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

Point of care HIV testing in dental settings in high-income countries: A mixed-methods systematic review

OBJECTIVES

Expanding HIV testing beyond specialized services has been a key strategic approach to eliminating the transmission of HIV. In recent years, dental settings have been identified as offering an opportunity for delivering point of care HIV testing (POCT) interventions. Intervention components and implementation strategies have varied across studies and there is uncertainty about the prevalence of undiagnosed HIV in the dental patient population. Therefore, this systematic review aimed to synthesize the HIV testing outcomes of intervention studies, identify the core components of POCT interventions implemented in dental settings; and understand the barriers and facilitators to intervention implementation.

METHODS

A mixed-methods systematic review was undertaken. Two authors reviewed abstracts and full papers for inclusion and appraised the studies using the Mixed Methods Appraisal Tool. A convergent integrated mixed methods study design underpinned the synthesis. Outcomes were presented using descriptive statistics. Intervention components were mapped to the Template for Intervention Description and Replication (TIDieR) checklist. Barriers and facilitators were described using a narrative thematic analysis.

RESULTS

POCT was offered to 22 146 dental patients, 62.5% accepted POCT. Intervention studies that reported higher uptake of testing utilized a dedicated dental or researcher staff member to provide testing, integrated testing and provided results within the routine dental appointment and adopted a provider-initiated universal approach to offering testing. Six themes emerged that were pertinent to the barriers and facilitators to HIV testing in dental setting.

CONCLUSIONS

POCT uptake in dental settings was comparable with other non-specialized health settings. Key to the operationalization of the intervention were perceptions about its value and relevance to the dental patient population, attitudes toward the intervention, logistical barriers to its implementation, the risk of HIV testing stigma to the patient-practitioner relationship and maximising the fit of the intervention within the constraints of the dental setting.

The roles of the general practitioner and sexual health centre in HIV testing: comparative insights and impact on HIV incidence rates in the Rotterdam area, the Netherlands - a cross-sectional population-based study

BACKGROUND

Access to HIV testing is crucial for detection, linkage to treatment, and prevention. In less urbanised areas, reliance on general practitioners (GPs) for HIV testing is probable, as sexual health centres (SHC) are mostly located within urbanised areas. Limited insight into individuals undergoing HIV testing stems from sparse standard registration of demographics at GPs. This cross-sectional study aims (1) to assess and compare HIV testing at the GP and SHC, and (2) to assess population- and provider-specific HIV incidence.

METHODS

Individual HIV testing data of GPs and SHC were linked to population register data (aged ≥ 15 years, Rotterdam area, 2015-2019). We reported the proportion HIV tested, and compared GP and SHC testing rates with negative binomial generalised additive models. Data on new HIV diagnoses (2015-2019) from the Dutch HIV Monitoring Foundation relative to the population were used to assess HIV incidence.

RESULTS

The overall proportion HIV tested was 1.14% for all residents, ranging from 0.41% for ≥ 40-year-olds to 4.70% for Antilleans. The GP testing rate was generally higher than the SHC testing rate with an overall rate ratio (RR) of 1.61 (95% CI: 1.56-1.65), but not for 15-24-year-olds (RR: 0.81, 95% CI: 0.74-0.88). Large differences in HIV testing rate (1.36 to 39.47 per 1,000 residents) and GP-SHC ratio (RR: 0.23 to 7.24) by geographical area were observed. The GPs' contribution in HIV testing was greater for GP in areas further away from the SHC. In general, population groups that are relatively often tested are also the groups with most diagnoses and highest incidence (e.g., men who have sex with men, non-western). The overall incidence was 10.55 per 100,000 residents, varying from 3.09 for heterosexual men/women to 24.04 for 25-29-year-olds.

CONCLUSIONS

GPs have a pivotal role in HIV testing in less urbanised areas further away from the SHC, and among some population groups. A relatively high incidence often follows relatively high testing rates. Opportunities to improve HIV testing have been found for migrants, lower-educated individuals, in areas less urbanised areas and further away from GP/SHC. Strategies include additional targeted testing, via for example SHC branch locations and outreach activities.

