title: The persistent problem of late HIV diagnosis in people with AIDS: a population-based study in Italy, 1999-2013.
abstract: OBJECTIVE
  Despite the wide accessibility to free human immunodeficiency virus (HIV) testing and combined antiretroviral therapy (cART), late HIV diagnosis remains common with severe consequences at individual and population level. This study aimed to describe trends of late HIV testing and to identify their determinants in the late cART era in Italy.
  
  
  METHODS
  We conducted a population-based, nationwide analysis of the Italian National AIDS Registry data (AIDS - acquired immune deficiency syndrome) for the years 1999-2013.
  
  
  METHODS
  Late testers (LTs) were defined as people with AIDS (PWA) whose first HIV-positive test preceded AIDS diagnosis by 3 months or less. Odds ratios (ORs) with the corresponding 95% confidence intervals (CIs) were estimated to examine factors associated with being LTs. Joinpoint analysis was used to estimate annual percent changes (APCs) of LTs' proportion over time.
  
  
  RESULTS
  Among 20,753 adult PWA, 50.8% were LTs. Italian PWA showed a lower proportion of LTs than non-Italian PWA (46.5% vs 68.2%). Among Italian PWA, the odds of being LTs was higher in men than in women (OR = 2.62, 95% CI: 2.38-2.90); in the age groups below 35 years and over 49 years at diagnosis (OR = 1.24, 95% CI: 1.12-1.37 and OR = 1.51, 95% CI: 1.38-1.67, respectively) vs PWA aged 35-49 years; and in those infected through sexual contact as compared with injecting drug use (OR = 13.34, 95% CI: 12.06-14.76 for heterosexual contact and OR = 8.13, 95% CI: 7.30-9.06 for male-to-male sexual contact). The proportion of LTs increased over time among Italians, especially in the latest period (APC2006-2013= 5.3, 95% CI: 3.8-6.9). The LTs' proportion resulted higher, though stable, among PWA aged ≥50 years. Conversely, an increasing trend was observed among PWA aged 18-34 years (APC = 5.3, 95% CI: 4.5-6.1). The LTs' proportion was persistently higher among PWA who acquired HIV infection through sexual contact, even if a marked increase among injecting drug users was observed after 2005 (APC = 11.4, 95% CI: 5.7-17.5).
  
  
  CONCLUSIONS
  The increasing trend of LTs' proportion in the late cART era highlights the need of new strategies tailored to groups who may not consider themselves to be at a high risk of infection. Active promotion of early testing and continuous education of infection, especially among young people, need to be implemented.
authors.affiliation: Unit of Cancer Epidemiology, CRO Aviano National Cancer Institute, Aviano, Italy. Electronic address: mtaborelli@cro.it.
authors.forename: M
authors.initials: M
authors.lastname: Taborelli
authors.affiliation: Unit of Cancer Epidemiology, CRO Aviano National Cancer Institute, Aviano, Italy.
authors.forename: S
authors.initials: S
authors.lastname: Virdone
authors.affiliation: Centro Operativo AIDS, Istituto Superiore di Sanità, Rome, Italy.
authors.forename: L
authors.initials: L
authors.lastname: Camoni
authors.affiliation: Centro Operativo AIDS, Istituto Superiore di Sanità, Rome, Italy.
authors.forename: V
authors.initials: V
authors.lastname: Regine
authors.affiliation: Unit of Cancer Epidemiology, CRO Aviano National Cancer Institute, Aviano, Italy.
authors.forename: A
authors.initials: A
authors.lastname: Zucchetto
authors.affiliation: Servizio Sanità, Salute ed Assistenza, Istituto Nazionale di Statistica, Rome, Italy.
authors.forename: L
authors.initials: L
authors.lastname: Frova
authors.affiliation: Servizio Sanità, Salute ed Assistenza, Istituto Nazionale di Statistica, Rome, Italy.
authors.forename: E
authors.initials: E
authors.lastname: Grande
authors.affiliation: Centro Operativo AIDS, Istituto Superiore di Sanità, Rome, Italy.
authors.forename: S
authors.initials: S
authors.lastname: Boros
authors.affiliation: Unit of Cancer Epidemiology, CRO Aviano National Cancer Institute, Aviano, Italy.
authors.forename: L
authors.initials: L
authors.lastname: Dal Maso
authors.affiliation: Scientific Directorate, CRO Aviano National Cancer Institute, Aviano, Italy.
authors.forename: P
authors.initials: P
authors.lastname: De Paoli
authors.affiliation: Unit of Cancer Epidemiology, CRO Aviano National Cancer Institute, Aviano, Italy.
authors.forename: D
authors.initials: D
authors.lastname: Serraino
authors.affiliation: Centro Operativo AIDS, Istituto Superiore di Sanità, Rome, Italy.
authors.forename: B
authors.initials: B
authors.lastname: Suligoi
mesh_terms: D000163:Acquired Immunodeficiency Syndrome / Q000188:drug therapy / Q000453:epidemiology*; D000293:Adolescent; D000328:Adult; D057210:Delayed Diagnosis / Q000706:statistics & numerical data*; D005260:Female; D015658:HIV Infections / Q000175:diagnosis*; D006801:Humans; D007558:Italy / Q000453:epidemiology; D008297:Male; D008875:Middle Aged; D012042:Registries; D012307:Risk Factors; D055815:Young Adult
keywords: AIDS; HIV testing; Italy; Late testers; Population-based