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Studies of missed opportunities for earlier diagnosis of HIV have shown that patients with undiagnosed HIV often present to healthcare settings numerous times before eventually receiving their diagnosis.


The aim of the study was to assess missed opportunities for HIV testing among people newly diagnosed with HIV.


In this observational retrospective study, we collected data from the Estonian Health Board on new HIV cases in people aged 16–49 years diagnosed in 2014–15 and from the Estonian Health Insurance Fund database for treatment invoices on their contacts with healthcare services in the 2 years preceding diagnosis. Diagnoses on treatment invoices were categorised as HIV indicator conditions using ICD-10 codes.


Of 538 newly diagnosed HIV cases (62.5%; 336 men), 82% had visited healthcare services at least once during the 2 years before HIV diagnosis; the mean number of visits was 9.1. Of these, 16% had been tested for HIV and 31% had at least one ICD-10 code for an HIV indicator condition on at least one of their treatment invoices. In 390 cases of HIV indicator conditions, only 5% were tested for HIV. Of all new HIV cases aged 20–49 years from high-incidence regions (defined as priority groups in national testing guidance), 18% had been tested.


The HIV testing rate in the 2 years before an HIV diagnosis was very low, even in the presence of an HIV indicator condition. This emphasises the importance of implementing the Estonian HIV testing guidelines.


