AIDS Behav (2013) 17:235–241
DOI 10.1007/s10461-011-0117-6
ORIGINAL PAPER
High Rates of Late HIV Diagnosis Among People Who Inject
Drugs Compared to Men Who Have Sex with Men
and Heterosexual Men and Women in Australia
Handan Wand • Rebecca Guy • Matthew Law •
David P. Wilson • Lisa Maher
Published online: 5 January 2012
Ó Springer Science+Business Media, LLC 2011
Abstract We aimed to estimate temporal trends in the
proportion of HIV diagnoses which could be characterized
as recent infections in Australia for men who have sex with
men (MSM), people who inject drugs (PWID), and heter-
osexual men and women using modified back-projection
methodology based on data sources from HIV/AIDS Sur-
veillance database. The proportion of HIV diagnoses
among MSM that can be classified as recent infections
increased in MSM, heterosexual men and women consis-
tently. However, after initial increases during 1996–2000,
the proportion of overall recent infections estimated among
PWID declined by 50% in 2007 compared to 2000 (from
23 to 11%). These data suggest that late HIV diagnoses
were more common among PWID compared to other
groups. Ongoing prevention efforts need to be coupled with
targeted testing and treatment efforts to increase the diag-
nosis of recent infection in PWID and reduce apparent
inequities in access to screening.
Keywords HIV testing
Injecting drug users
Late
presenters
Australia
Resumen El objetivo fue estimar las tendencias tempo-
rales en la proporción de diagnósticos de VIH que podrı́a
ser caracterizado como infecciones recientes en Australia
para los hombres que tienen sexo con hombres (HSH),
usuarios de drogas inyectables (PWID), y los hombres
Electronic supplementary material The online version of this
article (doi:10.1007/s10461-011-0117-6) contains supplementary
material, which is available to authorized users.
H. Wand (&)
R. Guy
M. Law
D. P. Wilson
L. Maher
Faculty of Medicine, Kirby Institute, University of New South
Wales, 45 Beach Street, Coogee, Sydney, NSW 2034, Australia
e-mail: hwand@kirby.unsw.edu.au
heterosexuales y las mujeres que usan modificación de
retroproyección metodologı́a basada en las fuentes de datos
de base de datos de vigilancia del VIH/SIDA. La proporción
de diagnósticos de VIH entre los HSH que se pueden cla-
sificar como infecciones recientes en hombres aumentó
MSM, heterosexuales y las mujeres constantemente. Sin
embargo, después de los aumentos iniciales durante el
perı́odo 1996-2000, la proporción del total de las infecci-
ones recientes estimados entre PWID disminuido en un
50% en 2007 respecto a 2000 (del 23% al 11%). Estos datos
sugieren que a fines diagnósticos de VIH eran más comunes
entre PWID en comparación con otros grupos. Los esfuer-
zos en curso de prevención deben ir acompañadas de
pruebas selectivas y los esfuerzos de tratamiento para au-
mentar el diagnóstico de infección reciente en PWID y re-
ducir las desigualdades evidentes en el acceso al cribado.
Introduction
Australia is internationally recognized for its effective
response to the HIV epidemic since it first started in the early
1980s. As the epidemic has matured, men with a history of
homosexual contact continue to make up the majority of the
new diagnoses in Australia. According to the annual surveil-
lance report (2008) male homosexual contact accounted for
*76% of the total HIV diagnoses while heterosexual contact
(male/female) and injecting drug use make up *12 and *4%
of the total diagnoses, respectively [1]. Low level of HIV
infection among Australian drug injectors by global standards
has been directly linked to the success of effective imple-
mentation of need and syringe programs (NSPs). Since 1995,
NSPs are the primary source of injecting equipment for a
majority of people who inject drugs in Australia and have been
proven to be very effective in controlling the epidemic [2].
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236
Monitoring the HIV epidemic is essential to effective
prevention efforts. In most industrialized countries like
Australia, routine surveillance relies on HIV/AIDS case
reporting of new diagnoses to monitor the extent and trends
in the epidemic. Case reporting has value, in that it is
population-based and requires minimal resources to main-
tain, however it fails to provide information about trends in
incidence because many infections are not diagnosed until
years after they occur [3, 4]. Understanding the proportion
of cases which were acquired recently (within a year) is
key indicator to assess trends in incidence rates and their
