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Original research
Tracking missed opportunities for an early HIV diagnosis in a population of people living with HIV with known time of infection
  1. Dimitrios Basoulis1,
  2. Evangelia Georgia Kostaki2,
  3. Dimitrios Paraskevis2,
  4. Angelos Hatzakis2,
  5. Mina Psichogiou1
  1. 11st Internal Medicine Department, Laiko General Hospital, National and Kapodistrian University of Athens, Athens, Attica, Greece
  2. 2Department of Hygiene, Epidemiology and Medical Statistics, National and Kapodistrian University of Athens School of Health Sciences, Athens, Greece
  1. Correspondence to Dr Dimitrios Basoulis, 1st Internal Medicine Department, Laiko General Hospital, National and Kapodistrian University of Athens, Athens, Attica, Greece; dimitris.bassoulis{at}


Purpose The goal of 90-90-90 first requires the expansion of access to HIV testing. Our aim was to record frequencies of HIV indicator conditions (ICs) and identify missed opportunities for an early HIV diagnosis.

Methods We retrospectively identified ICs in a population of 231 people living with HIV with known infection dates who attended our clinic. The study population was divided into four groups: (1) those self-tested pre-emptively (47/231, 20.3%), (2) those offered targeted testing based on risk factors (67/231, 29%), (3) those tested after an IC (73/231, 31.6%) and (4) those who were not offered testing after an IC (44/231, 19%). HIV acquisition dates were estimated by molecular clock analysis.

Results A total of 169 healthcare contacts (HCCs) were recorded. The most frequent HCC was mononucleosis-like syndrome (20.1%), unexplained weight loss (10.7%) and STIs (10.1%). AIDS-defining conditions were detected in 11.8%. Only 62.4% (73/117) of those with an IC were offered testing after their first HCC. Patients in group 4 had statistically significant delay in diagnosis compared with group 3 (109.1 weeks (IQR 56.4–238.6) vs 71.6 weeks (IQR 32.3–124.6)). The proportion of patients diagnosed as late presenters in each group was: (1) 16/47 (34%), (2) 37/67 (55.2%), (3) 43/73 (58.9%) and (4) 27/44 (61.4%) (p=0.027).

Conclusions Our study uses a combination of molecular and clinical data and shows evidence that late presentation occurs in a high proportion of patients even in the presence of an IC. Given that risk-based targeted testing has low coverage, IC-guided testing provides a reasonable alternative to facilitate earlier HIV diagnosis and to improve late diagnosis across Europe and globally.

  • diagnosis
  • epidemiology (molecular)
  • epidemiology (clinical)
  • HIV clinical care
  • testing

Statistics from


  • Handling editor Francesca Ceccherini-Silberstein

  • Presented at 20th Panhellenic Infectious Diseases Conference, 5–8 March 2020, Athens, Greece; 30th ECCMID, 18–21 April, Paris, France.

  • Contributors DB performed clinical data collection, statistical analysis and authored the manuscript, EGK and DP performed molecular clock analysis and reviewed the manuscript, AH assisted in statistical analysis, aided in interpreting results, reviewed the manuscript, MP had the original concept and designed the study, reviewed the manuscript and had final supervision.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • Patient consent for publication Not required.

  • Ethics approval The study has been approved by the Laiko General Hospital Scientific and Ethics Board, in accordance with the ethical standards laid down in the 1964 Declaration of Helsinki and its later amendments and national laws. Written informed consent from all study participants was obtained for analysis of their genetic material and inclusion in the study.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data availability statement Data are available at the National and Kapodistrian University of Athens repository, "Pergamos" (

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