Introduction

Late presentation (LP) of HIV infection represents an important barrier in achieving the UNAIDS goals to end AIDS epidemic by 2030. Despite multiple efforts to establish strategies to improve the early diagnosis of HIV infection, the prevalence of LP remains high (between 40–60% in developed countries [1–3] and higher in developing countries [4]) and has not decreased during the last years. In Spain, results from the most recent study within the Cohort of the Spanish HIV/AIDS Research Network (CoRIS) showed an overall LP prevalence of 46.9% from 2004 to 2013 [5]. According to the last treatment cascade estimates [6], 13% of people living with HIV in Spain are unaware of it. Of those diagnosed, 97.3% were on ART, of whom 90.4% had an undetectable viral load. In 2014 the Spanish Ministry of Health published national guidelines for promoting early HIV diagnosis [7]. They recommended offering HIV testing when there is an in case of indication or clinical suspicion of HIV infection or AIDS but also recommended routine offer of HIV screening. So far, there is no information on whether the implementation of these guidelines have had an impact on LP prevalence.

The implications of LP are widespread: increased risk of morbidity and mortality [8, 9], suboptimal virologic and immunologic effectiveness of antiretroviral therapy [10], increased risk of transmission due to lack of awareness of HIV serostatus [11, 12] as well as higher negative impact on healthcare costs [13]. However, while it is clear that LP carries a risk for the development of AIDS-related diseases and death, [5] its relationship with the development of non-AIDS diseases is less clear, based only on studies that relate poor immunologic status to its development. To the best of our knowledge, there are very few studies that directly evaluate LP as a risk factor for the development of non-AIDS events.

Therefore, the aims of this study are (i) to estimate the prevalence and associated risk factors of LP and late presentation with advanced disease (LPAD) and their changes over time in the period 2004–2018, and (ii) to estimate the impact of LP and LPAD on the development of clinical outcomes including AIDS-defining events (ADE), serious non-AIDS events (SNAE) and mortality in participants from the CoRIS cohort.

Materials and methods

Results

Of the 15,509 antiretroviral naïve individuals enrolled in CoRIS until the 30th November 2018, 14,876 individuals were included (S1 Fig) of whom 12,652 (85.0%) were men, 9,182 (61.7%) were MSM, 3,742 (25.2%) had a university degree and 10,800 (72.6%) were from Europe, mostly from Spain (8,725, 58.7%). At enrolment, median age was 35.2 years (1st-3rd quartile: 28.9, 42.9), median CD4 count was 397 cells/μL (215, 592), 1,961 (13.2%) individuals had an AIDS diagnosis and 5,102 (34.3%) had a viral load ≥100,000 copies/mL (Table 1).

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Table 1. Sociodemographic and clinical characteristics of the participants included, and prevalence of late presentation and late presentation with advanced disease according to their characteristics at enrolment, Spain, 2004–2018 (n = 14,876).

https://doi.org/10.1371/journal.pone.0249864.t001

Late presentation and late presentation with advanced disease: Magnitude, trends and risk factors

Total number of late presenters was 6,636 (prevalence 44.6%; 95%CI 43.8, 45.4) and of late presenters with advanced disease was 3,931 (26.4%; 95%CI 25.7, 27.1). Annual prevalence of LP and LPAD is shown in Fig 1. In 2004–2008 the prevalence of LP was 51.8% (95%CI 50.4, 53.3); it decreased to 40.9% (95%CI 39.4, 42.4) in 2009–2012 and remained stable at 42.0% (95%CI 40.8, 43.2) during 2013–2018 (p-value for trend <0.001). Likewise, the prevalence of LPAD decreased from 33.9% (95%CI 32.5, 35.3) in 2004–2008 to 22.7% (95%CI 21.5, 24.0) in 2009–2012 and remained stable with a modest increase up to 23.6% (95%CI 22.6, 24.7) during 2013–2018 (p-value for trend<0.001).

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Fig 1. Annual prevalence of LP and LPAD, 2004–2018.

https://doi.org/10.1371/journal.pone.0249864.g001

Among individuals older than 50 years, prevalence of LP was 63.8% and of LPAD was 46.5% (Table 1). Around 60% of IDU and of heterosexual men had LP and more than 40% had LPAD. Among persons originating from SSA, prevalence of LP was almost 60% and prevalence of LPAD was around 35%. Around 60% and of persons with primary or less educational level had LP and around 39% had LPAD.

