Missed opportunities for HIV testing of patients diagnosed with an indicator condition in primary care in Catalonia, Spain

HIV and HCV screening by non-infectious diseases physicians: can we improve testing and hidden infection rates?

Background

Missed opportunities for Human Immunodeficiency Virus (HIV) and Hepatitis C Virus (HCV) testing remain high. We aimed to ascertain the knowledge of screening guidelines and attitudes of non-infectious disease (ID) hospital physicians and assess the impact of a 1-h session on screening rates and diagnoses.

Methods

This interventional study consisted of a 1-h training session on HIV and HCV epidemiology and testing guidelines for non-ID physicians. Pre-and post-session questionnaires compared the knowledge of the guidelines and attitudes toward screening before and after the session. Rates of screening and diagnoses were compared in three 6 months periods: before, immediately after, and 24 months ±4 after the session.

Results

A total of 345 physicians from 31 departments participated in these sessions. Before the session, 19.9% (28% medical, 8% surgical) and 17.9% (30% medical, 2.7% surgical) were aware of HIV and HCV testing guidelines, respectively. The willingness to routinely test increased from 5.6 to 22%, whereas not ordering tests decreased from 34.1 to 2.4%. HIV screening rates significantly increased by 20% after the session (7.7 vs. 9.3 tests per 103 patients; p < 0.001), and the effect persisted until the long-term period. The HIV diagnosis rate increased globally (3.6 vs. 5.2 HIV diagnoses per 105 patients; p = 0.157), mainly because of medical services (4.7 vs. 7.7 per 105 patients; p = 0.082). The HCV screening rate increased significantly immediately and in the long term only in medical services (15.7 and 13.6%, respectively). The new active HCV infection rates increased immediately and declined steeply thereafter.

Conclusion

A short session for non-ID physicians can improve HIV/HCV screening, increase diagnosis, and contribute to disease elimination.

Community-based HIV testing through a general health check event in a high HIV-prevalent multicultural area in Rotterdam, The Netherlands: a pilot study on feasibility and acceptance

BACKGROUND

HIV testing is crucial for finding the remaining cases in a declining HIV epidemic in The Netherlands; providing HIV testing in non-traditional settings may be warranted. We conducted a pilot study to determine the feasibility and acceptability of a community-based HIV testing (CBHT) approach with general health checks to improve HIV test uptake.

METHODS

CBHT's main conditions were low-threshold, free-of-charge, general health check, and HIV education. We interviewed 6 community leaders, 25 residents, and 12 professionals/volunteers from local organizations to outline these main conditions. Walk-in test events were piloted at community organizations, providing HIV testing along with body mass index (BMI), blood pressure, blood glucose screening, and HIV education (October 2019 to February 2020). Demographics, HIV testing history, risk perception, and sexual contact were collected via questionnaires. To evaluate the pilots' feasibility and acceptance, we utilized the RE-AIM framework and predefined goals, incorporating quantitative data from the test events and qualitative input from participants, organizations, and staff.

RESULTS

A total of 140 individuals participated (74% women, 85% non-Western, median age 49 years old). The number of participants during the seven 4-h test events ranged from 10 to 31. We tested 134 participants for HIV, and one was found positive (positivity 0.75%). Almost 90% of the participants were never tested or > 1 year ago, and 90% perceived no HIV risk. One-third of the participants had one or more abnormal test results on BMI, blood pressure, or blood glucose. The pilot was well-rated and accepted by all parties. The staff had concerns about waiting time, language problems, and privacy. Participants hardly indicated these concerns.

CONCLUSIONS

This CBHT approach is feasible, acceptable, and well-suited for testing not (recently) tested individuals and detecting new cases. Besides reducing HIV-associated stigma and increasing HIV test acceptance, offering multiple health tests may be appropriate as we frequently observed multiple health problems. Whether this laborious approach is sustainable in the micro-elimination of HIV and should be deployed on a large scale is questionable. CBHT like ours may be suitable as a supplement to more sustainable and cost-effective methods, e.g., proactive HIV testing by general practitioners and partner notification.

Targeting fast-track goals: Missed opportunities for HIV testing in the Community of Madrid

INTRODUCTION

In Spain HIV testing is recommended to people with risk behaviors for HIV and with indicator conditions (IC) related to HIV infection. Missed diagnostic opportunities (MO) are defining as situations where these recommendations are not followed.

OBJECTIVE

To characterize MO due to risk behaviors (directed) and due to IC (indicated) among people diagnosed with HIV in the Region of Madrid.