associated risk factors which can inform and refine HIV
prevention programs [5–7].
New testing methods, such as the Serological Testing
Algorithm for Recent HIV Seroconversion (STARHS),
distinguish recent from long-standing HIV infections and
have the potential to add important information to HIV
surveillance systems [8]. The approach is applied to indi-
vidual specimens in which the presence of anti-HIV-1
antibody has already been confirmed, [9, 10]. Some assays
such as the detuned and BED ELISAs rely primarily on
antibody to differentiate recent from long-standing infec-
tion whereas others rely on the strength of the antibody/
antigen bounding or the presence/absence of antibodies to
particular antigens. There are a number of limitations to the
STARHS assays. For example, none are licensed for clin-
ical use and their applicability and accuracy are still under
investigation. It is recommended that the assays are only
used on a population basis. However, these assays are not
very widely used and to date only small pilot studies using
such assays have been conducted in Australia.
In this study, we estimated the proportion of HIV
diagnoses which could be classified as recent infections
using a modified back-projection technique by the three
risk groups in Australia, namely: men who have sex with
men (MSM), people who inject drugs (PWID) and male
and female heterosexuals [11]. The methodology utilized in
this study did not require a test for a biomarker and made
maximal use of information available from routine sur-
veillance databases.
Since age can be considered a strong determinant both
for the epidemic and testing behaviors [12], results were
presented by age groups (\40 vs. C40 years old). Higher
rates of long-standing infection in older age groups may
reflect barriers in access to health care, lower educational/
socio-economic status or discrimination associated with
HIV infection. Older age has also been shown to a sig-
nificant risk factor for disease progression since older
persons have diminished immune function and more
comorbidities [13, 14]. Finally, from a public health per-
spective, it is likely that late diagnoses will be associated
with an increased risk for HIV transmission.
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AIDS Behav (2013) 17:235–241
Methods
HIV Surveillance Data
In Australia, there are three main HIV/AIDS case reporting
data sources available: (1) HIV diagnoses (first HIV-posi-
tive diagnoses) (2) recent infections; and (3) AIDS diag-
noses. HIV diagnoses recorded in the Australian national
HIV/AIDS surveillance system are classified as recent HIV
infections where an individual has a previous negative or
indeterminate antibody test result or was diagnosed with a
seroconversion illness in the previous 12 months. Results
are presented overall and by the main risk groups: MSM,
PWID and heterosexuals.
Estimation of Recent Infections
Our methodology is based on the probabilistic link between
the distribution of ‘‘time from infection’’ and ‘‘distribution
of time-to-testing’’ through the ‘‘expected numbers of new
HIV diagnoses’’ and new HIV infections. This link incor-
porates the proportions of recent infections among newly
diagnosed individuals with a back calculation approach
that utilizes surveillance data for HIV diagnosis. HIV
diagnoses were adjusted for multiple reporting [15].
Modified back-projection methodology was explained in
the Appendix.
All analyses were presented overall and by age groups in
each risk group. R-Software 2.9.2 was used in all estima-
tion procedures.
Results
Table 1 presents the estimated proportions of recent
infections by transmission groups and stratified by age
groups (\40 versus C40 years old) during 1996–2007. The
proportion of recent infections among younger MSM
(\40 years old) was estimated to have increased from
*26% (95% CI 22–30) in 1996 to 39% (95% CI 34–44) in
2007; this increase was from *14% (95% CI 10–18) in
1996 to *24% (95% CI 19–28) among older MSM
(C40 years). The proportion of recent infections among
younger PWID (\40 years old) was estimated to have
increased from *9% (95% CI 2–21) in 1996 to *25%
(95% CI 12–42) in 2000; however, this initial increase
slowly declined to *18% (95% CI 4–36) in 2007; among
older PWID (C40 years), proportion of recent infections
were more than doubled initially (from 4% in 1996 to
*10% in 1999), however, there was no notable increase
during 2000–2007, in fact, it was slowly declined to a ten
year low *8% (95% CI 1–40) in 2007.
AIDS Behav (2013) 17:235–241 237