Life-time HIV testing among people who inject drugs in Iran: results from the National Rapid Assessment and Response survey

Background

HIV testing is recommended for people who inject drugs (PWID). The aim of this study was to determine the prevalence of lifetime HIV testing among PWID and to better understand the predictors for HIV testing in a convenience sample across Iran.

Materials and methods

This study is a secondary analysis of Iran's National Rapid Assessment and Response survey conducted between October 2016 and March 2017. Analysis includes the 999 people who reported injecting drugs across the capital cities of 21 provinces. Data were collected by using the venue-based application of the Time Location Sampling (TLS) frame. Chi-square tests were used to examine the difference between HIV testing across different quantitative variables. Logistic regression was used to determine the predictors of life-time HIV testing. Analysis was performed using STATA V.12 software with a significance level of 95%.

Results

Most participants were male (n = 902, 93.50%), and over half (n = 555, 59.17%) were older than 35 years old. About one-third, (n = 326, 38%) of people interviewed were single and another one-third (n = 251, 29%) reported being divorced. Over two-thirds of participants (n = 678, 69.78%) in this study reported lifetime HIV testing. The results from a multiple variable logistic regression showed people with a university education were more likely to have been previously tested for HIV than illiterate people (OR = 18.87, 95%CI 2.85-124.6, value of p = 0.002). Those individuals who reported ever receiving methadone treatment were 2.8 times more likely to have been tested for HIV than individuals without methadone treatment experience (OR = 2.89, 95%CI 1.53-5.42, value of p < 0.001). Needle syringe sharing in last month, was negatively associated with life-time HIV testing (OR = 0.29, 95%CI 0.17-0.48, value of p < 0.001).

Conclusion

Despite Iran's wide availability and access to counseling services for HIV testing in key populations, the proportion of PWID being tested for HIV could be improved. Developing effective strategies to increase people's understanding and awareness of the importance of and need for HIV prevention and familiarity with HIV testing sites is an essential step in increasing HIV testing for this population. Studies on more recent HIV testing are required to better assess and understand the frequency of HIV testing among PWID in Iran.

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.

Area-based comparison of risk factors and testing rates to improve sexual health care access: cross-sectional population-based study in a Dutch multicultural area

OBJECTIVES

Areas with high sexually transmitted infection (STI) testing rates may not require additional strategies to improve testing. However, it may be necessary to intervene in areas with elevated STI risk, but with low STI testing rates. We aimed to compare STI-related risk profiles and STI testing rates by geographical area to determine areas for improvement of sexual healthcare access.

DESIGN

Cross-sectional population-based study.

SETTING

Greater Rotterdam area, the Netherlands (2015-2019).

PARTICIPANTS

All residents aged 15-45 years. Individual population-based register data were matched with laboratory-based STI testing data of general practitioners (GPs) and the only sexual health centre (SHC).

OUTCOME MEASURES

Postal code (PC) area-specific STI risk scores (based on age, migratory background, education level and urbanisation), STI testing rates and STI positivity.

RESULTS

The study area consists of approximately 500 000 residents aged 15-45 years. Strong spatial variation in STI testing, STI positivity and STI risk was observed. PC area testing rate ranged from 5.2 to 114.9 tests per 1000 residents. Three PC clusters were identified based on STI risk and testing rate: (1) high-high; (2) high-low; (3) low, independently of testing rate. Clusters 1 and 2 had comparable STI-related risk and STI positivity, but the testing rate differed greatly (75.8 vs 33.2 per 1000 residents). Multivariable logistic regression analysis with generalised estimating equation was used to compare residents in cluster 1 and cluster 2. Compared with cluster 1, residents in cluster 2 more often did not have a migratory background, lived in less urbanised areas with higher median household income, and more distant from both GP and SHC.

CONCLUSION

The determinants associated with individuals living in areas with high STI-related risk scores and low testing rates provide leads for improvement of sexual healthcare access. Opportunities for further exploration include GP education, community-based testing and service (re)allocation.