Independent risk factors for LP compared to non-LP (Table 2) included older age (adjusted PR 1.36; 95%CI 1.30, 1.43 for 30–49 years and 1.77; 95%CI 1.65, 1.89 for ≥50 years vs <30 years) and transmission category, with IDU (aPR 1.49; 95%CI 1.33, 1.68), heterosexual men (aPR 1.41; 95%CI 1.27, 1.57) and heterosexual women (aPR 1.27; 95%CI 1.15, 1.41) having higher risks of LP compared to MSM. Other risk factors for LP were low educational level (aPR 1.31; 95%CI 1.20, 1.43 for primary education and 1.09; 95%CI 1.04, 1.14 for secondary education vs university) and region of origin with individuals originating from SSA (aPR 1.17; 95%CI 1.10, 1.25) and LA (aPR 1.23; 95%CI 1.16, 1.30) showing a higher risk of LP than Europeans. Similar risk factors were observed when we compared participants with LPAD with those without (Table 2).

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Table 2. Independent risk factors associated with late presentation and late presentation with advanced disease, Spain, 2004–2018 (N = 14,876).

https://doi.org/10.1371/journal.pone.0249864.t002

Overall risk factors for LP and LPAD were confirmed during the three time periods considered (S1 Table). Nevertheless, adjusted LP prevalence were not homogeneous across transmission categories, as shown in Fig 2. Specifically, the adjusted prevalence of LP decreased from 28.4% in 2004–2008 to 22.6% in 2009–2012 in MSM and from 37.6% in 2004–2008 to 32.3% in 2009–2012 in heterosexual men, while adjusted LP prevalence in heterosexual women remained stable around 30%-33% during the whole 15-years period. Furthermore, while adjusted LP prevalence in MSM and heterosexual men, after an initial decrease from 2004–2008 to 2009–2012, remained stable during 2013–2018, adjusted LP prevalence in IDU continued to decrease from 39.4% in 2004–2008 to 34.3% in 2009–2012 to 30.1% in 2013–2018.

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Fig 2. Adjusted prevalence of late presentation by transmission category and time-period.

https://doi.org/10.1371/journal.pone.0249864.g002

Impact of late presentation and late presentation with advanced disease on morbidity and mortality

Of 14,876 participants, 13,031 (87.6%) had available follow-up data: 5,790 (87.3%) had LP and 3,412 (86.8%) had LPAD, with a total of 69,142 person-years (PY) of follow-up. Table 3 shows the number of participants experiencing each outcome, incidence rates (IR) per 100 PY of follow-up and incidence rate ratios for LP and LPAD.

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Table 3. Impact of late presentation and late presentation with advanced disease on the composite endpoint, first ADE, first SNAE and overall mortality, Spain, 2004–2018, (N = 13,031 and 69,142 persons-year of follow-up).

https://doi.org/10.1371/journal.pone.0249864.t003

Overall, 435 non-late presenters and 726 late presenters experienced any of the events defined by the composite endpoint, with an IR of 1.21 (95%CI 1.10, 1.33) x100 PY in non-late presenters and of 2.34 (95%CI 2.17, 2.52) in late presenters, with an adjusted incidence rate ratio (aIRR) of 1.34 (95%CI 1.20, 1.50). IR for first ADE was almost double in participants with LP (IR: 0.99; 95%CI 0.88, 1.12) than in participants who were diagnosed early (IR: 0.51; 95%CI 0.44, 0.59), with an aIRR of 1.39 (95%CI 1.18, 1.64). 406 participants with LP experienced an SNAE with a rate of 1.32 (95%CI 1.19, 1.45) as did 262 participants non-late presenters with an IR of 0.73 (95%CI 0.65, 0.83), giving an aIRR of 1.22 (95%CI 1.01, 1.47). LP was associated with an increased risk of liver events (aIRR 1.74; 95%CI 1.12, 2.71), and neoplasms (aIRR 1.32; 95%CI 1.08, 1.63). Higher mortality rates were observed in late presenters (IR: 1.00; 95%CI 0.89, 1.11) than in non-late presenters (IR: 0.36; 95%CI 0.30, 0.42), with an aIRR of 1.71 (95%CI 1.41, 2.08).