Table 1 Model predicted % recent infections: overall and by age groups \40 vs. 40? (1996–2007)
Year Model predicted % newly acquired infections (95% CI)
MSM  PWIDà
\40 years C40 years \40 years C40 years

1996 26.1% (22–30) 13.6% (10–18) 9.0% (2–21) 4.0% (1–55)

1997 27.0% (22–31) 16.1% (12–21) 12.7% (4–30) 6.0% (2–51)
1998 28.6% (24–33) 17.8% (13–23) 17.8% (4–32) 8.9% (3–41)
1999 32.2% (28–37) 19.7% (14–26) 22.6% (11–41) 10.2% (1–39)
2000 36.0% (31–40) 22.3% (17–28) 24.8% (12–42) 9.9% (1–38)
2001 38.8% (34–43) 25.3% (19–31) 23.5% (12–38) 9.7% (1–48)
2002 40.3% (34–44) 27.5% (22–34) 20.6% (8–44) 10.9% (1–50)
2003 40.4% (36–44) 27.9% (22–33) 20.0% (7–38) 13.7% (1–39)
2004 39.9% (35–43) 27.2% (22–33) 19.9% (7–34) 15.8% (3–43)
2005 39.6% (35–43) 26.4% (22–31) 17.9% (5–41) 14.5% (4–35)
2006 39.1% (34–43) 25.2% (21–30) 17.4% (7–43) 10.7% (1–42)
2007 39.0% (34–44) 23.6% (19–28) 18.3% (4–36) 8.0% (1–40)
 
Heterosexual–male* Heterosexual–female
\40 years C40 years \40 years C40 years

1996 7.7% (2–23) 11.2% (3–30) 7.8% (3–22) 12.2% (5–29)

1997 9.2% (2–21) 14.5% (5–32) 9.0% (4–30) 14.7% (6–38)
1998 12.0% (4–25) 16.6% (7–30) 11.3% (5–29) 16.4% (7–35)
1999 15.2% (5–32) 17.0% (8–35) 14.7% (7–35) 16.5% (7–35)
2000 18.3% (10–35) 16.7% (7–32) 18.3% (8–38) 16.2% (6–34)
2001 20.9% (10–38) 16.3% (6–30) 21.4% (10–42) 15.8% (5–32)
2002 21.7% (11–38) 16.8% (8–32) 22.4% (12–44) 16.5% (7–33)
2003 20.7% (9–35) 18.4% (10–35) 20.8% (7–39) 18.3% (8–39)
2004 20.3% (10–35) 19.1% (10–33) 19.6% (9–36) 19.2% (9–39)
2005 21.1% (10–37) 19.3% (10–33) 20.2% (10–40) 19.5% (10–40)
2006 23.2% (12–37) 19.7% (11–34) 22.9% (13–42) 20.0% (10–38)
2007 25.0% (15–38) 19.4% (11–32) 25.5% (15–44) 19.7% (10–37)
 
P = 0.488 (z-statistics = 0.693) for MSM \40 vs. MSM C40
à
P = 0.553 (z-statistics = 0.593) for PWID \40 vs. PWID C40
* P = 0.956 (z-statistics = 0.05) for heterosexual-male \40 vs. heterosexual-male C40
 
P = 0.969 (z-statistics = -0.038) for heterosexual-female \40 vs. heterosexual-female C40

In younger heterosexuals (\40 years old male and
female), initial increases in estimated recent infections
leveled off after 2000 and ranged from *18% (95% CI
10–35)–25% (95% CI 15–38); in older male heterosexuals
(C40 years old), the proportion of recent infections
increased from *11% (95% CI 3–30) in 1996 to 19%
(95% CI 11–32); similar increase was observed among
older females (C40 years old) from *12% (95% CI 5–29)
in 1996 to *20% (95% CI 10–37) in 2007.
Figure 1a–d presents the log odds ratios of long standing
HIV infections as a nonlinear smooth function of calendar
year for each exposure groups. We relied on the visual
presentation of the models to assess the temporal trends in
long standing HIV infections over the calendar years.
Consistent with the back-projection method, all the curves
showed a similar sharp decline from1991; however, this
decline was not sustained among PWID with an upward
curvature observed since 2002.
Discussion
HIV reporting plays a critical role in monitoring the epide-
miology and magnitude of the epidemic. However, because
HIV infection can remain asymptomatic for many years,
newly reported cases represent both recent and long-standing

