Skip to main navigation menu Skip to main content Skip to site footer

Review article: Biomedical intelligence

Vol. 146 No. 3334 (2016)

Late presentation to HIV care despite good access to health services: current epidemiological trends and how to do better

  • Katharine EA Darling
  • Anna Hachfeld
  • Matthias Cavassini
  • Ole Kirk
  • Hansjakob Furrer
  • Gilles Wandeler
Cite this as:
Swiss Med Wkly. 2016;146:w14348



In 2014, there were 36.9 million people worldwide living with human immunodeficiency virus (PLWH), of whom 17.1 million did not know they were infected. Whilst the number of new human immunodeficiency virus (HIV) infections has declined globally since 2000, there are still regions where new infection rates are rising, and diagnosing HIV early in the course of infection remains a challenge.

Late presentation to care in HIV refers to individuals newly presenting for HIV care with a CD4 count below 350 cells/µl or with an acquired immune deficiency syndrome (AIDS)-defining event. Late presentation is associated with increased patient morbidity and mortality, healthcare costs and risk of onward transmission by individuals unaware of their status. Further, late presentation limits the effectiveness of all subsequent steps in the cascade of HIV care. Recent figures from 34 countries in Europe show that late presentation occurs in 38.3% to 49.8% of patients newly presenting for care, depending on region. In Switzerland, data from patients enrolled in the Swiss HIV Cohort Study put the rate of late presentation at 49.8% and show that patients outside established HIV risk groups are most likely to be late presenters. Provider-initiated testing needs to be improved to reach these groups, which include heterosexual men and women and older patients. The aim of this review is to describe the scale and implications of late presentation using cohort data from Switzerland and elsewhere in Europe, and to highlight initiatives to improve early HIV diagnosis. The importance of recognising indicator conditions and the potential for missed opportunities for HIV testing is illustrated in three clinical case studies.


