Epidemiological Factors Place Patients at Risk for Missed Diagnosis

Diagnosing HIV
Diagnosing HIV
Further testing implementation needed to include all patients with symptoms and conditions of HIV-1.

A national multicenter cross-sectional study of adults with newly diagnosed HIV-1 in Sweden found that 37% of the patients could have been diagnosed at an earlier stage, according to a study published in PLoS One. The odds for missed presentation varied with certain epidemiological factors. These findings suggest there are opportunities to address missed presentations of HIV-1. Researchers with the Karolinska Institute and Karolinska University Hospital, Stockholm, Sweden thus sought to identify which subsets of patients did not get tested for HIV-1 upon evaluation by the physician.

Patients were grouped in 2 categories as either non-late presenters (nLPs) or late presenters (LPs) whose CD4+ T-cell was below 350 cells/mm3 or they developed AIDS within 3 months of diagnosis. Primary outcomes in the study were either missed presentation, defined as a missed diagnosis, or patient neglect of symptoms. 

For the LPs, the most common missed presentation was wasting syndrome and Candida esophagitis mostly occurring in the primary care setting (55%). In the nLPs group, oral candida, other STI, seborrheic  dermatitis, PHI-like illness and blood dyscrasia were the most commonly missed HIV associated conditions.  Again, most of the HIV associated conditions were missed in the primary care setting (58%) and some in sexually transmitted infection/skin clinics (16%).

Weight loss (19%) and fatigue (15%) were the most neglected symptoms in LPs.  “PHI like syndrome” was the most commonly neglected symptom in nLPs.

“Among Swedish born patients, 39% were tested on physician initiative due to symptoms and 35% by their own initiative. Among patients from the East, the reason for testing was equally distributed whereas the majority (64%) of patients from Sub-Saharan Africa were tested due to screening and only 12% on their own initiative, which was significantly different from the other groups (P =.001).”

While the vast majority of LPs in Sweden are migrants, the researchers noted that “symptomatic patients from high prevalent countries were less likely to be missed by the physician at seeking health care and also to neglect their symptoms, compared to patients born in Sweden.”

The study showed that missed diagnosis by the health care provider was of greater importance than patient neglect of symptoms.  There are many reasons for physicians not offering an HIV test such as “lack of training, self confidence in offering a test, concerns about the consent process, and competing priorities.” 

Since an expanded timeframe would likely only accentuate these findings, “strategies to identify these patients, without obvious epidemiological indicators of HIV, and other undiagnosed individuals should have the highest priority in the combat against the HIV-1 epidemic.”

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Brännström J, Svedhem V, Marrone G, et al. Symptomatic patients without epidemiological indicators of HIV have a high risk of missed diagnosis: a multi-centre cross sectional study. PLoS One. 2016;11(9):e0162503. doi: 10.1371/journal.pone.0162503.