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238
Fig. 1 Risk of long-standing infections by calendar year (1991–2007) (Unit for y-axis is logit[P(long-standing infection)])
infection. In this study we estimated proportion of recently
acquired HIV infection using a naval methodology based on
Australia’s national surveillance database.
Consistent with the observed numbers, the estimated
trend in the proportion of recent infections increased over
the years in all three exposure categories, particularly
among MSM. Overall, recent infections were more com-
mon among those younger than 40 years of age across the
exposure groups. Since 2000 we estimated that more than
*40% of the HIV diagnoses among younger (\40 years)
MSM were acquired in last 12 months, compared to
*28% among older (40? years) MSM. Australian testing
guidelines [16] recommend men who have sex with men to
be tested for sexually transmitted infections including HIV
at least once a year. Results from nationally representative
sample of HIV negative gay men reported older age
(40 years or older) being the significant predictor of not
being tested for HIV according to the recommended fre-
quency. Delayed HIV diagnosis has been related to the
older age in several other studies [17–19].
Rates of recently acquired HIV infection among heter-
osexual males and females has been flat since year 2000.
However, as far as can be ascertained using national sur-
veillance data, the majority of reported diagnoses are either
in people from a high HIV prevalence country, or in people
with a partner from a high risk HIV prevalence country [1].
Since 2000 the overall proportion (regardless of age) of
recent infections among PWID declined from *23% to
*11% indicating that late presentation with long-standing
HIV infection has become more common in recent years
among PWID, compared to the other groups. This is
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AIDS Behav (2013) 17:235–241
consistent with lower median CD4 counts at presentation
with HIV infection in PWID compared with MSM [1]. This
decline may be partially attributed to the heroin shortage in
2001. It is widely acknowledged that, since 2001 in Aus-
tralia, there has been a shortage in the heroin supply,
resulting in some reduction in PWID, and also an estimated
decline in hepatitis C virus (HCV) incidence [20]. After an
initial increase in the late 1990s, the rate of HIV trans-
mission through injecting drug use has been relatively flat
in Australia [1]. This plateau in HIV incidence during the
2000s may reflect these patterns of reduced PWID as well
as the reduction in the late presentations among PWID.
This could also be because, in many settings, PWID face
greater barriers to accessing health care, including testing
and treatment, than other risk groups [21–24]. Norms of
frequent HIV testing is apparent among Australian MSM
[25], may not be as well developed among PWID. Because
many PWID in Australia do not perceive themselves to be
at risk of HIV infection [26, 27]. Late diagnosis of HIV
infection in this group may potentially increase secondary
transmission through injection risk behaviours such as
sharing needles/syringe or other drug preparation equip-
ment, as well as unprotected sex. In addition, estimates
suggest that more than 70% of new cases of hepatitis C
virus (HCV) infection are associated with injecting drug
use [28, 29]. HCV is also known to be more common in
people with HIV than in the general population because of
shared risk factors for viral transmission. In Australia, it is
estimated that about 13% of people with HIV also have
hepatitis C [30]. It is possible that a person with HIV will
not know they have HCV unless they are specifically tested
AIDS Behav (2013) 17:235–241
for the hepatitis virus. Therefore, the compounding effect
of coinfection makes the care for these patients a major
challenge. Increased awareness of potential HIV and HCV
infections and transmissions should be encouraged not only
among PWID themselves but also among health care pro-
viders who primarily take care of this already marginalised
population. A recent study also reported shorter survival
after HIV diagnosis among PWID compared to other
groups [31]. Although HIV prevalence among PWID in
Australia remains low at 1% or less [11], it is important to
investigate reasons for the discrepancy between the groups
in recent infections as a proportion of all HIV infections
reported here. Innovative strategies needed with improved
access to testing and antiretroviral medication among HIV-
infected IDUs.
The estimated proportion of diagnoses categorized as
recent infections was consistently higher among those
younger than 40 years of age across all transmission
groups. The largest proportion of recent infections was
observed among younger MSM with *40% estimated
during the period of 2000–2007. The heterosexual trans-
mission group (male/female), overall, men and women