METHODS

A total of 109 participants newly diagnosed with HIV were recruited from 7 health centers (April 2018-March 2019) by a telephone survey. Diagnostic opportunities were defined as any contact with the healthcare system in which an HIV test should have been carried out. Frequency of MO was calculated within the previous 2 years from HIV diagnosis.

RESULTS

Of the 32 directed and indicated diagnostic opportunities, 96.9% and 57.8% respectively resulted in MO. Overall, 83.8% of diagnostic opportunities resulted in MO.

CONCLUSION

MO, both directed and indicated, are an important area for improvement to reduce late diagnosis.

Targeting fast-track goals: Missed opportunities for HIV testing in the Community of Madrid

INTRODUCTION

In Spain HIV testing is recommended to people with risk behaviors for HIV and with indicator conditions related to HIV infection. Missed diagnostic opportunities (MO) are defining as situations where these recommendations are not followed.

OBJECTIVE

To characterize MO due to risk behaviors (directed) and due to indicator conditions (indicated) among people diagnosed with HIV in the Region of Madrid.

METHODS

A total of 109 participants newly diagnosed with HIV were recruited from 7 health centers (April 2018-March 2019) by a telephone survey. Diagnostic opportunities were defined as any contact with the healthcare system in which an HIV test should have been carried out. Frequency of MO was calculated within the previous 2 years from HIV diagnosis.

RESULTS

Of the 32 directed and indicated diagnostic opportunities, 96.9 and 57.8% respectively resulted in MO. Overall, 83.8% of diagnostic opportunities resulted in MO.

CONCLUSION

MO, both directed and indicated, are an important area for improvement to reduce late diagnosis.

Promoting HIV indicator condition-guided testing in hospital settings (PROTEST 2.0): study protocol for a multicentre interventional study

Background

Late presentation remains a key barrier towards controlling the HIV epidemic. Indicator conditions (ICs) are those that are AIDS-defining, associated with a prevalence of undiagnosed HIV > 0.1%, or whose clinical management would be impeded if an HIV infection were undiagnosed. IC-guided HIV testing is an effective strategy in identifying undiagnosed HIV, but opportunities for earlier HIV diagnosis through IC-guided testing are being missed. We present a protocol for an interventional study to improve awareness of IC-guided testing and increase HIV testing in patients presenting with ICs in a hospital setting.

Methods

We designed a multicentre interventional study to be implemented at five hospitals in the region of Amsterdam, the Netherlands. Seven ICs were selected for which HIV test ratios (proportion of patients with an IC tested for HIV) will be measured: tuberculosis, cervical/vulvar cancer or high-grade cervical/vulvar dysplasia, malignant lymphoma, hepatitis B and C, and peripheral neuropathy. Prior to the intervention, a baseline assessment of HIV test ratios across ICs will be performed in eligible patients (IC diagnosed January 2015 through May 2020, ≥18 years, not known HIV positive) and an assessment of barriers and facilitators for HIV testing amongst relevant specialties will be conducted using qualitative (interviews) and quantitative methods (questionnaires). The intervention phase will consist of an educational intervention, including presentation of baseline results as competitive graphical audit and feedback combined with discussion on implementation and opportunities for improvement. The effect of the intervention will be assessed by comparing HIV test ratios of the pre-intervention and post-intervention periods. The primary endpoint is the HIV test ratio within ±3 months of IC diagnosis. Secondary endpoints are the HIV test ratio within ±6 months of diagnosis, ratio ever tested for HIV, HIV positivity percentage, proportion of late presenters and proportion with known HIV status prior to initiating treatment for their IC.

Discussion

This protocol presents a strategy aimed at increasing awareness of the benefits of IC-guided testing and increasing HIV testing in patients presenting with ICs in hospital settings to identify undiagnosed HIV in Amsterdam, the Netherlands.

Trial registration

Dutch trial registry: NL7521. Registered 14 February 2019.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12879-021-06183-8.

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).

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

BACKGROUND

In Australia, one-third of human immunodeficiency virus (HIV) diagnoses occur late, with an estimated 11% of people with HIV unaware of their diagnosis. Undiagnosed and untreated HIV infection increases morbidity in the HIV positive person and allows onward transmission of HIV.

AIM

To determine the rate of HIV testing in acute general medicine patients with HIV indicator conditions (IC) and evaluate the effectiveness of an educational intervention in improving testing rates.