561 participants with LPAD and 600 with non-LPAD experienced at least one event defined by the composite endpoint, with an IR of 3.00 (95%CI 2.76, 3.26) in participants with LPAD, an IR of 1.24 (95%CI 1.14, 1.34) in those with non-LPAD, and an aIRR of 1.66 (95%CI 1.46, 1.89). LPAD was associated with increased risk of developing an ADE (aIRR: 1.89; 95%CI 1.61, 2.23) and an SNAE (aIRR: 1.45; 95%CI 1.18, 1.78) and with increased risk of liver events (aIRR: 2.13; 95%CI 1.30, 3.50) and neoplasms (aIRR: 1.70; 95%CI 1.32, 2.19). Finally, participants with LPAD had higher mortality rates (IR: 1.30; 95%CI 1.15, 1.47) than non-late presenters with advanced disease (IR: 0.40; 95%CI 0.34, 0.46) with a two-fold increase in the risk of death (aIRR: 2.04; 95%CI 1.64, 2.54).

Discussion

This cohort study demonstrates that LP remains a major health issue in Spain. We observed a LP prevalence of 44.8% for the whole study period (2004–2018), and although a reduction was observed in 2009–2012, current data show a trend towards stabilization since then. We also observed a negative impact of both LP and LPAD on the occurrence of clinical outcomes, including ADE, SNAE and death.

We observed a similar LP prevalence in a previous CoRIS study [5], consistent with data from studies in the COHERE’s Europe region [18, 19] as well as in other European studies. (France 48% [1], Italy 54% [2], Belgium 44% [3], Germany 58.% [20], Switzerland 45% [21]). Similarly, the LPAD prevalence of 26% was close to the one observed in Belgium (24%, [3]), but slightly lower than the one described in the European region (33% [18, 19]) and in other nearby countries (France 29% [1], Italy 37% [2], Germany 36% [20]). Despite the decreasing trend from 2004–2008 to 2009–2012 and the publication in 2014 of the national guidelines on early HIV diagnosis [7], our estimates show a trend towards stabilization since then. The reasons why the prevalence of LP has stopped decreasing may be linked to the persistent low HIV testing frequency in Spain, which is around 20% [22]. This low rate may be due on one hand to the lack of awareness about HIV infection, the stigma as well as the lack of knowledge about health care services, and on the other hand to the lack of testing offer by the healthcare providers [22]. Promoting HIV testing should increase early HIV diagnosis in Spain.

The still high LP prevalence observed in our study may result from the influence of those factors classically associated with LP itself. As detected in other studies performed in geographically closely related regions [1, 2, 19, 20, 23, 24]. HIV acquisition mechanisms other than homosexual contact, as well as older age, low educational level and migrant status are consistently risk factors for LP and LPAD throughout the period. With respect to the HIV exposure group, a low self-perceived HIV-risk may be the reason why LP prevalence is higher among heterosexuals and those whose acquisition mechanism is unknown [25]. Furthermore, although IDU remains an important risk factor for LP, we observed that IDUs had the greatest decrease in LP prevalence, as observed in other studies [2, 5], which might be the consequence of an active engagement and linkage to care in centers designed for harm reduction programs in Spain. Consistent with data from CoRIS [5] and COHERE [26], we observed an increased risk of LP in participants with lower educational level. A higher educational level is associated with a more frequent access and use of health services; it may also be associated with increased health literacy and cognitive skills that improve health-related choices [26]. Furthermore, Fakoya I et al. [27] found that migrants had good access to primary care once they arrived in Europe and before their first positive HIV test, but language difficulties, lack of social support and cultural background (i.e.: the use of traditional medicine in the home country) were barriers to more frequent HIV testing and prevention after their arrival. [27, 28]. Díaz A et al. [29] demonstrated that risk of LP was stronger among migrants with low compared to high educational level in a Spanish sexually transmitted infections center.