  1. UNAIDS World AIDS Day 2015 AIDS by the numbers 2015. In.; 2015.
  2. Kohler P, Schmidt AJ, Cavassini M, Furrer H, Calmy A, Battegay M, et al. The HIV care cascade in Switzerland: reaching the UNAIDS/WHO targets for patients diagnosed with HIV. AIDS. 2015;29:2509–15.
  3. Hill A, Pozniak A. HIV treatment cascades: how can all countries reach the UNAIDS 90-90-90 target? AIDS. 2015;29:2523–5.
  4. Ryom L, Boesecke C, Gisler V, Manzardo C, Rockstroh JK, Puoti M, et al. Essentials from the 2015 European AIDS Clinical Society (EACS) guidelines for the treatment of adult HIV-positive persons. HIV Med. 2016;17:83–8.
  5. INSIGHT START Study Group. Initiation of Antiretroviral Therapy in Early Asymptomatic HIV Infection. N Engl J Med. 2015,373:795–807.
  6. Mocroft A, Lundgren JD, Sabin ML, Monforte A, Brockmeyer N, Casabona J, et al. Risk factors and outcomes for late presentation for HIV-positive persons in Europe: results from the Collaboration of Observational HIV Epidemiological Research Europe Study (COHERE). PLoS Med. 2013;10:e1001510.
  7. Krentz HB, Auld MC, Gill MJ. The high cost of medical care for patients who present late (CD4 <200 cells/microL) with HIV infection. HIV Medicine. 2004;5:93–8.
  8. Wasserfallen JB, Hyjazi A, Cavassini M. Comparison of HIV-infected patients’ characteristics, healthcare resources use and cost between native and migrant patients. Int J Public Health. 2009;54:5–10.
  9. Marks G, Crepaz N, Janssen R. Estimating sexual transmission of HIV from persons aware and unaware that they are infected with the virus in the USA. AIDS. 2006;20:1447–50.
  10. Hachfeld A, Ledergerber B, Darling K, Weber R, Calmy A, Battegay M, et al. Reasons for late presentation to HIV care in Switzerland. J Int AIDS Soc. 2015;18:20317.
  11. Office fédéral de la santé publique: Nombre de cas de VIH et d’IST en 2014: rapport, analyses et tendances. Bulletin de l’OFSP. 2015;21:341–74.
  12. Gazzard B, Clumeck N, d'Arminio Monforte A, Lundgren JD. Indicator disease-guided testing for HIV – the next step for Europe? HIV Med. 2008;9(Suppl 2):34–40.
  13. Sullivan AK, Raben D, Reekie J, Rayment M, Mocroft A, Esser S, et al. Feasibility and effectiveness of indicator condition-guided testing for HIV: results from HIDES I (HIV indicator diseases across Europe study). PLoS One. 2013;8:e52845.
  14. Mocroft A, Reiss P, Gasiorowski J, Ledergerber B, Kowalska J, Chiesi A, et al. Serious fatal and nonfatal non-AIDS-defining illnesses in Europe. J Acquir Immune Defic Syndr. 2010;55:262–70.
  15. Antinori A, Coenen T, Costagiola D, Dedes N, Ellefson M, Gatell J, et al. Late presentation of HIV infection: a consensus definition. HIV Med. 2011;12:61–4.
  16. MacCarthy S, Bangsberg DR, Fink G, Reich M, Gruskin S. Late presentation to HIV/AIDS testing, treatment or continued care: clarifying the use of CD4 evaluation in the consensus definition. HIV Med. 2014;15:130–4.
  17. Kozak M, Zinski A, Leeper C, Willig JH, Mugavero MJ. Late diagnosis, delayed presentation and late presentation in HIV: proposed definitions, methodological considerations and health implications. Antivir Ther. 2013;18:17–23.
  18. Champenois K, Cousien A, Cuzin L, Le Vu S, Deuffic-Burban S, Lanoy E, et al. Missed opportunities for HIV testing in newly-HIV-diagnosed patients, a cross sectional study. BMC Infect Dis. 2013;13:200.
  19. Branson BM, Handsfield HH, Lampe MA, Janssen RS, Taylor AW, Lyss SB, et al. Revised recommendations for HIV testing of adults, adolescents, and pregnant women in health-care settings. Morbidity & Mortality Weekly Report Recommendations & Reports. 2006;55:1–17; quiz CE11-14.
  20. British HIV Association, British Association of Sexual Health and HIV, British Infection Society. UK National Guidelines for HIV Testing 2008. In.; 2008.
  21. National Institute for Health and Care Excellence (NICE). Increasing the uptake of HIV testing to reduce undiagnosed infection and prevent transmission among men who have sex with men. Public Health Guidance 34. In.; 2011.
  22. National Institute for Health and Care Excellence (NICE). Increasing the uptake of HIV testing to reduce undiagnosed infection and prevent transmission among black African communities living in England. Public Health Guidance 33. In.; 2011.
  23. UNAIDS epidemiology figures 2013: Switzerland. In.; 2013.
  24. Office fédéral de la santé publique: Dépistage du VIH et conseil initiés par les médecins. Bulletin de l'OFSP. 2007 ;21:371–3.