METHODS

Single-centre, tertiary hospital, before-after study of general medicine inpatients with IC for 12 weeks prior and 10 weeks post an educational intervention focusing on recommendations for HIV testing including IC. The REASON Cohort Discovery Tool was used to search for the IC using ICD-10 codes and laboratory data. The presence of IC was estimated, and HIV testing rates before and after the intervention were compared. Regression analysis was utilised to identify characteristics associated with HIV testing.

RESULTS

Of 1414 admissions in the baseline period and 946 in the post-period, 161 (11.4%) and 132 (14.0%) had at least one IC present respectively. There were 18 (11.2%) HIV tests performed for admissions with IC in the pre-period which increased to 27 (20.5%) (P = 0.028) in the post-period. Younger patients were more likely to be tested and regression analysis identified the educational intervention (adjusted odds ratio) 2.2 (1.1, 4.4) to be significantly associated with testing.

CONCLUSIONS

Although HIV testing rates for IC doubled following the intervention, they remained unacceptably low. The recently introduced electronic medical record presents opportunities to prompt HIV testing.

Hepatitis C and HIV combined screening in primary care: A cluster randomized trial

Hepatitis C virus (HCV) and HIV are major causes of worldwide disease. We aimed to evaluate the effect of a combined screening programme, which included a risk-assessment questionnaire and rapid tests for point-of-care diagnosis, on screening and new diagnosis rates. This prospective, cluster randomized study was carried out in primary care. The intervention arm included a 4-hour educational programme, the use of a risk-assessment questionnaire and rapid tests. In the control centres, only the educational intervention was provided. The main variables compared were the screening coverage and the number and rate of new HCV and HIV diagnoses. Of a total of 7991 participants, 4670 (58.5%) and 2894 (36.2%) presented a risk questionnaire for HIV or HCV, respectively. The younger participants, men and those from Latin America and Eastern Europe, showed the greatest risk of presenting with a positive questionnaire. The overall screening coverage was higher within the intervention arm (OR 17.7; 95% CI 16.2-19.5; P < .001). Only two HIV-positives were identified compared to one in control centres. The rate of HCV diagnoses was higher among intervention centres, with 37 versus seven positive tests (OR 5.2; 95% CI 2.3-11.6; P < .001). Of them, 10 were new diagnoses and 27 had been previously diagnosed, although not linked to care. In conclusion, a simple operational programme can lead to an increase in HCV and HIV screening rates, compared to an exclusively educational programme. The selection of at-risk patients with a self-questionnaire and the use of rapid tests significantly increased the diagnostic rate of HCV infection.

Missed opportunities for HIV testing in patients newly diagnosed with HIV in Morocco

Background

In Morocco, of the estimated 29,000 people living with HIV in 2011, only 20% were aware of their HIV status. More than half of diagnoses were at the AIDS stage. We assumed that people who were unaware of their infection had contacts with the healthcare system for HIV indicators that might prompt the healthcare provider to offer a test. The aim was to assess missed opportunities for HIV testing in patients newly diagnosed with HIV who accessed care in Morocco.

Methods

A cross-sectional study was conducted in 2012–2013 in six Moroccan HIV centers. Participants were aged ≥18, and had sought care within 6 months after their HIV diagnosis. A standardized questionnaire administered during a face-to-face interview collected the patient’s characteristics at HIV diagnosis, HIV testing and medical history. Contacts with care and the occurrence of clinical conditions were assessed during the 3 years prior to HIV diagnosis. Over this period, we assessed whether healthcare providers had offered HIV testing to patients with HIV-related clinical or behavioral conditions.

Results

We enrolled 650 newly HIV-diagnosed patients (median age: 35, women: 55%, heterosexuals: 81%, diagnosed with AIDS or CD4 < 200 cells/mm³: 63%). During the 3 years prior to the HIV diagnosis, 71% (n = 463) of participants had ≥1 contact with the healthcare system. Of 323 people with HIV-related clinical conditions, 22% did not seek care for them and 9% sought care and were offered an HIV test by a healthcare provider. The remaining 69% were not offered a test and were considered as missed opportunities for HIV testing. Of men who have sex with men, 83% did not address their sexual behavior with their healthcare provider, 11% were not offered HIV testing, while 6% were offered HIV testing after reporting their sexual behavior to their provider.

Conclusions

Among people who actually sought care during the period of probable infection, many opportunities for HIV testing, based on at-risk behaviors or clinical signs, were missed. This highlights the need to improve the recognition of HIV clinical indicators by physicians, further expand community-based HIV testing by lay providers, and implement self-testing to increase accessibility and privacy.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12879-020-05711-2.

