World Journal of AIDS, 2013, 3, 197-200 Published Online September 2013 ( 197
Diagnosis of HIV Delay: Lost Opportunities
P. Jiménez-Aguilar1, A. Romero Palacios1, G. García-Dominguez1, J. Borrallo-Torrejon1,
E. Vergara-Moragues1,2, E. Cruz-Rosales1, A. Vergara de Campos1
1Infectious Diseases Service, Puerto Real University Hospital, Cadiz, Spain; 2Department of Education, International University of
La Rioja (UNIR), Logroño, Spain.
Received March 27th, 2013; revised April 27th, 2013; accepted May 27th, 2013
Copyright © 2013 P. Jiménez-Aguilar et al. This is an open access article distributed under the Creative Commons Attribution Li-
cense, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
The diagnosis delay in new cases of HIV infection is a frequent fact. Our objective was to detect and analyse the lost
opportunities and describ e the characteristics of these patients. Method: Th e search was done by a revision of personal
histories of new diagnosis of HIV infection from 1st January to 31st December 2011 in the database of VACH. We se-
lected those that had consulted a doctor in the previous year in the Emergency area, Primary Care and Specialised Con-
sultations in the database of the histories of the Public Health Service. We called low attendance if they came 1 - 3
times and high if over 3. We grouped patients into those that fulfilled criteria of diagno sis delay by count of CD4s. We
called no diagnosis delay to those that had count of CD4 over 350, diagnosis delay under 350 and advanced disease
under 200. Results: There were 107 new cases. The global percentage of DD was 61.7% of cases. From these, 45.38%
fulfilled criteria of AD. It was possible to find information about the existence of previous sanitary attendance in 59
patients. From these 58% were diagnosed with delay, fulfilling criteria of AD in 27%. The predominant means of in-
fection was sexual. 35 patients atten ded a healthcare level, 19 two and 5 three. 47.5% co nsulted over 3 times. They re-
quested a total of 274 consultations. Discussion: The diagnosis delay is a reality. It took our attention that from 59 pa-
tients having requested previous medical assistance 58% were diagnosed with delay and 27% fulfilled criteria of AD.
We found that almost half of them had been attended in 4 and up to 14 times, in some occasions with suggestive symp-
toms of HIV infection. Facing this discovery we think that some intervention s should be undertaken to get an early di-
agnosis and the control of the outbreak.
Keywords: HIV; Diagnosis Delay
1. Introduction
The diagnosis delay in the new cases of HIV infection in
Spain was a frequent fact (45% - 67%) and recognised
some years ago [1,2]. This helps to explain that the out-
break is not under control [3] and that every year thou-
sands of new people infected by HIV are diagnosed [1].
There exists factors that depend on the own infected with
HIV people [3] but others that involve the Public Health
System in which there would be th e responsibility of tak-
ing part. Our objective is to detect and analyze the lost
opportunities and describe the epidemiological characte-
ristics of the patients diagnosed with delay.
2. Material and Methods
The search of new cases was made by a protocolled revi-
sion of the clinical histories of the new cases diagnosed
of HIV infection in Puerto Real University Hospital In-
fectious Disease Clinical Management Unit, which sani-
tary area included approximately 320,000 people in the
period from 1st January to 31st December 2011, in our
database VACH (AdvanCedHiv 2009, Medial Desarrol-
los S.L.) updated version v.2. We selected those that had
anytime gone to consult a doctor from the Andalusian
Public Health Service in the previous year to the diagno-
sis in the Emergency area, General Practitioner or spe-
cialized consultations.
We grouped patients into those that met the criteria of
diagnosis delay by the count of CD4. This way we called
no diagnosis delay to those that had CD4 counts over 350,
diagnosis delay under 350 and advanced disease to
counts under 200.