Improving provider-initiated testing for HIV and other STI in the primary care setting in Amsterdam, the Netherlands: Results from a multifaceted, educational intervention programme

BACKGROUND

In the Netherlands, general practitioners (GPs) play a key role in HIV testing. However, the proportion of people diagnosed with late-stage HIV remains high, and opportunities for earlier diagnosis are being missed. We implemented an educational intervention to improve HIV and STI testing in primary care in Amsterdam, the Netherlands.

METHODS

GPs were invited to participate in an educational program between 2015 and 2020, which included repeat sessions using audit and feedback and quality improvement plans. Data on HIV, chlamydia and gonorrhoea testing by GPs were collected from 2011 through 2020. The primary outcome was HIV testing frequency, which was compared between GPs before and after participation using Poisson regression. Secondary outcomes were chlamydia and gonorrhoea testing frequencies, and positive test proportions. Additional analyses stratified by patient sex and age were done.

FINDINGS

GPs after participation performed 7% more HIV tests compared to GPs before participation (adjusted relative ratio [aRR] 1.07, 95%CI 1.04-1.09); there was no change in the proportion HIV positive tests (aRR 0.87, 95%CI 0.63-1.19). HIV testing increased most among patients who were female and ≤19 or 50-64 years old. After participation, HIV testing continued to increase (aRR 1.02 per quarter, 95%CI 1.01-1.02). Chlamydia testing by GPs after participation increased by 6% (aRR 1.06, 95%CI 1.05-1.08), while gonorrhoea testing decreased by 2% (aRR 0.98, 95%CI 0.97-0.99). We observed increases specifically in extragenital chlamydia and gonorrhoea testing.

CONCLUSIONS

The intervention was associated with a modest increase in HIV testing among GPs after participation, while the proportion positive HIV tests remained stable. Our results suggest that the intervention yielded a sustained effect.

Knowledge and Risk Behaviors Regarding Human Immunodeficiency Virus Transmission among Portuguese Healthcare Students

BACKGROUND

Human immunodeficiency virus (HIV), the agent responsible for acquired immunodeficiency syndrome, remains a worldwide public health problem. Therefore, this study aimed to assess Portuguese healthcare students' knowledge of HIV, identify risk behaviors for HIV transmission, and assess the frequency of HIV testing and its dissemination by general practitioners.

METHODS

A cross-sectional observational study was conducted using an anonymous questionnaire published online. The questionnaire was administered to Portuguese healthcare students who voluntarily agreed to participate in the study after clarifying its objectives and procedures.

RESULTS

Most students were aware of the three main HIV transmission routes; however, 66.3% were unaware of the level A recommendation for HIV screening in adolescents and adults. In addition, 59.6% of the students were never informed by their general practitioner about HIV screening tests or risk behaviors for HIV transmission. Of the sample, 78.9% had never been tested for HIV infection. Of the 74.6% of sexually active students, 82.0% had or had already had unprotected sex (without a condom). Men showed riskier sexual behaviors than women. None of the inquiries reported intravenous drug use, and most students (69.9%) never shared personal objects.

CONCLUSION

General practitioners and awareness campaigns need to alert and disseminate HIV screening tests. Sexual health and risk behaviors should be addressed more frequently in schools to educate this population because prevention is the best strategy against HIV transmission/contraction.

Opt-in HIV testing in construction workplaces: an exploration of its suitability, using the socioecological framework

Background

Late diagnosis of HIV remains a challenge, despite improved testing and treatment. Testing is often targeted at high-risk groups; workplace events might normalise testing and allow access to a wider population. The construction workforce has a number of risk factors for HIV. In the Test@Work study, HIV tests were delivered within general health checks to construction employees, with high uptake and acceptability. This paper reports on the experiences of construction managers and health professionals involved in Test@Work and explores the suitability of construction worksites as a venue for opt-in HIV testing.

Methods

Qualitative interviews (n = 24) were conducted with construction managers who had facilitated health check/HIV testing (n = 13), and delivery partners (n = 11) including i) healthcare volunteers who had delivered general health checks (n = 7) and, ii) HIV professionals who had conducted HIV testing (n = 4) at 21 Test@Work events held on construction sites. Interviews explored their experiences of these events and views towards HIV testing in the workplace. Exit questionnaires (n = 107) were completed by delivery partners after every event, providing qualitative data identifying facilitators and barriers to effective delivery. Thematic analysis identified themes that were mapped against a socioecological framework.