Thus, we have found that the prevalence of late diagnosis remains high, especially in the most vulnerable group of patients, and that it has not decreased despite the publication of national guidelines on early HIV diagnosis [7]. This may be due in part to the difficulty of implementing recommendations as well as to the lack of resources [30]. For example, the quasi-experimental study ESTVIH [31] evaluated the feasibility of the application of different HIV diagnosis strategies in six Spanish primary care centers. Although healthcare workers expressed a high degree of interest in participating, only 26% of them recruited patients mainly because of the lack of time. Nevertheless, those trained to give pre and post-test counselling ordered the most tests [31]. A targeted strategy to identify persons with increased HIV risk has been proposed through the Drive 01 study [32]. The authors validated a structured questionnaire to assess HIV risk of exposure and indicator conditions specific to Spain, that predicted at 100% those individuals without infection and, if applied, it would make the test offer more efficient.

In terms of the clinical impact of LP, we found higher incidence rates for the composite endpoint and for ADE, SNAE and deaths both in patients presenting late compared to those with non-LP and in patients presenting with advanced disease, compared to those with non-LPAD. To the best of our knowledge, there is no other large cohort study which separately addresses ADE, SNAE and deaths.

Consistent with our results, researchers from the Dutch Athena cohort [33] and the MASTER cohort [34] observed an increased risk for the composite endpoint in participants with poor immune recovery.

As expected, the risk for ADE was higher in both the LP and the LPAD subgroups than in the non-LP and non-LPAD ones. Similarly, an Italian cohort [2] detected a reduction in LP mortality since the introduction of ART, which reflects the better management of frequent ADEs in these subgroups when the viral load is suppressed on ART.

Both LP and LPAD were associated with an increased risk for SNAE, compared with their counterparts. In the same cohort, Masía et al. [35] observed that the presence of ADE and the baseline CD4 count were risk factors for the development of SNAE and consequent overall mortality. Similarly, results from the D:A:D cohort showed that both last and nadir CD4 count were independent predictors of mortality due to ADE and SNAE [36]. Mocroft et al. [37] observed that a low CD4 count (<350 cells/μL) was associated with an increased risk of ADE or SNAE in patients from the EuroSIDA cohort. Possible mechanisms for the development of SNAE in LP [34] and LPAD [38] may be poor immune dysfunction, greater immune activation or persistent inflammation and oxidative stress. However, when interpreting these findings, it must be taken into account that there is great variability in SNAE definitions across studies, so results may not be directly comparable.

In terms of specific SNAE, consistent with our findings, Reekie et al. [39] found an increased incidence of some non-AIDS related cancers in patients with lower current CD4 count within the EuroSIDA Cohort. Impaired immunity could be certainly playing a role, as CD4 count depletion is associated with malignancy [40]. Moreover, CoRIS late presenter patients are older, and ageing-related immunosenescence is also linked with malignancies.

It may be argued that the association between LP and SNAE is confounded by age, which is a known risk factor for both conditions. For this reason, all our multivariable models are adjusted for age. Besides, Mocroft et al. [41] showed that the impact of high HIV progression risk (CD4 count ≤350 cells/μL, viral load ≥10,000 copies/mL) vs low (CD4 count ≥500 cells/μL, viral load <50 copies/mL) was greater in patients aged less than 30 years than in older patients. These findings highlight the important role of HIV infection in SNAE development even in groups with low risk of comorbidities development, such as young patients. Finally, we also observed an association between LP and LPAD and death from all causes. This finding is consistent with what was previously observed in the CoRIS cohort [5] especially for LPAD, with findings from Ingle et al [9].

The main strength of our study lies in being based on CoRIS, a large national cohort representative of the epidemiological situation of HIV-infected individuals in Spain. Furthermore, to the best of our knowledge, there is no other large cohort study which separately addresses ADE, SNAE and deaths, and the composite endpoint studied in relation to the LP and LPDA.

Our study has some limitations. First, we could not include all new HIV diagnoses in our analysis because 4% of cases lack information on CD4 count or ADE. Furthermore, LP prevalence may be overestimated because of a misclassification due to low CD4 count during acute HIV infection [42]. In addition, due to the low number of individuals experiencing some specific SNAE such as kidney events, these results should be interpreted with caution.

