To our knowledge, for the first time, our study provides nationwide representative data on late HIV diagnosis in France from the beginning of the HAART era. Our results showed that late diagnosis of HIV infection is still frequent in France despite wide access to free Voluntary Counselling and Testing (VCT), and more frequent among specific subgroups of patients, i.e. heterosexual males and migrants. Among the heterosexual population, late diagnosis is more frequent among people with children in a longstanding steady partnership and conversely is less likely among individuals with a large number of sexual partners. Among migrants, no difference was found between men and women and lack of steady partnership is associated with an increased risk. As the HIV epidemic situation in France is similar to that one in the rest of western Europe in respect of the profile of the infected group and the proportion of migrants 10
our results could be of relevance to European countries.
This study has several limitations. Data was collected in hospital settings and non response reached 41% of the randomised patients, with higher rates of refusal among those employed, mostly attributable to a lack of time for answering the questionnaire. In France, antiretroviral drugs are provided exclusively through hospital physicians’ prescription and management of HIV infection is mostly provided at hospital. Thus the hospital-based nature of the study allowed patients randomisation. Major socio-demographic and health-related characteristics of the non-respondents were collected, allowing for a weighting procedure accounting both for the unequal hazard of a patient to be randomised and for the participation bias. Thus, rate of late diagnosis are likely to be extrapolated to the whole population of persons living with HIV/AIDS and followed at hospital in France in 2002–2003. However, because of the cross sectional design of the study, the rate of late diagnosis might be underestimated due to higher mortality rates among persons diagnosed with advanced HIV infection even though mortality has dramatically decreased since 1996.
For 11% of patients, CD4 count during the study period was not documented. The global analysis was repeated first by assuming unknown status cases to be late testers, then non late testers. The findings remained unaltered when unknown cases were considered as late testers. As non late testers, the only difference concerned the proportion of injecting drug users, that was similar between late and non late testers.
The proportion of late testers in our study (33%) is comparable to that reported in other studies focusing on the same calendar period 4, 16
and appears to increase with time, as reported in other studies 11, 12, 17
High risk groups for late testing in our study were similar to those identified in the most recent studies conducted in European countries 4, 11, 16, 17
and in the United States 3
. Heterosexuals are at higher risk of late diagnosis than homosexual males who use VCT on a somewhat regular basis : in 2004, 87 % reported having ever been tested, 72 % in the two preceding years with an average of 2.8 tests 18
. Nevertheless late testing remains frequent in France among homosexuals: 27.6% in our study, as reported recently in England and Wales 19
or in Italy 20
Women are less likely to be diagnosed at advanced stages of disease progression. This situation might be related to routine prenatal testing and gynaecological follow-up. However among migrants, women were not diagnosed earlier than men which might be accounted for by younger age at HIV contamination and for late arrival in France. Diagnosis took place mostly during the very first period after arrival, as in another French study 21
. Most infections might have taken place in the country of origin as shown in English data 16
. Diagnosis concomitant with immigration supports the assumption of infection in the country of origin and either request or proposal of testing shortly after arrival.
Steady partnership appears to be determinant of testing behaviour. Among homosexual men, recent partnership appears as protective compared to longer duration of couple or absence of stable partner. This finding is supported by the ANRS-INVS Gay press study 18
, in which men in new established partnership are more likely to have performed an HIV test in the preceding 12 months (75.4 % vs. 43.2 to 46.3%, Velter A, personal communication). French natives in longer partnership (>5 years) are exposed to an increased risk of late diagnosis. In the 2004 French general population KABP survey 22
, individuals in shorter partnerships (<5 years) more often reported that they had ever thought they might have been infected and individuals in longer couples were less likely to report such a perception compared to singles. Individuals in longer partnerships (>5 years) were more likely to perceive they were at no risk than singles and individuals in recent couples (Beltzer N, personal communication).
In countries with concentrated epidemics, persons in steady partnership, with children are perceived to be at low risk and may not consider themselves at risk and thus do not seek voluntary counselling and testing (VCT). If infected, they are likely to be diagnosed with advanced HIV infection. Our findings suggest that promoting awareness of risk in longstanding couples and knowledge of one’s HIV status regardless of sexual risk behaviour and routine proposed of testing might complement the current testing policy aimed at populations and persons at risk. The association between welfare benefit and lower risk of late testing is consistent with this result since a free check up including an HIV test is offered to the beneficiaries on a routine basis.