Profile of new HIV diagnoses and risk factors associated with late diagnosis in a specialized outpatient clinic during the 2014-2018 period

INTRODUCTION

Late diagnosis (LD) of HIV infection is associated with an increase in morbidity and mortality and transmissibility. The aim of this study was to define the clinical characteristics of new diagnoses and clarify the risk factors (RF) associated with LD with or without advanced disease (AD) between 2014 and 2018.

METHODS

Patients with a new diagnosis of HIV infection treated in a specialised outpatient clinic of a third level hospital were included. LD with or without AD was defined as aCD4 count < 350 cel/mm³ or CD4 < 200 cel/mm³ respectively and/or the presence of any AIDS condition on diagnosis. An analysis was performed using binary logistic regression to analyse the RF associated with LD and the AD.

RESULTS

Of the 205 new diagnoses, 102 (50%) were LD. Age ≥ 32 years [(OR, 95% CI); 2.92 (1.52-5.59)], transmission different than in men who have sex with men [3.39 (1.56-7.34)] and hospitalisation on diagnosis [9.68 (2.63-35.68)] were RF associated with LD. On the other hand, having a concomitant sexually transmitted disease (STD) [.37 (.17-.77)] was associated with an early diagnosis. The results were similar when analysing the LD with AD except for the STD.

CONCLUSION

Knowledge of the clinical and epidemiological characteristics of new diagnoses of HIV infection and of the RF for LD with or without AD provides an opportunity for early diagnosis and to reduce transmissibility.

Impact of a structured HIV testing program in a hospital emergency department and a primary care center

Introduction

HIV testing guidelines are poorly implemented in most clinical settings. The best screening strategy and healthcare scenario are still unknown. The aim of our study is to evaluate the impact of a structured HIV testing intervention (DRIVE), compared to HIV testing as routinely performed in clinical practice, in two different clinical settings: a primary care center and an emergency department.

Methods

Prospective evaluation of an HIV testing strategy in two clinical settings from the same healthcare area. The DRIVE program included trained nurse practitioners to perform the screening, a questionnaire to assess the risk of exposure and HIV indicator conditions (RE&IC), and rapid HIV tests. The main variables between the DRIVE program and clinical practice were the absolute number of newly diagnosed HIV infections and testing coverage.

Results

The DRIVE program included 5,329 participants, of which 51.2% reported at least one positive answer in the questionnaire. The estimated HIV testing coverage was significantly higher in the DRIVE program than in the routine clinical practice (7.17% vs. 0.96%, p < 0.001), and was better in the primary care center than in the emergency department with the two strategies. Twenty-two HIV-positive people were identified, with a rate of 8.6‰ in the emergency department vs. 2.2‰ in the primary care center (p = 0.001). A higher rate of new HIV diagnoses was found in the DRIVE program compared to routine clinical practice (29.6 vs. 3.1 per 100,000 patients attended; p < 0.001).

Conclusions

An easy-to-implement, structured intervention increased the absolute number of new HIV diagnoses and HIV tests, compared to routine clinical practice.

Outcome of an HIV education program for primary care providers: Screening and late diagnosis rates

Background

Late HIV diagnosis remains one of the challenges in combating the epidemic. Primary care providers play an important role in screening for HIV infection. Our study aims to evaluate the relationship between knowledge and barriers to HIV testing and screening outcomes. The impact of an education program for primary care providers, towards improving HIV testing and late diagnosis rates, is also assessed.

Methods

A self-administered questionnaire that was developed within the framework of the European project OptTEST was used to examine HIV knowledge and barriers to HIV testing scores before and after being involved in an HIV education program. A quasi-experimental design with pre- and post-intervention measures was performed to investigate its impact. We performed multivariable logistic regression analysis to assess the relationship between variables for the HIV testing offer.

Results

A total of 20 primary care centers and 454 primary care staff were included. Baseline OptTEST results showed that more knowledgeable staff offered an HIV test more frequently (OR 1.07; CI 95% 1.01–1.13; p = 0.027) and had lower barrier scores (OR 0.89; CI 95% 0.77–0.95; p = 0.005). Nurses had lower scores in knowledge-related items (OR 0.28; CI 95% 0.17–0.46; p<0.001), but higher scores in barrier-related items than physicians (OR 3.28; CI 95% 2.01–5.46; p<0.001). Specific centers with more knowledgeable staff members had a significant association with a greater level of new HIV diagnosis rates (OR 1.61; CI 95% 1.04–2.49; p = 0.032). After the intervention, we found that 12 out of 14 individual questions showed improved scores. In the 6 months after the training program, we similarly found a higher HIV testing rate (OR 1.19; CI 1.02–1.42; p = 0.036).

