Primary Health Care: An Opportunity for Early Identification of People Living With Undiagnosed HIV Infection

R Martin-Iguacel; C Pedersen; JM Llibre; J Søndergaard; J Jensen; LH Omland; IS Johansen; N Obel; LD Rasmussen


HIV Medicine. 2019;20(6):404-417. 

In This Article

Abstract and Introduction


Objectives: We aimed to determine the fraction of HIV-diagnosed individuals who had primary health care (PHC) contacts 3 years prior to HIV diagnosis and whether the risk of HIV diagnosis and degree of immunodeficiency were associated with the frequency of visits or procedures performed.

Methods: We used data from national registries to conduct a population-based nested case–control study. Cases were individuals diagnosed with HIV infection in Denmark from 1998 to 2016. Population controls were extracted from the general population matched 13:1 on gender and age. We used conditional logistic regression. As there was a statistically significant interaction, analyses were further stratified by gender and Danish/non-Danish origin.

Results: We identified 2784 cases and 36 192 controls. Ninety-three per cent of cases and 88% of controls attended PHC at least once in the 3 years prior to diagnosis, with a higher median number of visits to PHC (NVPC) for cases. We found a statistically significant positive association between NVPC and risk of subsequent HIV diagnosis in men and non-Danish women. A U-shaped association between NVPC and risk of HIV diagnosis among Danish women. No substantial association between NVPC and degree of immunodeficiency was found. Risk of HIV diagnosis and degree of immunodeficiency were weakly associated with type of procedures performed.

Conclusions: For most HIV-infected individuals, there seem to be many opportunities for earlier diagnosis in PHC. In men and non-Danish women, the risk of HIV diagnosis but not the degree of immunodeficiency was related to NVPC. The results suggest that the type of medical procedure performed cannot not be used as a guide by the primary physician to indicate which patients to test.


Despite the enormous advances achieved in the management of HIV infection, it is estimated that approximately 40% of people living with HIV (PLHIV) world-wide[1] and 15% in Europe[2,3] are unaware of their HIV status. An American study reported that more than one-third of the new HIV transmissions in the USA occurred from individuals unaware of their HIV diagnosis.[4] Recent data from the European Centre for Disease Prevention and Control[5] and other surveillance studies[6–9] indicate that around half of the newly diagnosed PLHIV are at late stages of the disease at the time of the diagnosis (CD4 cell count < 350 cells/μL). Thus, late HIV diagnosis remains a major concern globally with high costs both for the individual and for public health. It is associated with increased morbidity and mortality for the individual,[7,10,11] jeopardized CD4 cell recovery, poorer response to antiretroviral treatment (ART),[12,13] increased health care costs[14] and increased risk of transmission of HIV in the community.[15–19] Furthermore, knowledge of HIV status is associated with risk behaviour reduction, with the potential of reducing onward transmission.[19]

Targeted HIV testing is recommended in conditions where HIV infection is seen with an increased frequency, so-called indicator conditions (ICs),[20–22] in certain groups with a high risk of HIV infection [people who inject drugs (PWID), men who have sex with men (MSM) and populations originating from countries with a high HIV prevalence], and in pregnant women. Despite these recommendations, several studies have shown that PLHIV have had frequent contacts with health care services in the years prior to their HIV diagnosis, often presenting as risk groups or with ICs, representing missed opportunities for earlier HIV diagnosis.[7,23–28] Therefore, efforts to identify potential barriers to HIV testing and to improve the rate of earlier HIV diagnosis are crucial.[29–31] HIV risk factors pertaining to primary care are poorly described. Therefore, we aimed to assess the fraction of individuals diagnosed with HIV infection who had primary health care (PHC) contacts in the 3-year period prior to HIV diagnosis and investigated whether the risk of HIV diagnosis and degree of immunodeficiency were associated with the frequency of visits or the type of procedures performed in PHC.