We investigated the sanitary database of the unique
personal history of the Andalusian Public Health Service
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Diagnosis of HIV Delay: Lost Opportunities
in the hospital database to know the number of times that
the patient had consulted a doctor in the emergency area,
general practitioners and sp ecialized consultation s during
the previous year to the diagnosis and the motifs of that
consultation. Furthermore, we analyzed patients that had
attended one or several healthcare lev els. As to the range
of frequency of attention, we called low attendance to
those patients that came between one and three times to
any level of healthcare and high attendance to tho se who
came over 4 times. With this information a database was
performed and the data was analyzed with the SPSS 18.0
statistical programme.
3. Results
In the period of time between 2005 and 2011, 107 cases
were diagnosed. In our series the global percentage of di-
agnosis delay was 61.7% of the cases (66 patients). From
these, 45.38% (30 patients) fulfilled the criteria of ad-
vanced disease.
It was possible to find information about the existence
of sanitary assistance in the previous year to the diagno-
sis in 59 patients (45 men and 14 women). The median of
age found was 40 years-old. From these, 34 were diag-
nosed with delay (58%), fulfilling the criteria of ad-
vanced disease in 16 (27%). The main way of infection
was the sexual one: 49% heterosexual and 47% homo-
sexual. The use of intravenous drugs meant 3% of the
As to the cultural level 54% did not have any studies
or just primary studies and 36% had medium or higher
education. 35 patients attended an only healthcare level
(60% GPs, 23 Emergencies and 17% specialized consul-
tations), 19 to two levels and 5 patients to the three
healthcare levels. In relation to the frequency of atten-
dance, 52% of patients had low attendance and 47.5%
went over three times. They applied for a total of 274
consultations, among which we highlight: 14.6% due to
febrile syndromes without apparent focus, 11.7% for
constitutional syndrome, 10.6% for diarrhea, 9.8% had
any sexually transmitted d isease (STD), 8.8% respiratory
symptoms with or without fever and 8.4% for derma-
tological lesions.
4. Discussion
The objective of our present work is to transfer some re-
flections after checking some clinical facts in the daily
routine practice of an infectious disease consultation that
has concerned us. The HIV outbreak is not under con-
trol in Spain [1,3]. Several thousands new people are in-
fected each year, despite consciousness raising cam-
paigns and the information transmitted to the population
and the affected organizations. In the last 6 years, in the
Infectious Diseases Clinical Management Unit, we have
diagnosed 107 new cases of infected people by HIV,
mainly male (74.8%) and in 90.7% of cases the way of
transmission was the sexual one.
The diagnosis delay g oes on being a reality both in the
rest of the Span ish series (45% - 67%) [1,4 ,5] and in ours,
with unacceptable percentages. There exists another da-
tum even more worrying, which is that more than 25% of
the cases had the criteria of an advance disease or even
that 1 of each 4 cases had been diagnosed coinciding with
an opportunistic disease of AIDS [1,4]. Our results were
even a bit higher: 61.7% of diagnosis delay and from
these, 45.38% presented with advanced disease criteria.
What attracts our attention is that from 59 p atients that
in any occasion had asked for medical assistance previ-
ously, 58% were diagnosed with delay, fulfilling crite-
rion of advance disease in 27%. Furthermore we find that
almost half of the cases (44.7%) had attended any doctor
from 4 to 14 times or even in the three healthcare levels.
However, it should be marked that the study being retro-
spective is a limitation, since it is difficult to get all the
data, and some cases could have been underestimated
due to private centres attendance, which have not been
taken into account. In our series a total of 274 consulta-
tions were made, in many cases with symptoms that cli-
nically were suggestive of HVI infection.
Patients diagnosed with delay had mainly consulted
for constitutional syndromes, febrile syndromes without
apparent focus, diarrhoea, sexually transmitted diseases,
dermatological lesions, respiratory infections and otorhi-
nolaryngological symptoms in one and multiple occa-
sions without anyone asking for an HIV detection test.
(Table 1).