aged 40 years or older presented a slightly lower frequency
of recent infections compared to those younger than
40 years of age. Recent infections were least common
among older PWID ranging from *8 and *16% com-
pared to the other exposure groups during the same period.
Understanding trends in recent HIV infections is
increasingly important in order to inform efforts to more
effectively and completely monitor the epidemic, allocate
resources, and plan and implement programs to prevent the
spread of HIV. Australia’s HIV/AIDS surveillance system
is considered to be one of the best in the world since most
industrialized countries do not collect public health data on
all HIV diagnoses. For example, the United States and
most European countries rely on other sources such as
population sites and AIDS notifications [32]. Accurate
characterization of HIV diagnoses is important to ensure
appropriate targeting of interventions to those groups at
highest risk. It is important to understand the true burden of
the epidemic across all exposure groups and the corre-
sponding need for testing and treatment. It is crucial that
testing is sufficiently frequent and accessible to ensure that
people with HIV are diagnosed as rapidly as possible to
reduce the risk of transmission through unprotected sex or
sharing of injecting equipment. To improve the ability to
track new HIV infections, it is important to distinguish
between recent and long standing infections. In the absence
of universally accepted accurate tests for classifying
infections as recent versus long-standing, high quality
surveillance data will continue to provide important
insights into the epidemic.
239
Currently, there is no widely accepted methodology in
the world to estimating numbers of people with HIV.
Various estimation approaches exist, using different sour-
ces of data, and many countries do not appear to produce
any estimates [32–35]. All methods based on significant
assumptions which generally cannot be ascertained. The
back-projection method was originally developed by
Brookmeyer and Gail [36] based on purely AIDS data. It
has been extensively used to estimate the numbers of
individuals who were previously infected with HIV based
on the probability distribution of the incubation period, that
is, the time from HIV infection to AIDS. However, the
availability of effective therapies since mid 1990s changed
the distribution of the incubation period in ways that are
difficult to quantify. Since then several researchers pro-
posed modified versions of the back-projection method [11,
37–40]. Methodology used in this study has common ele-
ments with the previous studies [11, 39] but is the first to
estimate trends in the proportion of recent infections in the
HIV epidemic by using a statistical technique which
combines data sources from routine surveillance without
requiring data linkage or laboratory assessments.
The back-projection analyses do have limitations, pri-
marily in the assumptions required to generate the model.
Furthermore, although the relationship among newly
acquired HIV infection, HIV diagnosis and AIDS diagnosis
(until 1987) is to some extent exploited in generating the
progression rate distribution, it is not possible for external
information, for example rates of HIV testing, to be built
into the models using the current formulation. It is also a
well-known limitation of back-projection analyses that
estimates of recent HIV incidence, the period that is of
most interest, are highly uncertain [11]. Additionally,
reporting delays are well known problem of national sur-
veillance systems. Finally, relatively small sample sizes for
heterosexual (males/females) and PWID groups caused
wide confidence intervals around the estimates. Therefore,
results should be interpreted with great caution.
Conclusion
Late diagnosis of HIV infection in PWID remains a sig-
nificant health problem with important implications for
HIV-related morbidity and mortality [30]. Older age was
also determined to be associated with late diagnoses
regardless of the transmission groups. Targeted prevention
efforts need to be coupled with increased uptake of testing
and treatment particularly by PWID in order to reduce the
divergence between the transmission groups. This study
reveals a need to develop interventions that increase HIV
testing and facilitate earlier entry into care.
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240
Acknowledgments The Kirby Institute is funded by the Australian
Government Department of Health and Ageing, and is affiliated with
the Faculty of Medicine, The University of New South Wales. The
content of this publication is solely the responsibility of the authors
and does not necessarily represent the official views of any of the
institutions mentioned above.
Funding This research received no specific grant from any funding
agency.
Conflict of interest None.
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