{
  "abstract": "Background Rate of new HIV diagnoses in recent years has remained stable across Europe and proportion of late presentation at diagnosis continues to be high, as highlighted by latest ECDC report. Despite longstanding recommendations to expand routine and community-based testing, cross-country evidence linking national testing frameworks to late diagnosis remains limited. We aimed to assess whether structural and legal characteristics of HIV testing systems are associated with late presentation rates.Methods We conducted an ecological cross-sectional study including countries from WHO European Region. Two composite indices were developed a priori: an HIV Test Legal Stringency Index, capturing HIV-specific regulatory requirements (explicit legal mention, HIV-specific consent procedures, written consent, mandatory pre-test counselling), and an HIV Testing Accessibility Index, reflecting structural facilitation (routine offer, indicator-condition guidelines, community testing, self-testing availability, integrated models). Higher scores indicated greater procedural regulation and structural normalization, respectively. Index components were identified through structured review of national legislation and official public health documents in the local language for each country. AI-assisted search tools supported systematic document retrieval, with manual verification of extracted information. Components were coded as binary and summed without weighting. Variables were assessed as of 2024 to ensure temporal alignment. Primary outcome was the country-level proportion of new HIV diagnoses with CD4 <350 cells/mm3, extracted from the ECDC HIV/AIDS Surveillance in Europe 2025 (2024 data). Countries without complete late presentation data were excluded, yielding 42 countries for analysis.Results In multivariable models adjusted for geographic macro-area and national HIV incidence rates, higher HIV Testing Accessibility Index scores were independently associated with lower late presentation rates (p = 0.01). Each one-point increase in the accessibility score was associated with approximately a 6% lower late presentation rate. In contrast, the legal stringency index was not significantly associated with late diagnosis ( figure 1). Results remained consistent in sensitivity analyses adjusting for testing rates, restricted to the 24 countries with available data.Conclusions Our findings suggest that the degree of legal stringency alone may not represent the primary structural barrier to timely HIV diagnosis. Rather, greater accessibility to HIV testing appears to be associated with lower rates of late presentation. These results reinforce need for structured implementation policies aimed at normalizing HIV testing within routine healthcare settings and expanding low-threshold access models. Coordinated advocacy efforts involving clinicians, public health authorities, and policy-makers are essential to translate these findings into scalable testing strategies.Abstract OC7 Figure 1Association between testing accessibility, legal stringency, and late HIV diagnosis (CD4 <350 cells/mm3) across countries in the WHO European Region (2024). Each point represents one country. Lines indicate linear regression estimates adjusted for geographic macro-area and national HIV incidence rates",
  "authors": [
    {
      "affiliations": [
        "Department of Public Health and Infectious Diseases, Sapienza University of Rome, Rome, Italy"
      ],
      "name": "L Bortolani"
    },
    {
      "affiliations": [
        "Department of Public Health and Infectious Diseases, Sapienza University of Rome, Rome, Italy"
      ],
      "name": "A Lazzaro"
    },
    {
      "affiliations": [
        "Department of Public Health and Infectious Diseases, Sapienza University of Rome, Rome, Italy"
      ],
      "name": "F Alessi"
    },
    {
      "affiliations": [
        "Department of Public Health and Infectious Diseases, Sapienza University of Rome, Rome, Italy"
      ],
      "name": "M Ridolfi"
    },
    {
      "affiliations": [
        "Department of Public Health and Infectious Diseases, Sapienza University of Rome, Rome, Italy"
      ],
      "name": "E Altavilla"
    },
    {
      "affiliations": [
        "Department of Public Health and Infectious Diseases, Sapienza University of Rome, Rome, Italy"
      ],
      "name": "V Bleve"
    },
    {
      "affiliations": [
        "Department of Public Health and Infectious Diseases, Sapienza University of Rome, Rome, Italy"
      ],
      "name": "G Ceccarelli"
    },
    {
      "affiliations": [
        "Department of Public Health and Infectious Diseases, Sapienza University of Rome, Rome, Italy"
      ],
      "name": "CM Mastroianni"
    },
    {
      "affiliations": [
        "Department of Public Health and Infectious Diseases, Sapienza University of Rome, Rome, Italy"
      ],
      "name": "G d’Ettorre"
    }
  ],
  "title": "OC7 From regulation to implementation: a cross-country ecological analysis of HIV testing frameworks and late diagnosis in Europe",
  "uid": "73c7f171-0bb2-5337-a94c-f4a4de492d4c"
}