December 12, 2002
Spain offers its entire population free voluntary confidential HIV testing at primary care centers, hospitals, and genitourinary clinics. Additionally, some cities maintain sites that offer anonymous HIV counseling and testing. Since 1997, all patients can receive HAART free of charge, which has led to more than a 60 percent reduction in AIDS incidence and mortality.
AIDS cases in Spain are reported to a national system on a specific report form that lists the month and year of AIDS diagnosis and the first positive HIV test result. Researchers also used other variables on the AIDS case report form: sex, age, HIV transmission category, prison record, province of residence, and country of origin.
The study focuses on AIDS patients more than fourteen years old whose cases were reported through June 30, 2001, with a first AIDS defining condition diagnosed from January 1994 through December 2000. Researchers define "late testers" as cases reporting the first HIV positive test result in the month in which AIDS was diagnosed or in the preceding month. The authors divided cases into those diagnosed in 1994 through 1996, and those diagnosed in 1998 through 2000. Those time periods pre- and post-date the widespread use of HAART. The authors left 1997 out because that was a transition year during which the treatments became generally available.
From 1994 to 1996, 24.1 percent of the 18,755 diagnosed AIDS cases were late testers. From 1998 to 2000, late testers increased to 35.3 percent of the 7,825 cases diagnosed. Among the late testers, 12.7 percent and 11.3 percent respectively died within three months of the date of the first positive HIV test result. From 1995 to 2000, the number of AIDS diagnoses declined by 67 percent among patients who were previously aware of their HIV infection versus a 36 percent decline among late testers.
The authors find the greatest decline in AIDS diagnoses, 52 percent, occurred from 1996 to 1998, coinciding with the spread of HAART. The trend among late testers was not directly affected by the introduction of HAART. For each transmission category, AIDS incidence showed a much smaller decline among late testers. Incidence of AIDS attributed to homo/bisexual and heterosexual contact among late testers now exceeds the incidence among non- late testers. Assuming that earlier diagnosis of late-testing AIDS cases would have led to their plotting a trend similar to the remaining cases, the study asserts that AIDS incidence in 2000 would have been 17 percent lower.
Among cases diagnosed in 1998-2000, late testers were independently associated with the male sex; older than 44; transmission categories other than injection drug use; residence in provinces with low AIDS incidence; and country of origin other than Spain. Except for province of residence, the same variables were associated with late-testing cases from 1994-1996. Patients in prison or with a prison record were far less likely to be late testers than the remaining cases. Spanish prisons offer voluntary HIV testing and antiretroviral treatment.
Women and injection drug users registered lower proportions among late testers, perhaps due to women's greater use of healthcare services and the practice of offering HIV testing to pregnant women, and to drug users' greater awareness of risk and the fact that addiction treatment and harm- reduction programs offer testing. Late testers were more likely to have come from a country of origin other than Spain, reflecting possible cultural and language barriers. Patients from provinces with a low incidence of AIDS registered higher proportions of late testing in the era of HAART, which could be a result of low suspicion of HIV infection in such small towns or rural areas, or cultural taboos that inhibit requesting or prescribing the test.
The researchers conclude that disseminating more information to the public about the benefits of HIV testing, and greater availability and accessibility of HIV testing sites could help foster an attitude of normalcy toward HIV testing. They urge clinicians to incorporate HIV testing more frequently (confidentially and with patients' informed consent) into their standard diagnostic procedures.