Missed opportunities for HIV testing persist despite a single educational intervention: how can we close this evidence-practice gap?

Missed Opportunities in HIV Testing in Turkiye: Implications for Late Diagnoses

BACKGROUND

Late diagnosis of HIV infection is a major global problem. In Turkiye, only 41%-50% of people living with HIV are diagnosed, suggesting that many opportunities for HIV testing might be missed.

SETTING

The aim of this study was to determine the missed testing opportunities for HIV in healthcare settings in Turkiye and the predictors for missed opportunities (MOs).

METHODS

The study included patients with a new HIV diagnosis, presenting to care between January 2018 and December 2020. They were given a verbal questionnaire face to face, by a telephone call or an online meeting for visits to a health care setting within the year before their diagnosis. Electronic medical records were also examined.

RESULTS

The sample included 198 patients with at least 1 visit to any health care setting, with a total of 1677 visits. Patients had an indication for HIV testing in 51.3% (861/1677) of the visits; an HIV test was not offered in 77.9% (671/861) and was considered a MO. The highest number of MOs was in emergency departments (59.8%) (180/301). The most common reason for visiting was constitutional symptoms and indicator conditions (55.4%) (929/1677). University graduates and those with a CD4+ T-cell count <200/mm 3 were more likely to have a MO.

CONCLUSIONS

Many opportunities to diagnose HIV at an early stage are missed in health care settings in Turkiye. Considering the rapidly increasing number of new diagnoses in the last decade, urgent action needs to be taken.

Enhancing indicator condition-guided HIV testing in Taiwan: a nationwide case-control study from 2009 to 2015

BACKGROUND

Although indicator condition (IC)-guided HIV testing (IC-HIVT) is effective at facilitating timely HIV diagnosis, research on IC categories and the related HIV risk in Taiwan is limited. To improve the adoption and spread of IC-HIVT in Taiwan, this study compared the IC categories of people living with HIV (PLWH) and non-HIV controls and investigated delays in the diagnosis of HIV infection.

METHODS

This nationwide, retrospective, 1:10-matched case-control study analyzed data from the Notifiable Diseases Surveillance System and National Health Insurance Research Database to evaluate 42 ICs for the 5-year period preceding a matched HIV diagnostic date from 2009 to 2015. The ICs were divided into category 1 ICs (AIDS-defining opportunistic illnesses [AOIs]), category 2 ICs (diseases associated with impaired immunity or malignancy but not AOIs), category 3 ICs (ICs associated with sexual behaviors), and category 4 ICs (mononucleosis or mononucleosis-like syndrome). Logistic regression was used to evaluate the HIV risk associated with each IC category (at the overall and annual levels) before the index date. Wilcoxon rank-sum test was performed to assess changes in diagnostic delays following an incident IC category by HIV transmission routes.

RESULTS

Fourteen thousand three hundred forty-seven PLWH were matched with 143,470 non-HIV controls. The prevalence results for all ICs and category 1-4 ICs were, respectively, 42.59%, 11.16%, 15.68%, 26.48%, and 0.97% among PLWH and 8.73%, 1.05%, 4.53%, 3.69%, and 0.02% among non-HIV controls (all P < 0.001). Each IC category posed a significantly higher risk of HIV infection overall and annually. The median (interquartile range) potential delay in HIV diagnosis was 15 (7-44), 324.5 (36-947), 234 (13-976), and 74 (33-476) days for category 1-4 ICs, respectively. Except for category 1 for men who have sex with men, these values remained stable across 2009-2015, regardless of the HIV transmission route.

CONCLUSIONS

Given the ongoing HIV diagnostic delay, IC-HIVT should be upgraded and adapted to each IC category to enhance early HIV diagnosis.

Underutilised human immunodeficiency virus testing in the setting of invasive pneumococcal disease

People living with human immunodeficiency virus (HIV) are at increased risk of invasive pneumococcal disease (IPD). We assessed whether patients with invasive Streptococcus pneumoniae, in blood or cerebrospinal fluid, underwent HIV serology testing over a 5-year period. We found that only 39 inpatients out of 156 (25%) with IPD were tested for HIV and thus conclude that such testing is not being undertaken according to some guidelines in patients with IPD. Education and implementation strategies are required to increase testing.

