BC-CfE data is not available externally due to prohibitions in service contracts with our funders or data providers. Institutional policies stipulate that all external data requests require collaboration with a BC-CfE research. For more information or to make a request, please contact Irene Day, Senior Director, Internal and External Relations and Strategic Development: iday@ 123456cfenet.ubc.ca .

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