In conclusion, LP remains a major problem in Spain, with higher prevalence among certain populations, and is associated with greater morbidity and mortality. Public policies should be implemented to expand screening and early diagnosis of HIV infection for a focus on those at greatest risk of late presentation. As an example, targeted diagnostic programs could be run in emergency department, primary care and other medical centers; HIV testing could be considered as a priority in primary care protocols and information campaigns aimed at medical professionals could be carried out to publicize and improve the application of clinical guidelines.

Supporting information

Acknowledgments

This study would not have been possible without the collaboration of all patients, medical and nursery staff and data mangers who have taken part in the Project.

Executive committee

Santiago Moreno, Inma Jarrín, David Dalmau, Maria Luisa Navarro, Maria Isabel González, Federico Garcia, Eva Poveda, Jose Antonio Iribarren, Félix Gutiérrez, Rafael Rubio, Francesc Vidal, Juan Berenguer, Juan González, M Ángeles Muñoz-Fernández.

Fieldwork data management and analysis

Inmaculada Jarrin, Belén Alejos, Cristina Moreno, Carlos Iniesta, Luis Miguel Garcia Sousa, Nieves Sanz Perez, Marta Rava.

BioBanK HIV Hospital General Universitario Gregorio Marañón

M Ángeles Muñoz-Fernández, Irene Consuegra Fernández.

Hospital General Universitario de Alicante (Alicante)

Esperanza Merino, Gema García, Irene Portilla, Iván Agea, Joaquín Portilla, José Sánchez-Payá., Juan Carlos Rodríguez, Lina Gimeno, Livia Giner, Marcos Díez, Melissa Carreres, Sergio Reus, Vicente Boix, Diego Torrús.

Hospital Universitario de Canarias (San Cristóbal de la Laguna)

Ana López Lirola, Dácil García, Felicitas Díaz-Flores, Juan Luis Gómez, María del Mar Alonso, Ricardo Pelazas., Jehovana Hernández, María Remedios Alemán, María Inmaculada Hernández.

Hospital Universitario Central de Asturias (Oviedo)

Víctor Asensi, Eulalia Valle, María Eugenia Rivas Carmenado, Tomás Suárez-Zarracina Secades, Laura Pérez Is.

Hospital Universitario 12 de Octubre (Madrid)

Rafael Rubio, Federico Pulido, Otilia Bisbal, Asunción Hernando, Lourdes Domínguez, David Rial Crestelo, Laura Bermejo, Mireia Santacreu.

Hospital Universitario de Donostia (Donostia-San Sebastián)

José Antonio Iribarren, Julio Arrizabalaga, María José Aramburu, Xabier Camino, Francisco Rodríguez-Arrondo, Miguel Ángel von Wichmann, Lidia Pascual Tomé, Miguel Ángel Goenaga, Mª Jesús Bustinduy, Harkaitz Azkune, Maialen Ibarguren, Aitziber Lizardi, Xabier Kortajarena, Mª Pilar Carmona Oyaga, Maitane Umerez Igartua.

Hospital General Universitario De Elche (Elche)

Félix Gutiérrez, Mar Masiá, Sergio Padilla, Catalina Robledano, Joan Gregori Colomé, Araceli Adsuar, Rafael Pascual, Marta Fernández, José Alberto García, Xavier Barber, Vanessa Agullo Re, Javier Garcia Abellán, Reyes Pascual Pérez, María Roca.

Hospital Universitari Germans Trias i Pujol (Can Ruti) (Badalona)

Roberto Muga, Arantza Sanvisens, Daniel Fuster.

Hospital General Universitario Gregorio Marañón (Madrid)

Juan Berenguer, Juan Carlos López Bernaldo de Quirós, Isabel Gutiérrez, Margarita Ramírez, Belén Padilla, Paloma Gijón, Teresa Aldamiz-Echevarría, Francisco Tejerina, Francisco José Parras, Pascual Balsalobre, Cristina Diez, Leire Pérez Latorre, Chiara Fanciulli.

Hospital Universitari de Tarragona Joan XXIII (Tarragona)

Francesc Vidal, Joaquín Peraire, Consuelo Viladés, Sergio Veloso, Montserrat Vargas, Montserrat Olona, Anna Rull, Esther Rodríguez-Gallego, Verónica Alba, Alfonso Javier Castellanos, Miguel López-Dupla.