Conclusions

This study highlights the association between knowledge and barriers to HIV testing, including HIV testing rates. It shows that it is possible to modify knowledge and reduce perceived barriers through educational programs, subsequently improving HIV screening outcomes.

Primary prevention

HIV infection is still not controlled in Spain. New HIV infection prevention strategies are required, especially in populations of higher incidence, by means of combined interventions. Early diagnosis and treatment of HIV-infected individuals is the most cost-effective strategy to control the epidemic, including interventions designed to motivate behavioural changes. These types of campaigns must not only be directed to the general population through mass channels, but also to key populations through more specific channels and messages. Biomedical interventions like pre-exposure prophylaxis, uses a combination of biomedical tools to reduce the risk of HIV acquisition, and are usually accompanied of behavioural interventions. The influence of structural factors, social justice and defending the rights of people living with HIV have a significant impact on prevention strategies. Structural interventions are designed to influence these factors that make some individuals or populations more vulnerable to HIV infection.

Early diagnosis

There is broad agreement on the impact that underdiagnosis and late diagnosis of HIV infection have on the health of people with HIV and on the persistence of the epidemic due to an inadvertent increase in transmission. The need to develop strategies that increase the number of diagnoses, and specifically the number of early diagnoses, is therefore urgent. Many such strategies have been launched in other countries and, in Spain, have been recommended by the Ministry of Health, Social Services and Equality (MSSSI). The multidisciplinary group recommends the review and implementation of different measures in both health and community settings.

Primary health care: an opportunity for early identification of people living with undiagnosed HIV infection

OBJECTIVES

We aimed to determine the fraction of HIV-diagnosed individuals who had primary health care (PHC) contacts 3 years prior to HIV diagnosis and whether the risk of HIV diagnosis and degree of immunodeficiency were associated with the frequency of visits or procedures performed.

METHODS

We used data from national registries to conduct a population-based nested case-control study. Cases were individuals diagnosed with HIV infection in Denmark from 1998 to 2016. Population controls were extracted from the general population matched 13:1 on gender and age. We used conditional logistic regression. As there was a statistically significant interaction, analyses were further stratified by gender and Danish/non-Danish origin.

RESULTS

We identified 2784 cases and 36 192 controls. Ninety-three per cent of cases and 88% of controls attended PHC at least once in the 3 years prior to diagnosis, with a higher median number of visits to PHC (NVPC) for cases. We found a statistically significant positive association between NVPC and risk of subsequent HIV diagnosis in men and non-Danish women. A U-shaped association between NVPC and risk of HIV diagnosis among Danish women. No substantial association between NVPC and degree of immunodeficiency was found. Risk of HIV diagnosis and degree of immunodeficiency were weakly associated with type of procedures performed.

CONCLUSIONS

For most HIV-infected individuals, there seem to be many opportunities for earlier diagnosis in PHC. In men and non-Danish women, the risk of HIV diagnosis but not the degree of immunodeficiency was related to NVPC. The results suggest that the type of medical procedure performed cannot not be used as a guide by the primary physician to indicate which patients to test.

Indicator condition-guided HIV testing with an electronic prompt in primary healthcare: a before and after evaluation of an intervention

OBJECTIVE

Indicator condition (IC)-guided HIV testing is a strategy for the diagnosis of patients with HIV. The aim of this study was to assess the impact on the proportion of HIV tests requested after the introduction of an electronic prompt instructing primary healthcare (PHC) physicians to request an HIV test when diagnosing predefined IC.

METHODS

A prospective interventional study was conducted in 2015 in three PHC centres in Barcelona to assess the number of HIV test requests made during the implementation of an electronic prompt. Patients aged 18-65 years without HIV infection and with a new diagnosis of predefined IC were included. The results were compared with preprompt (2013) and postprompt data (2016).

RESULTS

During the prompt period, 832 patients presented an IC (median age 41.6 years [IQR 30-54], 48.2% female). HIV tests were requested in 296 individuals (35, 6%) and blood tests made in 238. Four HIV infections were diagnosed (positivity rate 1.7%, 95% CI 0.5% to 4.4%). The number of HIV tests requested based on IC increased from 12.6% in 2013 to 35.6% in 2015 (p<0.001) and fell to 17.9% after removal of the prompt in 2016 (p<0.001). Younger patient age (OR 0.97, 95% CI 0.96 to 0.98), birth outside Spain (OR 1.53, 95% CI 1.06 to 2.21) and younger physician age (OR 0.97, 95% CI 0.96 to 0.99) were independent predictive factors for an HIV test request during the prompt period. The electronic prompt (OR 3.36, 95% CI 2.70 to 4.18) was the factor most closely associated with HIV test requests. It was estimated that 10 (95% CI 3.0 to 26.2) additional new cases would have been diagnosed if an HIV test had been performed in all patients presenting an IC.