In our opinion, the explanation of this phenomenon
go es over the simple knowledge of the diagnosis criterions
and lies on the fact that some professionals go on having
queries about an adequate performance. The HIV infec-
tion was treated in a different way from other infections
during the 80s and 90s, because of the consequences of
marginalization and the impact it had, which has been
known as “AIDS excepcionalism” [6,7]. Since then this
approach has changed a lot but it has probably not been
correctly conveyed to professionals, even in the intern-
ship formation. Since 2005, at least, there exists argu-
ments against this uniqueness [6,7]: there exists HART
which is not used due to delayed diagnosis, a sufficient
mobimortality reduction and mother-child transmission
[8]. In 2006 the specific Guideline CDC made upwards
recommendations to increase the offer to these HIV-test
in homosexual, IV drug users, p eop le with a high number
of couples or immigrants from countries with the high
prevalence [9]. All publications, advices and recommen-
dations, from then, went in the same direction : to support
the HIV test active offer not only for the diagnosis but to
propose treatment [10-12]. In Spain there are no doubts
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Diagnosis of HIV Delay: Lost Opportunities
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Table 1. Analysis of epidemiological characteristics of patients as they presented or not clinical criteria of diagnosis delay.
CD-4(N) N.
Patients Sex Mode of
Transmission Number of Healthcare Levels
Consulted Attendance Symptomatology
NDD (>350) 25 Men:2,
Women:5 HTX:10, HMX:15,
One Level:16 (PHC:9; ES:5;
EC:2), Two Levels:6, Three
Levels:3 Low:12, High:13
Constitutional sd.:14,
Febrile sd.l:12, Diarrhea:9,
Inf. Resp. Aff:6,
Dermatological lesions:5,
STD:5, ORL symptoms:5
(<350 - 200) 18 Men:14,
Women:4 HTX:9, HMX:8,
One Level:11 (PHC:6; ES:2;
EC:3), Two Levels:6,
Three Levels:1 Low:10, High:8
Constitutional sd.:5, Febril
sd:6, Diarrhea:4, Inf. Resp.
Aff.:4, Dermatological
lesions:7, STD:5, ORL
symptoms:5, CNS:3
AD (<200) 16 Men:11,
Women:5 HTX:10, HMX:4,
IVDU:2 One Level:8 (PHC:6; ES:1; EC:1),
Two Levels:7, Three Levels:2 Low:9, High:7
Constitutional sd.:6,
Febrile sd.:8, Diarrhea:3,
Inf. Resp. Aff: 4,
Dermatological lesions:4,
STD:4, ORL symptoms:4,
N: number; NDD: no diagnosis delay; DD: diagnosis delay; AD: advanced disease; HTX: heterosexuals; HMX: homosexuals; IVDU: intravenous drug users;
PHC: primary health care; ES: emergency service; EC: specialised consultations; Sd: syndrome; Inf resp. Tr. Aff.: inferior respiratory tract affect ation; STD:
sexually transmitted disease; ORL: otorhinolaryngological; CNS: central nervous system. Symptomatology: number of consultations made with relevant symp-
about it since the proposal of treatment is done righ t after
the diagnosis if it is indicated by the doctor.
But apart from the patients that require attendance be-
cause of presenting with clinical suspicion, our position
is that HIV test should be included without any reserve
and even without previous information. There exists pro-
posals of active strategies to detect HIV even in patients
without clinical suspicion, with an experience in this
sense not only in Asiatic countr ies [13] but in Spain [14]
which has demonstrated the profitability of these strate-
gies in the early detection of HIV infected people [14,
In conclusion, there exists factors for the diagnosis de-
lay not only in relation to the own citizen but others that
implies the Public Sanitary System [16]. Because of all
this, we consider that both the autonomic and national
scientific societies and the sanitary institutions should
take active action in ending the doctors caution and nor-
malize the HIV infection as any prevalent STD in our en-
vironment to achieve the early diagnosis and control of
the outbreak.
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