This is the first study investigating the status of late HIV diagnosis and its factors in Iran. We found that late diagnosis was prevalent among Iranian patients (53%). Existing evidence show that prevalence of late HIV diagnosis is high in other studies. Accordingly, the reported prevalence ranged from 25% in Columbia to 70.1% in China [14, 15]. It is a major concern for the country because people with late HIV diagnosis receive ART late and, as a result, loses opportunities for counseling, education, and substance abuse treatment, resulting in the spread of HIV in the community. Evidence confirms that ART has the maximum effect on viral load and mortality rate from AIDS in the early stages of the disease. Therefore, ART is recommended to be initiated for all HIV-positive people immediately after diagnosis [16].
Moreover, we found that people who inject drugs (PWID) had the highest risk of late diagnosis. Like our study, a study conducted in China show that odds of late diagnosis in PWID was two times higher than other people [17]. Due to the severe social discrimination and stigma against both drug abuse and HIV in Iran, PWID avoid seeking medical services, including tests for HIV diagnosis. The literature has well established that ART is less prevalent in PWID than people who do not inject drugs. Additionally, in counties with free health services for HIV patients, medical care utilization is very low due to the patients’ social situations and family problems [18, 19].
In this study, the probability of late diagnosis was significantly greater in Iranian men than women. Other studies confirmed that male gender is a major risk factor of risky behaviors such as HIV late diagnosis [20]. For example, Rice et al., Sun et al. and Agaba et al. suggested that male gender is significantly associated with a higher risk of late HIV diagnosis [21,22,23]. This result could be attributed to two reasons. First, most PWID are men on the one hand, and late diagnosis is highly prevalent among PWID on the other hand. Therefore, men PWID are dominant in the AIDS population and have a higher frequency of late diagnosis than women [24]. Second, studies show that men generally are less likely to seek out health care than women. These studies have highlighted the fear of developing a disease as a significant barrier to seek medical care in men [25].
We found that the risk of late diagnosis was higher in older patients than in younger ones. A review of the literature also confirms that older age is the predominant predictor of late presentation of HIV [16, 22, 23, 26]. Studies show that older patients have a low-risk perception relative to HIV, and therefore are less likely to be tested for HIV [8]. Late diagnosis is a significant factor of mortality in older people, and in fact, these groups obtain the most significant benefit from ART compared to other age groups [27]. Low education and knowledge and low risk perception about the disease have been mentioned as the main reasons for late diagnosis in older people. Low education is also associated with low socioeconomic status, affecting health and medical services [28, 29].
Another identified risk factor of late HIV diagnosis was co-infection with TB. Gesesew et al. showed that HIV people with TB co-infection were about 2 times at risk of late HIV diagnosis [9].
This study showed that the prevalence of late HIV diagnosis was the lowest in mother-to-child transmission compared to the other transmission modes. Currently, a program called PMTCT (prevention of mother-to-child transmission) is being implemented [30]. All mothers are tested for HIV during pregnancy and are provided with HIV counseling. Preventive treatment should be given to the baby if the mother’s test is positive. All infants born to HIV-positive mothers are also screened for HIV prophylaxis after birth and HIV. If a baby is infected with HIV, they will receive the same care and treatment services as other HIV-positive patients for the rest of their lives. This program aims to reduce the rate of mother-to-child transmission, one of the goals of the HIV prevention and control program recommended to countries by WHO and UNAIDS [31]. This study confirms the effectiveness of PMTCT on early HIV diagnosis. Therefore, it is recommended to improve the program and expand it to all regions of Iran.
This study’s results provide implications for Iranian policymakers and health providers. First, the percentage of late diagnosis is high and require more attention. Second, policymakers should design programs to perform screening among high-risk subgroups including PWID and FSWs. These groups should be encouraged to seek earlier diagnosis and treatment. Iranian policymakers should conduct scaling up HIV testing, making a considerable percentage of individuals infected with HIV receive HIV test [32]. Moreover, we recommend performing the mass screening of HIV and expanding counseling centers for high-risk groups, including FSWs and PWID. Furthermore, the increased coverage of ART is recommended to improve patient survival.
We used registered data for this study as one of the study’s limitations. Moreover, we did not measure some critical variables in late diagnosis and survival. Therefore, we could not assess their effects on late diagnosis or survival and could not control their confounding effects. Furthermore, the precision and validity of our retrospective study’s data are questionable because the data were not collected for research objectives. Accordingly, the retrospective studies may potentially produce selection bias or information bias, and therefore, may distract the final results. Additionally, registered data lack data verification and do not have complete data/follow-up.