Hospital Universitario y Politécnico de La Fe (Valencia)

Marta Montero Alonso, José López Aldeguer, Marino Blanes Juliá, María Tasias Pitarch, Iván Castro Hernández, Eva Calabuig Muñoz, Sandra Cuéllar Tovar, Miguel Salavert Lletí, Juan Fernández Navarro.

Hospital Universitario La Paz/IdiPAZ

Juan González-Garcia, Francisco Arnalich, José Ramón Arribas, Jose Ignacio Bernardino de la Serna, Juan Miguel Castro, Ana Delgado Hierro, Luis Escosa, Pedro Herranz, Víctor Hontañón, Silvia García-Bujalance, Milagros García López-Hortelano, Alicia González-Baeza, Maria Luz Martín-Carbonero, Mario Mayoral, Maria Jose Mellado, Rafael Esteban Micán, Rocio Montejano, María Luisa Montes, Victoria Moreno, Ignacio Pérez-Valero, Guadalupe Rúa Cebrián, Berta Rodés, Talia Sainz, Elena Sendagorta, Natalia Stella Alcáriz, Eulalia Valencia.

Hospital San Pedro Centro de Investigación Biomédica de La Rioja (CIBIR) (Logroño)

José Ramón Blanco, José Antonio Oteo, Valvanera Ibarra, Luis Metola, Mercedes Sanz, Laura Pérez-Martínez.

Hospital Universitario Miguel Servet (Zaragoza)

Piedad Arazo, Gloria Sampériz.

Hospital Universitari MutuaTerrassa (Terrasa)

David Dalmau, Angels Jaén, Montse Sanmartí, Mireia Cairó, Javier Martinez-Lacasa, Pablo Velli, Roser Font, Marina Martinez, Francesco Aiello

Complejo Hospitalario de Navarra (Pamplona)

Maria Rivero Marcotegui, Jesús Repáraz, María Gracia Ruiz de Alda, María Teresa de León Cano, Beatriz Pierola Ruiz de Galarreta.

Corporació Sanitària Parc Taulí (Sabadell)

María José Amengual, Gemma Navarro, Manel Cervantes Garcia, Sonia Calzado Isbert, Marta Navarro Vilasaro.

Hospital Universitario de La Princesa (Madrid)

Ignacio de los Santos, Jesús Sanz Sanz, Ana Salas Aparicio, Cristina Sarria Cepeda, Lucio Garcia-Fraile Fraile, Enrique Martín Gayo.

Hospital Universitario Ramón y Cajal (Madrid)

Santiago Moreno, José Luis Casado Osorio, Fernando Dronda Nuñez, Ana Moreno Zamora, Maria Jesús Pérez Elías, Carolina Gutiérrez, Nadia Madrid, Santos del Campo Terrón, Sergio Serrano Villar, Maria Jesús Vivancos Gallego, Javier Martínez Sanz, Usua Anxa Urroz, Tamara Velasco.

Hospital General Universitario Reina Sofía (Murcia)

Enrique Bernal, Alfredo Cano Sanchez, Antonia Alcaraz García, Joaquín Bravo Urbieta, Ángeles Muñoz Perez, Maria Jose Alcaraz, Maria del Carmen Villalba.

Hospital Nuevo San Cecilio (Granada)

Federico García, José Hernández Quero, Leopoldo Muñoz Medina, Marta Alvarez, Natalia Chueca, David Vinuesa García, Clara Martinez-Montes, Carlos Guerrero Beltrán, Adolfo de Salazar Gonzalez, Ana Fuentes Lopez.

Centro Sanitario Sandoval (Madrid)

Jorge Del Romero, Montserrat Raposo Utrilla, Carmen Rodríguez, Teresa Puerta, Juan Carlos Carrió, Mar Vera, Juan Ballesteros, Oskar Ayerdi.

Hospital Clínico Universitario de Santiago (Santiago de Compostela)

Antonio Antela, Elena Losada.

Hospital Universitario Son Espases (Palma de Mallorca)

Melchor Riera, María Peñaranda, Mª Angels Ribas, Antoni A Campins, Carmen Vidal, Francisco Fanjul, Javier Murillas, Francisco Homar, Helem H Vilchez, Maria Luisa Martin, Antoni Payeras.