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  1. World Health Organization (WHO). Consolidated guidelines on HIV testing services. Geneva: WHO; 2015. Available from: https://www.who.int/hiv/pub/guidelines/hiv-testing-services/en/
  2. Gourlay A, Noori T, Pharris A, Axelsson M, Costagliola D, Cowan S, et al. The Human Immunodeficiency Virus continuum of care in European Union countries in 2013: Data and challenges. Clin Infect Dis. 2017;64(12):1644-56.  https://doi.org/10.1093/cid/cix212  PMID: 28369283 
  3. Pharris A, Quinten C, Noori T, Amato-Gauci AJ, van Sighem A, Surveillance EHA, et al. Estimating HIV incidence and number of undiagnosed individuals living with HIV in the European Union/European Economic Area, 2015. Euro Surveill. 2016;21(48):30417.  https://doi.org/10.2807/1560-7917.ES.2016.21.48.30417  PMID: 27934585 
  4. Lyons MS, Lindsell CJ, Wayne DB, Ruffner AH, Hart KW, Fichtenbaum CJ, et al. Comparison of missed opportunities for earlier HIV diagnosis in 3 geographically proximate emergency departments. Ann Emerg Med. 2011;58(1) Suppl 1;S17-22.e1, S22.e1.  https://doi.org/10.1016/j.annemergmed.2011.03.018  PMID: 21684399 
  5. Champenois K, Cousien A, Cuzin L, Le Vu S, Deuffic-Burban S, Lanoy E, et al. Missed opportunities for HIV testing in newly-HIV-diagnosed patients, a cross sectional study. BMC Infect Dis. 2013;13(1):200.  https://doi.org/10.1186/1471-2334-13-200  PMID: 23638870 
  6. Burns FM, Johnson AM, Nazroo J, Ainsworth J, Anderson J, Fakoya A, et al. Missed opportunities for earlier HIV diagnosis within primary and secondary healthcare settings in the UK. AIDS. 2008;22(1):115-22.  https://doi.org/10.1097/QAD.0b013e3282f1d4b6  PMID: 18090399 
  7. Joore IK, Arts DL, Kruijer MJ, Moll van Charante EP, Geerlings SE, Prins JM, et al. HIV indicator condition-guided testing to reduce the number of undiagnosed patients and prevent late presentation in a high-prevalence area: a case-control study in primary care. Sex Transm Infect. 2015;91(7):467-72.  https://doi.org/10.1136/sextrans-2015-052073  PMID: 26126531 
  8. HiE. HIV Indicator Conditions: Guidance for Implementing HIV Testing in Adults in Health Care Settings. Copenhagen: Copenhagen University; 2012. Available from: http://hiveurope.eu/Portals/0/Guidance.pdf.pdf
  9. Statistics Estonia. Population statistics. Tallinn: Statistics Estonia; 2017. [Accessed 17 Jun 2018]. Available from: https://www.stat.ee/stat-population-at-beginning-of-year
  10. European Centre for Disease Prevention and Control (ECDC), World Health Organization (WHO) Regional Office for Europe. HIV/AIDS surveillance in Europe 2018–2017 data. Copenhagen: WHO Regional Office for Europe; 2018. Available from: https://ecdc.europa.eu/sites/portal/files/documents/hiv-aids-surveillance-europe-2018.pdf
  11. National Institute for Health Development (NIHD). HIV in Estonia. Narrative report for Global AIDS Monitoring 2017. Tallinn: NIHD; 2017. Available from: http://www.tai.ee/et/terviseandmed/uuringud/download/413
  12. Laisaar KT, Raag M, Lutsar I, Uusküla A. People living with HIV in Estonia: engagement in HIV care in 2013. Euro Surveill. 2016;21(43):30380.  https://doi.org/10.2807/1560-7917.ES.2016.21.43.30380  PMID: 27813471 
  13. Rüütel K, Kaur E, Epštein J. HIV nakkuse ja kaasuvate infektsioonide epidemioloogiline olukord Eestis, 2000-2017. [Epidemiology of HIV and associated infections in Estonia, 2000-2017]. Tallinn: National Institute for Health Development, Health Board; 2017. Estonian. Available from: http://www.tai.ee/et/terviseandmed/uuringud/download/445
  14. Soodla P, Rajasaar H, Avi R, Zilmer K, Kink K, Novikova L, et al. Design and structure of the Estonian HIV Cohort Study (E-HIV). Infect Dis (Lond). 2015;47(11):768-75.  https://doi.org/10.3109/23744235.2015.1061203  PMID: 26153824 
  15. Rüütel K, Kallavus K, Tomera I. OptTEST by HiE. Monitoring anonymous HIV testing in Estonia from 2005 to 2015. HIV Med. 2018;19(Suppl 1):16-20.  https://doi.org/10.1111/hiv.12587  PMID: 29488697 
  16. Kivimets K, Uuskula A. HIV testing and counselling in Estonian prisons, 2012 to 2013: aims, processes and impacts. Euro Surveill. 2014;19(47):20970.  https://doi.org/10.2807/1560-7917.ES2014.19.47.20970  PMID: 25443037 
  17. Ministry of Social Affairs. HIV-nakkuse testimise ja HIV-positiivsete isikute ravile suunamise tegevusjuhis. [Guidelines for HIV testing and referral to care for people with HIV]. Tallinn: Ministry of Social Affairs; 2012. Estonian. Available from: http://www.esid.ee/cms/tl_files/failid/failid/HIV_testimise_ja_ravile_suunamise_uuendatud_juhis_31.pdf
  18. Rüütel K, Lemsalu L, Lätt S. OptTEST by HiE. Monitoring HIV-indicator condition guided HIV testing in Estonia. HIV Med. 2018;19(Suppl 1):47-51.  https://doi.org/10.1111/hiv.12586  PMID: 29488700 
  19. Rüütel K, Lemsalu L. Monitoring HIV testing guidance implementation in Estonia. HepHIV 2017 Conference: HIV and Viral Hepatitis: Challenges of Timely Testing and Care Malta 2017.
  20. World Health Organization (WHO). International Statistical Classification of Diseases and Related Health Problems. 10th Revision (ICD-10). Geneva: WHO. [Accessed 17 Mar 2018]. Available from: http://www.who.int/classifications/icd/ICD10Volume2_en_2010.pdf
  21. Lhopitallier L, Moulin E, Hugli O, Cavassini M, Darling KEA. Missed opportunities for HIV testing among patients newly presenting for HIV care at a Swiss university hospital: a retrospective analysis. BMJ Open. 2018;8(6):e019806.  https://doi.org/10.1136/bmjopen-2017-019806  PMID: 29895647 
  22. Blasi F, Matteelli A. Indicator condition-guided HIV testing in Europe: a step forward to HIV control. Eur Respir J. 2013;42(3):572-5.  https://doi.org/10.1183/09031936.00179412  PMID: 24000248 
  23. Kapadia SN, Singh HK, Jones S, Merrick S, Vaamonde CM. Missed opportunities for HIV testing of patients tested for sexually transmitted infections at a large urban health care system from 2010 to 2015. Open Forum Infect Dis. 2018;5(7):ofy165.  https://doi.org/10.1093/ofid/ofy165  PMID: 30087904 
  24. Liggett A, Futterman D, Umanski GI, Selwyn PA. Missing the mark: ongoing missed opportunities for HIV diagnosis at an urban medical center despite universal screening recommendations. Fam Pract. 2016;33(6):644-8.  https://doi.org/10.1093/fampra/cmw075  PMID: 27507566 
  25. Inghels M, Niangoran S, Minga A, Yoboue JM, Dohoun L, Yao A, et al. Missed opportunities for HIV testing among newly diagnosed HIV-infected adults in Abidjan, Côte d’Ivoire. PLoS One. 2017;12(10):e0185117.  https://doi.org/10.1371/journal.pone.0185117  PMID: 28977006 
  26. Gullón A, Verdejo J, de Miguel R, Gómez A, Sanz J. Factors associated with late diagnosis of HIV infection and missed opportunities for earlier testing. AIDS Care. 2016;28(10):1296-300.  https://doi.org/10.1080/09540121.2016.1178700  PMID: 27144427 
  27. Zucker J, Patterson B, Ellman T, Slowikowski J, Olender S, Gordon P, et al. Missed opportunities for engagement in the prevenion continuum in a predominantly black and latino community in New York City. AIDS Patient Care STDS. 2018;32(11):432-7.  https://doi.org/10.1089/apc.2018.0127  PMID: 30398951 

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