Current evidence on the adoption of indicator condition guided testing for HIV in western countries: A systematic review and meta-analysis

BACKGROUND

Indicator condition (IC) guided testing for HIV is an effective way to identify undiagnosed people living with HIV, but studies suggest its implementation is lacking. This systematic review provides an overview of the adoption of IC-guided testing in Western countries.

METHODS

Seven ICs were selected: tuberculosis (TB), malignant lymphoma, hepatitis B, hepatitis C, cervical/vulvar carcinoma/intraepithelial neoplasia grade 2+ (CC/CIN2+, VC/VIN2+), and peripheral neuropathy (PN). Embase and Ovid MEDLINE were searched up to November 20th, 2020. Publications of all types, using data from ≥2009, reporting on HIV test ratios in patients ≥18 years in all settings in Western countries were eligible. HIV test ratios and positivity were reported per IC. A random effects-model for proportions was used to calculate estimated proportions (ES) with 95% CIs. This study was registered at PROSPERO, registration number CRD42020160243.

FINDINGS

Fifty-seven references, including 23 full-text articles and 34 other publications were included. Most (28/57) reported on HIV testing in TB. No reports on HIV testing in VC/VIN2+ or PN patients were eligible for inclusion. Large variation in HIV test ratios was observed between and within ICs, resulting from different testing approaches. Highest HIV test ratios (pooled ratio: 0·72, 95%CI 0·63-0·80) and positivity (0·05, 95% CI 0·03-0·06) were observed among TB patients, and lowest among CC/CIN2+ patients (pooled ES test ratio: 0·12, 95%CI 0·01-0·31, positivity: 0·00, 95%CI 0·00-0·00).

INTERPRETATION

IC-guided HIV testing is insufficiently implemented in Western countries. The large variation in test ratios provides insight into priority areas for implementing routine IC-guided HIV testing in the future.

FUNDING

HIV Transmission Elimination in Amsterdam (H-TEAM) consortium and Aidsfonds (grant number P-42,702).

Barriers to HIV testing in hospital settings within a culturally diverse urban district of Sydney, Australia

Background Eleven percent of people living with HIV in Australia remain unaware of their diagnosis, and there are missed opportunities for HIV testing in priority settings in New South Wales. HIV testing remains low outside of sexual health clinics with the exception of antenatal settings where HIV testing is routine. To understand why HIV testing rates are low, we sought to identify health worker-related barriers to HIV testing.

METHODS

We conducted an anonymous online survey to health workers in Western Sydney Local Health District (WSLHD) in September 2019. Tick-box, Likert scale responses were analysed using Chi-square and Kruskal-Wallis statistical tests, and free text responses were analysed with thematic analysis.

RESULTS

Three percent (n = 420) of WSLHD's estimated 14 000 health workers responded. These included 317 clinicians (171 nurses, 65 doctors, 56 allied health professionals (AHPs), 25 midwives, and 103 health workers in non-clinical roles). Health workers were from a variety of in-patient/out-patient settings. Many health workers (291/420, 69%; 95%CI = 64.9-73.7%) were unaware that HIV testing is offered in their areas; doctors (82%) and midwives (80%) were more aware than nurses (23%) and AHPs (11%) (P < 0.0001). Doctors (Likert score = 3.62; 3.45/5) and midwives (2.84; 2.76) were significantly more comfortable discussing and confidently offering HIV testing than nurses (2.42; 1.81) or AHPs (1.83; 0.91) (P < 0.0001 for both). The top five barriers to HIV testing were (1) procedural knowledge, (2) identification of at-risk patients, (3) HIV knowledge, (4) positive result management, and (5) privacy concerns. Free text responses highlighted perceived stigma, testing/result responsibilities and resource challenges as barriers to HIV testing.

CONCLUSIONS

Clinicians working in priority settings and with priority populations require more education and support to increase targeted HIV testing.