title: The late-presenting HIV-infected patient 30 years after the introduction of HIV testing: spectrum of opportunistic diseases and missed opportunities for early diagnosis.
abstract: The aim of the study was to describe the characteristics of HIV-infected late presenters, opportunistic diseases at diagnosis and missed opportunities to diagnose HIV infection earlier.
  
  
  
  In a retrospective cohort study, we reviewed the medical records of all adults with newly diagnosed HIV infection admitted to the Department of Infectious Diseases of the Vivantes Auguste-Viktoria Hospital, Berlin, Germany.
  
  
  
  In the 5-year period from 2009 to 2013, 270 late presenters were identified. The most common AIDS-defining conditions were oesophageal candidiasis (n = 136; 51%), wasting syndrome (n = 106; 40%) and pneumocystis pneumonia (n = 91; 34%). Fifty-five patients (21%) had presented with at least one HIV indicator condition on prior contact with health care services without being offered testing for HIV. Female patients and heterosexual men [not men who have sex with men ('non-MSM')] had a significantly higher chance of being among patients previously presenting with indicator conditions and not being tested [odds ratio (OR) 4.7; 95% confidence interval (CI) 2.2-10.0; P < 0.001; and OR 2.4; 95% CI 1.2-5.1; P < 0.01, respectively]. The most commonly missed indicator conditions were leucocytopenia (n = 13; 24%), thrombocytopenia (n = 12; 22%), oral candidiasis (n = 9; 16%), unexplained weight loss (n = 7; 13%), herpes zoster (n = 5; 9%) and cervical dysplasia/cancer (n = 4; 20% of women). The median time between presentation with an indicator condition and the diagnosis of HIV infection was 158.5 days [interquartile range (IQR) 40-572 days]. Patients with oral candidiasis and unexplained weight loss had the shortest time between the "missed opportunity" and the diagnosis of HIV infection. Fifty-five hospital admissions with a total cost of over EUR 500 000 and - most importantly - six in-hospital deaths might have been prevented if HIV testing had been performed in patients with documented indicator conditions.
  
  
  
  Indicator conditions are still missed by clinicians. Women and 'non-MSM' are at highest risk of presenting with an indicator condition but not being tested for HIV infection.
authors.affiliation: Department of Infectious Diseases, Vivantes Auguste-Viktoria Hospital, Berlin, Germany.
authors.forename: D
authors.initials: D
authors.lastname: Tominski
authors.affiliation: Department of Infectious Diseases, Vivantes Auguste-Viktoria Hospital, Berlin, Germany.
authors.forename: J
authors.initials: J
authors.lastname: Katchanov
authors.affiliation: BioControl Jena GmbH, Jena, Germany.
authors.forename: D
authors.initials: D
authors.lastname: Driesch
authors.affiliation: Department of Infectious Diseases, Vivantes Auguste-Viktoria Hospital, Berlin, Germany.
authors.forename: M B
authors.initials: MB
authors.lastname: Daley
authors.affiliation: Department of Infectious Diseases, Vivantes Auguste-Viktoria Hospital, Berlin, Germany.
authors.forename: A
authors.initials: A
authors.lastname: Liedtke
authors.affiliation: Department of Infectious Diseases, Vivantes Auguste-Viktoria Hospital, Berlin, Germany.
authors.forename: A
authors.initials: A
authors.lastname: Schneider
authors.affiliation: Septomics Research Center, Jena University Hospital, Jena, Germany.
authors.forename: H
authors.initials: H
authors.lastname: Slevogt
authors.affiliation: Department of Infectious Diseases, Vivantes Auguste-Viktoria Hospital, Berlin, Germany.
authors.forename: K
authors.initials: K
authors.lastname: Arastéh
authors.affiliation: Department of Infectious Diseases, Vivantes Auguste-Viktoria Hospital, Berlin, Germany.
authors.forename: H
authors.initials: H
authors.lastname: Stocker
mesh_terms: D017088:AIDS-Related Opportunistic Infections / Q000453:epidemiology* / Q000473:pathology; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D001604:Berlin; D057210:Delayed Diagnosis; D042241:Early Diagnosis; D005260:Female; D005858:Germany; D015658:HIV Infections / Q000150:complications* / Q000175:diagnosis*; D006801:Humans; D008297:Male; D008875:Middle Aged; D012189:Retrospective Studies
keywords: 
  AIDS
  ; 
  HIV
  ; HIV testing; female gender; indicator condition; late presentation