Late Presenters

One of the sub-themes of this conference is how to reach the illusive 10%, or 20% or 40%. Those people who have HIV but are not diagnosed. Unfortunately, I have not yet heard the answer.

Five posters look at this and it has been the subject, at least in part of the IAS Symposium on Patient Centered Care and the the EATG symposium on new technologies and Apps. Suffice to say this conundrum of how to reach the unreached, or in settings where there have been big gains, how to reach the persistent residual of untested patients has been a focus of many presentation.

Unfortunately, there is not an answer. I am not looking for the panacea, but some greater or closer consideration of this issue is greatly needed. What I would like to hear and I think many of us could learn from is "what caused someone to test now". People who have established infection, and then come forward for testing must have made that decision for some reason.

Patrick Sullivan, Rollins School of Public Health, Emory University, talking on technology based and at-home testing and PrEP services, gave an example from one man, characteristic of what his group was hearing, namely that being able to order on line was the thing that finally pushed him into action. Is that common? Can we build on this.

The posters focus more on describing the late presenter but unfortunately do not investigate their motivations for eventually testing. We do find out that many people had had contact with health services and that these were viewed as lost opportunities. Almost 50% of recent enrolees in the Swiss Cohort had missed opportunities (P#341);  starting late had less favorable outcomes (P#340); 1 in 4 people in an Edinburgh study were not tested in line with Guidelines (P#342); in a Lisbon sample 56% had clinical symptoms,prior to testing (P#343) and a further Lisbon based study found late presenters were presenting in hospitals and on wards and questioned the targeting of campaigns to specific groups(P# 344), given the diversity of late presenters. NONE of theses studies asked the patient.

It seems that while a focus on Key Populations is vital, this needs to be matched to be complemented with some focus on non-priority groups. Julio Montaner, describing new infections in his British Colombia population,  used phylogenetic sequencing to describe a situation where about 30%-40% of new infections are related to two large clusters. The remaining infections are much-much smaller clusters with about half of those infections happening locally and about half outside of BC. This tells us it is vitally important to focus on more prevalent settings and in communities with high rates of infection, but equally effort needs to be made to access those who don't respond to those messages and are not members of key affected populations.

Good food for thought and hopefully we can get some interest in finding out what actually tips the balance for people to seek testing, to engage in prevention and to access care.