Introduction HIV late diagnosis is one of three key indicators on sexual health in the Public Health Outcomes Framework. The British HIV Association (BHIVA) Standards of Care for People Living with HIV advocates the use of ‘look backs’ in the case of late and very late diagnosis of previous engagement with health care services to identify missed opportunities and areas for shared learning and development.

Methods Further to the look-back exercise undertaken on late and very late diagnoses presenting 2012–2016, we extended the use of the standardised look-back tool to ALL new diagnoses from late 2016 onwards.

Results In addition to anticipated missed opportunities being identified in the late and very late presentations, we identified 2 missed opportunities in much earlier presentations from within our own service! They related to failure to repeat the HIV test at test of cure (TOC) for gonorrhoea and subsequent Hepatitis vaccination appointments. In both cases the initial negative HIV test had been within the potential window period.

Discussion As a result of the look-back exercise we have learnt a valuable lesson about the fallibility of our own service and shared the learning within our multi-disciplinary team. We have encouraged all to remember to re-visit the sexual history and timing of sex in relation to testing at ‘quickie’ follow up visits for vaccination or TOC and repeated education about window periods.

We shall continue to utilise the look-back tool in all new HIV presentations and encourage colleagues to do likewise to maximise on identifying learning opportunities.