CONCLUSIONS

A significant increase in HIV test requests was observed during the implementation of the electronic prompt. The results suggest that this strategy could be useful in increasing IC-guided HIV testing in PHC centres.

HIV testing within general practices in Europe: a mixed-methods systematic review

BACKGROUND

Late diagnosis of HIV infection remains a key challenge in Europe. It is acknowledged that general practitioners (GPs) may contribute greatly to early case finding, yet there is evidence that many diagnostic opportunities are being missed. To further promote HIV testing in primary care and to increase the utility of available research, the existing evidence has been synthesised in a systematic review adhering to the PRISMA guidelines.

METHODS

The databases PubMed, Scopus and Embase were searched for the period 2006-2017. Two authors judged independently on the eligibility of studies. Through a mixed-methods systematic review of 29 studies, we provide a description of HIV testing in general practices in Europe, including barriers and facilitators.

RESULTS

The findings of the study show that although various approaches to target patients are used by GPs, most tests are still carried out based on the patient's request. Several barriers obstruct HIV testing in general practice. Included are a lack of communication skills on sexual health, lack of knowledge about HIV testing recommendations and epidemic specificities, difficulties with using the complete list of clinical HIV indicator diseases and lack of experience in delivering and communicating test results. The findings also suggest that the provision of specific training, practical tools and promotion programmes has an impact on the testing performance of GPs.

CONCLUSIONS

GPs could have an increased role in provider-initiated HIV-testing for early case finding. To achieve this objective, solutions to the reported barriers should be identified and testing criteria adapted to primary healthcare defined. Providing guidance and training to better identify priority groups for HIV testing, as well as information on the HIV epidemic's characteristics, will be fundamental to increasing awareness and testing by GPs.

HIV testing in Europe: Evaluating the impact, added value, relevance and usability of the European Centre for Disease Prevention and Control (ECDC)'s 2010 HIV testing guidance

Background: An evaluation of the 2010 ECDC guidance on HIV testing, conducted in October 2015–January 2016, assessed its impact, added value, relevance and usability and the need for updated guidance. Methods: Data sources were two surveys: one for the primary target audience (health policymakers and decision makers, national programme managers and ECDC official contact points in the European Union/European Economic Area (EU/EEA) countries and one for a broader target audience (clinicians, civil society organisations and international public health agencies); two moderated focus group discussions  (17 participants each); webpage access data; a literature citation review; and an expert consultation (18 participants) to discuss the evaluation findings. Results: Twenty-three of 28 primary target audience and 31 of 51 broader target audience respondents indicated the guidance was the most relevant when compared with other international guidance. Primary target audience respondents in 11 of 23 countries reported that they had used the guidance in development, monitoring and/or evaluation of their national HIV testing policy, guidelines, programme and/or strategy, and 29 of 51 of the broader target audience respondents reported having used the guidance in their work. Both the primary and broader target audience considered it important or very important to have an EU/EEA-level HIV testing guidance (23/28 and 46/51, respectively). Conclusion: The guidance has been widely used to develop policies, guidelines, programmes and strategies in the EU/EEA and should be regularly updated due to continuous developments in the field in order to continue to serve as an important reference guidance in the region.

Knowledge and Concern about STIs/HIV and Sociodemographic Variables Associated with Getting Tested for HIV Among the General Population in Spain

HIV testing is important in terms of prevention and treatment. However, HIV testing rates in the Spanish general population remains low. Therefore, HIV testing promotion constitutes a key issue. A high level of knowledge about HIV/AIDS is associated with having been tested for HIV. The general aim of this study was to determine the prevalence of people who had ever been tested for HIV in Spain. The sample consisted of 1,106 participants from the general population - 60.0% females and 40.0% males - aged between 17 and 55 years old. The assessment instruments were a questionnaire on sociodemographic data and HIV testing, a scale of knowledge about STIs and HIV/AIDS, and a scale of concern about STIs/HIV. Results showed that greater knowledge about STIs and HIV was associated with a greater likelihood of being tested for HIV (OR = .77; 95.0% CI = .73-.82; p < .05). In addition, higher concern about HIV/AIDS decreased the likelihood of not having been tested for HIV (OR = .87; 95.0% CI = .83-.92; p < .05). In fact, the higher participants concern about STIs was, the lower their likelihood of not having been tested for HIV was (OR = .87; 95.0% CI = .83-.91; p < .05). It is necessary to promote HIV testing in the general population as well as to consider their socio-demographic and psychological characteristics.