Results

Delivery partners reported high engagement of construction workers with workplace HIV testing, peer-to-peer encouragement for uptake, and value for accessibility of onsite testing. HIV professionals valued the opportunity to reach an untested population, many of whom had a poor understanding of their exposure to HIV risk. Managers valued the opportunity to offer workplace health checks to employees but some identified challenges with event planning, or provision of private facilities.

Conclusions

The construction sector is complex with a largely male workforce. Providing worksite HIV testing and education to an untested population who have poor knowledge about HIV risk helped to normalise testing, encourage uptake and reduce HIV-related stigma. However, there are practical barriers to testing in the construction environment. Rapid testing may not be the most suitable approach given the challenges of maintaining confidentiality on construction worksites and alternatives should be explored.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-022-13787-5.

How Do Family Physicians Perceive Their Role in Providing Pre-exposure Prophylaxis for HIV Prevention?-An Online Qualitative Study in Flanders, Belgium

Introduction:

In Belgium, the provision of pre-exposure prophylaxis (PrEP) for HIV prevention is centralized in specialized HIV clinics. Engaging family physicians in PrEP care could help scale-up its delivery and reach underserved populations. The objective of this study was to gain insight into family physicians' self-perceived roles in providing PrEP.

Methods

We conducted 16 online group discussions with a total of 105 Flemish family physicians, between November 2020 and February 2021. A brief online questionnaire assessed their socio-demographics and experience with sexual health. We analyzed verbatim transcribed data using a grounded theory approach.

Results

Despite limited awareness and experience, participants reported a high willingness to be more actively involved in PrEP care. Four potential roles for the family physician in PrEP care were identified: acting as low-threshold entry point for advice; opportunistic case finding of PrEP candidates; initiating appropriate care for PrEP-eligible clients; and ensuring high-quality follow-up care for PrEP users. Participants framed each of these roles within their current activities and responsibilities as primary care providers. Yet, participants differed in their views on the concrete operationalization of these roles, and in the extent of their involvement in PrEP. Particular challenges were a lack of experience with antiretrovirals, perceived limited exposure to clients at high HIV risk, and a lack of expertise and resources to conduct time-intensive risk assessments and counseling related to PrEP.

Conclusion

Belgian family physicians demonstrated a keen willingness to be involved in PrEP care, but had differing views on the practical implementation into their practices. Providing tailored training on sexual health and PrEP, and investing in collaboration between primary and secondary care, could optimize the integration of PrEP in the primary care practice.

Testing and healthcare seeking behavior preceding HIV diagnosis among migrant and non-migrant individuals living in the Netherlands: Directions for early-case finding

Objectives

To assess differences in socio-demographics, HIV testing and healthcare seeking behavior between individuals diagnosed late and those diagnosed early after HIV-acquisition.

Design

Cross-sectional study among recently HIV-diagnosed migrant and non-migrant individuals living in the Netherlands.

Methods

Participants self-completed a questionnaire on socio-demographics, HIV-testing and healthcare seeking behavior preceding HIV diagnosis between 2013–2015. Using multivariable logistic regression, socio-demographic determinants of late diagnosis were explored. Variables on HIV-infection, testing and access to care preceding HIV diagnosis were compared between those diagnosed early and those diagnosed late using descriptive statistics.

Results

We included 143 individuals with early and 101 with late diagnosis, of whom respectively 59/143 (41%) and 54/101 (53%) were migrants. Late diagnosis was significantly associated with older age and being heterosexual. Before HIV diagnosis, 89% of those with early and 62% of those with late diagnosis had ever been tested for HIV-infection (p<0.001), and respectively 99% and 97% reported healthcare usage in the Netherlands in the two years preceding HIV diagnosis (p = 0.79). Individuals diagnosed late most frequently visited a general practitioner (72%) or dentist (62%), and 20% had been hospitalized preceding diagnosis. In these settings, only in respectively 20%, 2%, and 6% HIV-testing was discussed.