  25. Office fédéral de la santé publique: Dépistage du VIH effectué sur l’initiative des médecins: recommandations pour les patients adultes. Bulletin de l'OFSP 2010:364-366.
  26. Office fédéral de la santé publique: Dépistage du VIH effectué sur l’initiative des médecins en présence de certaines pathologies (maladies évocatrices d’une infection à VIH) Bulletin de l'OFSP 2013:1–5.
  27. Office fédéral de la santé publique: Dépistage du VIH effectué sur l’initiative des médecins Bulletin de l'OFSP. 2015;21:237–41.
  28. Darling KE, Hugli O, Mamin R, Cellerai C, Martenet S, Berney A, et al. HIV Testing Practices by Clinical Service before and after Revised Testing Guidelines in a Swiss University Hospital. PLoS One. 2012;7:e39299.
  29. Darling KE, de Allegri N, Fishman D, Kehtari R, Rutschmann OT, Cavassini M, et al. Awareness of HIV testing guidelines is low among Swiss emergency doctors: a survey of five teaching hospitals in French-speaking Switzerland. PLoS One. 2013;8:e72812.
  30. Sanders GD, Bayoumi AM, Sundaram V, Bilir SP, Neukermans CP, Rydzak CE, et al. Cost-effectiveness of screening for HIV in the era of highly active antiretroviral therapy. N Engl J Med. 2005;352:570–85.
  31. Yazdanpanah Y, Sloan CE, Charlois-Ou C, Le Vu S, Semaille C, Costagliola D, et al. Routine HIV screening in France: clinical impact and cost-effectiveness. PLoS One. 2010;5:e13132.
  32. Burke RC, Sepkowitz KA, Bernstein KT, Karpati AM, Myers JE, Tsoi BW, et al. Why don’t physicians test for HIV? A review of the US literature. AIDS. 2007;21:1617–24.
  33. Mussini C, Antinori A, Bhagani S, Branco T, Brostrom M, Dedes N, et al. European AIDS Clinical Society Standard of Care meeting on HIV and related coinfections: The Rome Statements. HIV Med. HIV Med. 2016 Jun;17(6):445-52.
  34. Bath R, O’Connell R, Lascar M, Ferrand R, Strachan S, Matin N, et al. TestMeEast: a campaign to increase HIV testing in hospitals and to reduce late diagnosis. AIDS Care. 2016;28(5):608–11.
  35. Buetikofer S, Wandeler G, Kouyos R, Weber R, Ledergerber B. Prevalence and risk factors of late presentation for HIV diagnosis and care in a tertiary referral centre in Switzerland. Swiss Med Wkly. 2014;144:w13961.
  36. Op de Coul EL, van Sighem A, Brinkman K, van Benthem BH, van der Ende ME, Geerlings S, et al. Factors associated with presenting late or with advanced HIV disease in the Netherlands, 1996–2014: results from a national observational cohort. BMJ Open. 2016;6:e009688.
  37. Brannstrom J, Svedhem Johansson V, Marrone G, Wendahl S, Yilmaz A, Blaxhult A, et al. Deficiencies in the health care system contribute to a high rate of late HIV diagnosis in Sweden. HIV Med. 2016;17(6):425–35.
  38. Darling KE, Gloor E, Ansermet-Pagot A, Vaucher P, Durieux-Paillard S, Bodenmann P, et al. Suboptimal access to primary healthcare among street-based sex workers in southwest Switzerland. Postgrad Med J. 2013;89(1053):371–5.
  39. Suess A, Ruiz Perez I, Ruiz Azarola A, March Cerda JC. The right of access to health care for undocumented migrants: a revision of comparative analysis in the European context. Eur J Public Health. 2014;24:712–20.
  40. Migrant crisis in the Mediterranean. Lancet. 2015;385:1698.
  41. Fakoya I, Alvarez-del Arco D, Woode-Owusu M, Monge S, Rivero-Montesdeoca Y, Delpech V, et al. A systematic review of post-migration acquisition of HIV among migrants from countries with generalised HIV epidemics living in Europe: mplications for effectively managing HIV prevention programmes and policy. BMC Public Health. 2015;15:561.
  42. Joore IK, Arts DL, Kruijer MJ, Moll van Charante EP, Geerlings SE, Prins JM, et al. HIV indicator condition-guided testing to reduce the number of undiagnosed patients and prevent late presentation in a high-prevalence area: a case-control study in primary care. Sex Transm Infect. 2015;91:467–72.
  43. 1993 revised classification system for HIV infection and expanded surveillance case definition for AIDS among adolescents and adults. MMWR Recomm Rep. 1992;41:1–19.
  44. Mosimann V, Cavassini M, Hugli O, Mamin R, Achtari C, Peters S, et al. Patients with AIDS-defining cancers are not universally screened for HIV: a 10-year retrospective analysis of HIV-testing practices in a Swiss university hospital. HIV Med. 2014;15:631-4.
  45. HIV & CO Primo-infection: Symptômes, Risque d’infection, Se protéger. In.; 2015.

Most read articles by the same author(s)

1 2 > >>