Indicator condition based HIV testing: Missed opportunities for earlier diagnosis in men who have sex with men

INTRODUCTION

Contact with the healthcare system by a sample of seropositive men who have sex with men (MSM) prior to their HIV diagnosis are analysed, and missed opportunities (MO) for an earlier HIV diagnosis are identified.

METHODOLOGY

Between 2012-2013, an online survey was conducted among HIV-positive MSM, mainly recruited from gay websites. Those who were diagnosed with HIV between 2010-2013 were analysed. MO were defined as episodes prior to the HIV diagnosis in which the healthcare system was contacted due to an indicator condition of HIV infection and the test was not suggested. The proportion of missed opportunities were compared according to the type of indicator condition, the department consulted and the healthcare professional's knowledge that the patient was MSM.

RESULTS

Overall, 639 participants (66% of 966) reported 1,145 episodes with some indicator condition, the majority of these being identified in primary care (n=527; 46%). The highest percentage of MOs is also observed in primary care (63%). Although the indicator condition with the highest number of MOs was STIs (n=124), the highest percentage of MOs was observed in consultations due to diarrhoea with no known cause (69.8%). The percentage of MOs when the doctor knew that the patient was MSM was 40 vs. 70% when the doctor did not know.

CONCLUSION

The majority of HIV-positive MSM analysed in this study went to healthcare services for HIV-infection indicator conditions prior to their HIV diagnosis. Primary care was the most-frequently-visited department and is also where the most opportunities were missed to perform an HIV test, even when it was known that the patient was a MSM.

New HIV diagnoses among adults aged 50 years or older in 31 European countries, 2004-15: an analysis of surveillance data

BACKGROUND

The HIV burden is increasing in older adults in the European Union (EU) and European Economic Area (EEA). We investigated factors associated with HIV diagnosis in older adults in the 31 EU/EEA countries during a 12 year period.

METHODS

In this analysis of surveillance data, we compared data from older people (aged ≥50 years) with those from younger people (aged 15-49 years). We extracted new HIV diagnoses reported to the European Surveillance System between Jan 1, 2004, and Dec 31, 2015, and stratified them by age, sex, migration status, transmission route, and CD4 cell count. We defined late diagnosis as CD4 count of less than 350 cells per μL at diagnosis and diagnosis with advanced HIV disease as less than 200 cells per μL. We compared the two age groups with the χ² test for difference, and used linear regression analysis to assess temporal trends.

FINDINGS

During the study period 54 102 new HIV diagnoses were reported in older adults. The average notification rate of new diagnoses was 2·6 per 100 000 population across the whole 12 year period, which significantly increased over time (annual average change [AAC] 2·1%, 95% CI 1·1-3·1; p=0·0009). Notification rates for new HIV diagnoses in older adults increased significantly in 16 countries in 2004-15, clustering in central and eastern EU/EEA countries. In 2015, compared with younger adults, older individuals were more likely to originate from the reporting country, to have acquired HIV via heterosexual contact, and to present late (p<0·0001 for all comparisons). HIV diagnoses increased significantly over time among older men (AAC 2·2%, 95% CI 1·2-3·3; p=0·0006), women (1·3%, 0·2-2·4; p=0·025), men who have sex with men (5·8%, 4·3-7·5; p<0·0001), and injecting drug users (7·4%, 4·8-10·2; p<0·0001).

INTERPRETATION

Our findings suggest that there is a compelling need to deliver more targeted testing interventions for older adults and the general adult population, such as by increasing awareness among health-care workers and expanding opportunities for provider-initiated and indicator-condition-guided testing programmes.

FUNDING

European Centre for Disease Prevention and Control.

[Early diagnosis of HIV in Primary Care in Spain. Results of a pilot study based on targeted screening based on indicator conditions, behavioral criteria and region of origin]

Objetivos

Estimar la prevalencia de la infección por VIH en pacientes diagnosticados con una condición indicadora (CI) para el VIH y/o que habían tenido una conducta de riesgo para su adquisición y/o que provenían de países con elevada prevalencia. Determinar la aceptabilidad y viabilidad de ofrecer la prueba del VIH basada en CI y criterios conductuales y de origen en atención primaria (AP).

Diseño

Estudio transversal en una muestra de conveniencia.