Conclusion

A large proportion of people diagnosed late had previously tested for HIV and had high levels of healthcare usage. For earlier-case finding of HIV it therefore seems feasible to successfully roll out interventions within the existing healthcare system. Simultaneously, efforts should be made to encourage future repeated or routine HIV testing among individuals whenever they undergo an HIV test.

Understanding Reasons for HIV Late Diagnosis: A Qualitative Study Among HIV-Positive Individuals in Amsterdam, The Netherlands

Since the introduction of effective anti-retroviral therapy, early diagnosis and treatment of HIV have become increasingly important from individual and public health perspectives. People who are diagnosed with a CD4 count below 350 cells/µL blood are today considered to be “late” diagnoses. In an effort to understand the reasons for late diagnosis, we conducted in-depth interviews (n = 14) in Amsterdam, the Netherlands. Two main factors were identified: psychosocial factors and health-system factors. Psychosocial factors relate to people’s personal relationship with health professionals, low risk perception, fear related to the outcome of testing, and trauma from observed past experiences of living with HIV. Health-system factors relate to institutional barriers and missed opportunities during client-provider interactions. We conclude that in order to mitigate late diagnosis, the social and institutional context within which HIV testing is conducted should be addressed.

Rationale, design and initial results of an educational intervention to improve provider-initiated HIV testing in primary care

OBJECTIVES

In the Netherlands, general practitioners (GPs) perform two-thirds of sexually transmitted infection (STI) consultations and diagnose one-third of HIV infections. GPs are, therefore, a key group to target to improve provider-initiated HIV testing. We describe the design and implementation of an educational intervention to improve HIV testing by Amsterdam GPs and explore trends in GPs' testing behaviour.

METHODS

Interactive sessions on HIV and STI using graphical audit and feedback started in 2015. Participating GPs developed improvement plans that were evaluated in follow-up sessions. Laboratory data on STI testing by Amsterdam GPs from 2011 to 2017 were collected for graphical audit and feedback and effect evaluation. The primary outcome was the HIV testing rate: number of HIV tests per 10 000 person-years (PY). Secondary endpoints were chlamydia and gonorrhoea testing rates and HIV positivity ratios.

RESULTS

Since 2015, 41% of GPs participated. HIV testing rate declined from 2011 to 2014 (from 175 to 116 per 10 000 PY), more in women than men (176 to 101 versus 173 to 132), and stabilized from 2015 to 2017. The HIV positivity ratio declined from 0.8% in 2011 to 0.5% in 2017. From 2011 to 2017, chlamydia and gonorrhoea testing rates declined in women (from 618 to 477 per 10 000 PY) but remained stable in men (from 270 to 278).

CONCLUSIONS

The stabilization of the downward trend in HIV testing coincided with this educational intervention. Follow-up data are needed to formally assess the intervention's impact on GP testing behaviour whilst considering contextual factors and secular trends.

Who is providing HIV diagnostic testing? Comparing HIV testing by general practitioners and sexual health centres in five regions in the Netherlands, 2011-2018

OBJECTIVES

General practitioners (GPs) and sexual health centres (SHCs) are the main providers of HIV testing and diagnose two-thirds of HIV infections in the Netherlands. We compared regional HIV testing and positivity by GPs versus SHCs to gain insight into strategies to improve HIV testing, to enable timely detection of HIV infections.

METHODS

Laboratory data (2011-2018) on HIV testing by GPs and SHCs in five Dutch regions with varying levels of urbanisation were evaluated. Regional HIV testing rates per 10 000 residents ≥15 years (mean over period and annual) were compared between providers using negative binomial generalised additive models and additionally stratified by sex and age (15-29 years, 30-44 years, 45-59 years, ≥60 years). χ² tests were used to compare positivity percentage between the two groups of providers.

RESULTS

In the study period, 505 167 HIV tests (GP 36%, SHC 64%) were performed. The highest HIV testing rates were observed in highly urbanised regions, with large regional variations. The HIV testing rates ranged from 28 to 178 per 10 000 residents by GPs and from 30 to 378 per 10 000 by SHCs. Testing rates by GPs were lower than by SHCs in three regions and comparable in two. In all regions, men were tested less by GPs than by SHCs; for women, this varied by region. Among those aged 15-29 years old, GPs' testing rates were lower than SHCs', while this was reversed in older age categories in four out of five regions. The overall mean HIV positivity was 0.4%. In contrast to other regions, positivity in Amsterdam was significantly higher among individuals tested by GPs than by SHCs.