Hospital Universitario Virgen de la Victoria (Málaga)

Jesús Santos, Cristina Gómez Ayerbe, Isabel Viciana, Rosario Palacios, Carmen Pérez López, Carmen Maria Gonzalez-Domenec.

Hospital Universitario Virgen del Rocío (Sevilla)

Pompeyo Viciana, Nuria Espinosa, Luis Fernando López-Cortés.

Hospital Universitario de Bellvitge (Hospitalet de Llobregat)

Daniel Podzamczer, Arkaitz Imaz, Juan Tiraboschi, Ana Silva, María Saumoy, Paula Prieto.

Hospital Universitario Valle de Hebrón (Barcelona)

Esteban Ribera, Adrian Curran.

Hospital Costa del Sol (Marbella)

Julián Olalla Sierra, Javier Pérez Stachowski., Alfonso del Arco, Javier de la torre, José Luis Prada, José María García de Lomas Guerrero.

Hospital General Universitario Santa Lucía (Cartagena)

Onofre Juan Martínez, Francisco Jesús Vera, Lorena Martínez, Josefina García, Begoña Alcaraz, Amaya Jimeno.

Complejo Hospitalario Universitario a Coruña (Chuac) (A Coruña)

Ángeles Castro Iglesias, Berta Pernas Souto, Álvaro Mena de Cea.

Hospital Universitario Basurto (Bilbao)

Josefa Muñoz, Miren Zuriñe Zubero, Josu Mirena Baraia-Etxaburu, Sofía Ibarra Ugarte, Oscar Luis Ferrero Beneitez, Josefina López de Munain, Mª Mar Cámara López, Mireia de la Peña, Miriam Lopez, Iñigo Lopez Azkarreta.

Hospital Universitario Virgen de la Arrixaca (El Palmar)

Carlos Galera, Helena Albendin, Aurora Pérez, Asunción Iborra, Antonio Moreno, Maria Angustias Merlos, Asunción Vidal, Marisa Meca.

Hospital de la Marina Baixa (La Vila Joiosa)

Concha Amador, Francisco Pasquau, Javier Ena, Concha Benito, Vicenta Fenoll, Concepción Gil Anguita, José Tomás Algado Rabasa.

Hospital Universitario Infanta Sofía (San Sebastián de los Reyes)

Inés Suárez-García, Eduardo Malmierca, Patricia González-Ruano, Dolores Martín Rodrigo, Mª Pilar Ruiz Seco.

Hospital Universitario de Jaén (Jaén)

Mohamed Omar Mohamed-Balghata, María Amparo Gómez Vidal.

Hospital San Agustín (Avilés)

Miguel Alberto de Zarraga.

Hospital Clínico San Carlos (Madrid)

Vicente Estrada Pérez, Maria Jesús Téllez Molina, Jorge Vergas García, Juncal Pérez-Somarriba Moreno.

Hospital Universitario Fundación Jiménez Díaz (Madrid)

Miguel Górgolas, Alfonso Cabello, Beatriz Álvarez, Laura Prieto.

Hospital Universitario Príncipe de Asturias (Alcalá de Henares)

José Sanz Moreno, Alberto Arranz Caso, Cristina Hernández Gutiérrez, María Novella Mena.

Hospital Clínico Universitario de Valencia (València)

María José Galindo Puerto, Ramón Fernando Vilalta, Ana Ferrer Ribera.

Hospital Reina Sofía (Córdoba)

Antonio Rivero Román, Antonio Rivero Juárez, Pedro López López, Isabel Machuca Sánchez, Mario Frias Casas, Angela Camacho Espejo.

Hospital Universitario Severo Ochoa (Leganés)

Miguel Cervero Jiménez, Rafael Torres Perea.

Nuestra Señora de Valme (Sevilla)

Juan A Pineda, Pilar Rincón Mayo, Juan Macías Sanchez, Nicolás Merchante Gutierrez, Luis Miguel Real, Anais Corma Gomez, Marta Fernández Fuertes, Alejandro Gonzalez-Serna.

Hospital Álvaro Cunqueiro (Vigo)

Eva Poveda, Alexandre Pérez, Manuel Crespo, Luis Morano, Celia Miralles, Antonio Ocampo, Guillermo Pousada