Emplazamiento

Seis centros de AP en España.

Participantes

Los criterios de inclusión fueron: pacientes entre 16 y 65 años que presentaban al menos una de las CI propuestas y/o al menos uno de los criterios conductuales y/o de origen propuestos. Participaron 388 pacientes.

Intervención

Se ofreció la serología del VIH a todos los pacientes que cumplían con los criterios de inclusión.

Mediciones principales

Descripción de la frecuencia de CI, criterios conductuales y de origen. Prevalencia de infección por VIH. Nivel de aceptabilidad y viabilidad de la oferta de la prueba del VIH basada en criterios conductuales y de origen y CI.

Resultados

Un total de 174 pacientes presentaron una CI (44,84%). El criterio conductual más común fue: haber mantenido relaciones sexuales desprotegidas alguna vez en la vida con personas que desconocían su estado serológico para el VIH (298; 76,8%). Se diagnosticaron 4 pacientes VIH+ (1,03%). Todos presentaban una CI y eran hombres que mantenían sexo con hombres. El nivel de aceptabilidad en AP fue elevada.

Conclusiones

Ofrecer la prueba del VIH a pacientes con CI y criterios conductuales es viable y efectiva en AP.

The importance of registration of sexual orientation and recognition of indicator conditions for an adequate HIV risk-assessment

Background

HIV testing among risk groups and guided by HIV indicator conditions (IC) is widely recommended by European guidelines. In this study we investigated how these strategies are used by general practitioners (GP) and in other healthcare settings. The objectives of our study were to describe: 1) the proportion of consultations in primary care and other healthcare settings in the five years prior to diagnosis; 2) patient and GP perspectives on the primary healthcare providers’ awareness and registration of sexual orientation and ethnicity in the electronic medical record (EMR); and 3) the proportion of HIV-infected patients who had been diagnosed with an IC prior to HIV diagnosis.

Methods

A survey study (2014–2016) was conducted among newly diagnosed HIV-infected patients presenting at two HIV outpatient clinics in Amsterdam. We collected information on the number of consultations and extent of HIV testing in healthcare settings in the 5 years prior to HIV diagnosis; on patient and GP perspectives on the primary healthcare providers’ awareness of sexual orientation and ethnicity; and on preselected ICs and symptoms of acute HIV infection prior to diagnosis. GPs were also approached for further information.

Results

In the 5 years prior to HIV diagnosis, 82.9% of the 111 patients had one or more consultations with their GP, but only 34.8% had one or more HIV tests performed in general practice during this period. In more than 50% of cases the patients took the initiative for the positive HIV test. GPs stated that they were aware of the sexual orientation of 59.6% of their patients who were men who have sex with men (MSM); however, sexual orientation was only documented in the EMR in 34.0% of these cases. GPs also reported that they were aware that a patient was from an HIV endemic country in more than half of the cases. GPs diagnosed 48.3% of all ICs and 39.5% of this group was offered an HIV test at that time.

Conclusions

Documentation of sexual orientation and ethnicity, and IC-guided testing by GPs could be the starting point for more proactive provider-initiated HIV testing.

The need to scale up HIV indicator condition-guided testing for early case-finding: a case-control study in primary care

Background

European guidelines recommend offering an HIV test to individuals who display HIV indicator conditions (ICs). We aimed to investigate the incidence of ICs in primary care reported in medical records prior to HIV diagnosis.

Methods

We did a cross-sectional search in an electronic general practice database using a matched case-control design to identify which predefined ICs registered by Dutch GPs were most associated with an HIV-positive status prior to the time of diagnosis.

Results

We included 224 HIV cases diagnosed from 2009 to 2013, which were matched with 2,193 controls. Almost two thirds (n = 136, 60.7%) of cases were diagnosed with one or more ICs in the period up to five years prior to the index date compared to 18.7% (n = 411) of controls. Cases were more likely to have an IC than controls: in the one year prior to the index date, the odds ratio (OR) for at least one condition was 11.7 (95% CI: 8.3 to 16.4). No significant differences were seen in the strength of the association between HIV diagnosis and ICs when comparing genders, age groups or urbanisation levels. There is no indication that subgroups require a different testing strategy.

Conclusions

Our study shows that there are opportunities for IC-guided testing in primary care. We recommend that IC-guided testing be more integrated in GPs’ future guidelines and that education strategies be used to facilitate its implementation in daily practice.

Electronic supplementary material

The online version of this article (doi:10.1186/s12875-016-0556-2) contains supplementary material, which is available to authorized users.