ObjectivesAntiretroviral therapy reduces mortality and morbidity in HIV-infected individuals most markedly when initiated early, before advanced immunodeficiency has developed. Late presentation for diagnosis and care remains a significant challenge. To guide public health interventions effectively it is crucial to describe the factors associated with late presentation. MethodsCase surveillance data for all individuals newly diagnosed with HIV infection in Germany in the years 2001-2010 and data for the years 1999-2010 from the German Clinical Surveillance of HIV Disease (ClinSurv) cohort study, a large multicentre observational study, were analysed. Factors associated with late presentation (CD4 count < 350 cells/mL or clinical AIDS) were assessed using descriptive statistics and multivariable logistic regression methods. ResultsAmong 22 925 eligible patients in the national surveillance database, 49.5% were late presenters for HIV diagnosis. Among 6897 treatment-naïve patients in the ClinSurv cohort, 58.1% were late presenters for care. Late presenters for care were older (median 42 vs. 39 years for early presenters), more often heterosexuals from low-prevalence countries (18.1% vs. 15.5%, respectively) and more often migrants (18.2% vs. 9.7%, respectively; all P < 0.005). The probability of late presentation was >65% throughout the observation period in migrants. The probability of late presentation for care clearly decreased in men who have sex with men (MSM) from 60% in 1999 to 45% in 2010. ConclusionsIn Germany, the numbers of late presenters for HIV diagnosis and care remain high. The probability of late presentation for HIV diagnosis seems to be particularly high for migrants. These results argue in favour of targeted test promotion rather than opt-out screening. Late presentation for care seems to be an additional problem after HIV diagnosis.

After an initial peak in the mid-1980s, HIV incidence in men who have sex with men (MSM) declined in most western industrialised countries and then levelled off during the 1990s. Since the late 1990s, increasing numbers of newly diagnosed HIV infections in MSM have been observed in the majority of countries with large and visible MSM communities. Based on a review of national and international behavioural surveillance studies of MSM and national HIV surveillance data, we propose a model for the HIV epidemic in MSM in Germany. The model includes aspects such as individuals' increasing numbers of sexual partners and increasing frequency of unprotected anal intercourse, conditional condom use based on real or perceived HIV status of sexual partners (HIV 'serosorting') and sexual role assignments (insertive versus receptive based on HIV status (HIV 'seropositioning'), selection of partners and formation of sexual networks through seeking sexual partners on the internet, the introduction of HAART and changing HAART treatment strategies. All these aspects have been shown or are suspected to increase or decrease HIV transmission risk in MSM. We conclude that increasing HIV incidence in MSM in recent years has been fuelled by a spread of HIV in high-risk sexual networks with an increasing proportion of infections transmitted during highly infective early HIV infection, acquired mostly from casual sexual partners.

The course of the HIV epidemic in Germany can be modelled by back calculation until the beginning of the nineties. The recent course of the epidemic can only be derived from surveillance data of newly diagnosed HIV infections in conjunction with other data sources. Based on these surveillance data HIV incidence in Germany can be estimated to have been stable with 2000 to 2500 new infections per year since the early nineties, after having peaked in the early eighties. The most affected group are men who have sex with men followed by persons infected by heterosexual contact and migrants from high prevalence countries. The number of intravenous drug users has declined over the years and is now in fourth place. There are indications that increased risk behaviour and rising numbers of other sexually transmitted infections together with a change towards later initiation of antiretroviral therapy has led to an increase in new HIV infections in Germany in recent years. An improvement of the epidemiological surveillance for "indicator" STIs in combination with the assessment of risk behaviours in high risk groups would be desirable steps towards a second generation surveillance in Germany.

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