Missed opportunities for HIV testing among newly diagnosed HIV-infected adults in Abidjan, Côte d'Ivoire

Early antiretroviral treatment initiation has both individual benefits, through reduction of the risk of HIV-related morbidity and mortality [1,2], and collective benefits, through reduction of the risk of HIV transmission [3,4]. Recent World Health Organization guidelines recommend initiating unconditional treatment (i.e. regardless of CD4 count) for all people living with HIV (PLHIV) [5]. However, many PLHIV are diagnosed at an advanced stage of infection. In sub-Saharan Africa, an estimated 45–70% of PLHIV are screened with less than 200 CD4/mm3 [6–8]. Early treatment cannot be achieved without early screening.

Given the need to reduce the time between HIV infection and diagnosis, several studies have examined the healthcare pathway prior to diagnosis to identify opportunities for health professionals to offer HIV tests. These studies, mainly conducted in northern countries, show that almost all PLHIV receive some type of health care in the years before diagnosis, and many of them have clinical indicators (e.g., sexually transmitted infections, chronic diarrhea, tuberculosis) and/or non-clinical indicators (e.g., high-risk behaviors or membership in a high-risk group) that are potentially associated with HIV [9–15]. However, the number of HIV tests offered by health professionals based on these indicators remains insufficient [9–15]. To the best of our knowledge, only two studies have documented the healthcare pathway prior HIV diagnosis among newly diagnosed PLHIV in the African context, and neither fully describes the history of HIV testing opportunities among participants [8,16].

In Côte d’Ivoire, one of the West African countries hit hardest by the HIV epidemic [17], no study has documented the care pathway prior to diagnosis, and most PLHIV are diagnosed at advanced disease stage with low CD4 counts (<200 CD4/mm3) [7,18]. In light of this, we conducted a study of newly diagnosed PLHIV in order to characterize missed opportunities for testing and identify types of opportunities that are often missed.