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Background Late HIV diagnosis remains frequent in Italy. We investigated patient-reported barriers to HIV testing and patterns of healthcare access in the 12 months before HIV diagnosis, focusing on differences by clinical severity.Methods LESSAIDS is a multicenter prospective observational study enrolling 140 adults with new HIV diagnosis (March 2025–February 2026). Participants completed a predefined questionnaire on barriers to testing; healthcare contacts in the previous 12 months were described. Comparisons were performed between groups defined by CDC Classification (CDC C vs other than CDC C). Categorical variables are reported as n (%) and continuous variables as median (IQR). χ 2/Fisher’s exact and Kruskal–Wallis test were used as appropriate.Results Compared with non–CDC C (n=91), CDC C participants (n=49) were older (49 [40–52] vs 40 [31–48] years; p=0·003) and were all symptomatic at diagnosis (49/49, 100% vs 34/91, 37·4%; p=0·001). Sexual activity distribution differed (heterosexual: 34/47, 72·3% vs 26/88, 29·6%; MSM: 11/47, 23·4% vs 56/88, 63·6%; p=0·001). Sexually transmitted infections in the last year were less frequently reported in CDC C (8/47, 17·0% vs 29/88, 33·0%; p=0·048). Reasons for testing differed markedly: symptoms were the main driver in CDC C (44/49, 89·8% vs 27/91, 29·7%) whereas screening predominated in non–CDC C (64/91, 70·3% vs 5/49, 10·2%; p=0·001). In the year before diagnosis, CDC C participants more often attended the emergency department (≥1 visit: 21/36, 58·3% vs 13/59, 22·0%; >1 visit: 8/36, 22·2% vs 2/59, 3·4%; p=0·001) and tended to report >1 medical visit overall (27/45, 60·0% vs 31/80, 38·8%; p=0·058). After HIV diagnosis, time to infectious diseases visit was shorter in CDC C (2 [0–5] vs 5 [2–8] days; p=0·001), but time from infectious diseases consultation to ART initiation was longer (9 [4–15] vs 3 [0–8] days; p=0·001). Test refusal after a recommendation was more frequent in CDC C (any refusal: 15/46, 32·6% vs 10/87, 11·5%; p=0·005). ‘Did not know where to go’ emerged as a more relevant barrier in CDC C (very important: 5/41, 12·2% vs 1/77, 1·3%; p=0·02).Conclusion Advanced HIV disease was associated with more acute-care use, more frequent prior test refusal, and actionable navigation barriers. Systematic HIV testing should be offered in emergency settings in order to improve access pathways and reduce late diagnosis.Table 1Abstract P72 Table 1