CONCLUSIONS

This retrospective observational study shows that besides SHCs, who perform opt-out testing for key groups, GPs play a prominent role in HIV testing, especially in non-key populations, such as women and older individuals. Large regional variation exists, requiring region-specific interventions to improve GPs' HIV testing practices.

Factors Associated with Never Testing for HIV: Directions for Targeted Testing Interventions Among Men Who Have Sex with Men

Men who have sex with men (MSM) and who are unaware of their HIV infection contribute to onward HIV transmission and are more likely to progress to severe illness. We therefore assessed determinants of never testing for HIV among MSM living in the Netherlands. Between April and July 2019, 950 HIV-negative and 122 never-tested MSM completed a cross-sectional survey on sociodemographics, HIV testing behavior, and sexual risk taking, which was distributed through gay networking sites/apps. In never-tested MSM, median age was 37 (interquartile range = 22-51) years and 37 (30%) reported recent sexual risk behavior. Never testing was associated with younger age [adjusted odds ratio (aOR) per year increase = 0.98, 95% confidence interval (CI) = 0.97-1.00, p = 0.015], having sex with men and women (aOR = 2.85, 95% CI = 1.57-5.62, p = 0.001), and not knowing others living with HIV (aOR = 3.85, 95% CI = 2.35-6.32, p < 0.001) in multi-variable logistic regression analysis. A significant interaction effect between education level and residential area was observed (p = 0.001). Among higher-educated MSM, those living outside a large urban area had higher odds of never testing compared to those living in an urban area (aOR = 6.26, 95% CI = 2.42-16.24, p < 0.001). Lower-educated MSM had higher odds of never testing irrespective of residential area (large urban area: aOR = 12.06, 95% CI = 4.00-36.38; outside large urban area: aOR 9.29, 95% CI = 3.64-23.76; p < 0.001 for both). Among MSM recently exposed to sexual risk, never testing was associated with having sex with men and women (aOR = 2.80, 95% CI = 1.09-7.18, p = 0.032) and not knowing others with HIV (aOR = 4.91, 95% CI = 1.97-12.24, p = 0.001). To conclude, testing interventions for those never tested should be tailored to residential area and education level, and inclusive of bisexuality.

Evaluating a pilot process for reviewing late HIV diagnoses in England and Wales

Late HIV diagnosis is associated with significant mortality in people living with HIV (PLWH) and high numbers of missed opportunities (MO) for earlier testing have been identified. A pilot of a national late diagnosis review process (LDRP) was undertaken in 15 HIV services evaluating the feasibility of LDRP implementation, as a patient safety initiative. All newly diagnosed PLWH with CD4 counts <200 cells/mm³ were included, and healthcare episodes within 5 years of presentation reviewed. Of 127 patients identified, 40 (31.5%) had MO and were more often white, UK-born and suffered more serious harm around diagnosis. Of these, four were designated serious incidents (undergoing root cause analysis) and eight were serious learning events. Engagement with services where MO occurred was challenging, however 75% of services found the LDRP sustainable. Widespread implementation of the LDRP should enable progress with training and policy changes within external services, enabling earlier HIV diagnosis and preventing deaths.

Identifying key elements to inform HIV-testing interventions for primary care in Belgium

General practitioners (GPs) play a key role in reducing the hidden HIV-epidemic, but many diagnostic opportunities are missed in primary care. This study aimed at informing the development of an HIV-testing intervention for GPs in Flanders (Belgium) using formative research with a participatory approach. Through the active involvement of an advisory board and 16 group discussions with 122 Flemish GPs, GPs’ current HIV-testing practices and perceived practical relevance of 2 distinct HIV-testing strategies (i.e. provider-initiated testing of key populations and indicator condition-based testing) were explored in terms of their relevance and feasibility in routine primary care. Self-reported HIV-testing practices revealed that most tests performed were patient-initiated, pretest counseling was rarely done, and post-test counseling was offered mainly for patients with an HIV-diagnosis. GPs reported multiple barriers to provider-initiated HIV-testing, i.e. personal discomfort, fear of offending their patient, limited knowledge of benefits of early HIV-diagnosis, misconceptions about HIV-risks, lack of guidelines and time. Difficulties to identify patient’s sexual orientation or ethical concerns were mentioned as barriers for target group-based HIV testing. GPs assessed the current list of 64 indicator conditions as too difficult to integrate in routine care, deeming a reduced list of GP-relevant conditions as more feasible. Combined strategies (i.e. target group- and indicator-based testing) supported by official screening recommendations were perceived as successful strategies for provider-initiated HIV-testing in primary care. This formative research delivered qualitative evidence for the development of an HIV-testing intervention for primary care settings.

[HIV prevention with PrEP: Challenges and prospects]

Pre-exposure prophlaxis (PrEP) is the use of antiretroviral drugs by uninfected people to prevent human immunodeficiency virus (HIV) infection. PrEP is used by people who are at substantial risk of being exposed to HIV. Numerous clinical trials have confirmed its effectiveness in reducing HIV acquisition and PrEP has been approved and allowed in several countries including France. However, PrEP uptake remains low as concerns about increase in sexual risk behaviour with PrEP use in the wake of a growing epidemic of sexually transmitted infections, and fear of drug resistance have been expressed. As a result, the difference between the proportion of people on PrEP and the proportion of people who would be very likely to use PrEP if they could access it -otherwise known as the PrEP gap- remains high. Nowadays, studies continue to explore long-term effects of PrEP as well as expand the array of available technologies and regimens.

Development and Evaluation of an HIV-Testing Intervention for Primary Care: Protocol for a Mixed Methods Study

BACKGROUND

Late diagnosis of HIV fosters HIV transmission and may lead to hidden HIV epidemics. In Belgium, mathematical modeling indicates a high prevalence of undiagnosed HIV infections among men who have sex with men of non-Belgian origin and among sub-Saharan African migrants. Promotion of HIV testing facilitates early diagnosis, but diagnostic opportunities are missed in primary care.

OBJECTIVE

The intervention study aims to enhance provider-initiated HIV testing by GPs. This protocol presents the conceptual development, implementation, and evaluation of an HIV-testing intervention for Flemish general practitioners (GPs).

METHODS

A mixed methods evaluation design is used. Guided by a simplified intervention mapping approach, an evidence-based intervention was developed in collaboration, guided by an interdisciplinary advisory board. The intervention consisted of an evidence-based tool (ie, "HIV-testing advice for primary care") to support GPs in provider-initiated HIV testing. A modified stepped-wedge design compare two different intervention levels: (1) online dissemination of the HIV-testing advice and (2) dissemination with additional group-level training. Both conditions were compared against a control condition with no intervention. The effect of the intervention was measured using Poisson regression for national surveillance data. The primary outcome was the number of HIV diagnoses made by GPs. Secondary outcomes were HIV diagnoses among groups at risk for undiagnosed HIV, distribution of new diagnoses by CD4 cell count, number of HIV tests prescribed by GPs, and rate of new diagnoses by tests. To evaluate the intervention's implementation, the GPs' fidelity to the intervention and the intervention's feasibility and acceptability by GPs were assessed through (web-based) surveys and in-depth telephone interviews.

RESULTS

The study was funded in 2016 and ethically approved in January 2017. The implementation of the intervention started in January 2017 and ended in December 2018. Data was completed in October 2019 and was the starting point for the ongoing data analysis. The results are expected to be published in the second half of 2020.

CONCLUSIONS

Results of the intervention study will provide useful information on the intervention's effectiveness among Flemish GPs and can inform further development of official testing guidelines. Limitations of this real-life intervention approach are potential spill-over effects, delay in access to surveillance data, and little detailed information on HIV-testing practices among GPs.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04056156; https://clinicaltrials.gov/ct2/show/NCT04056156.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/16486.

Kaposi sarcoma among people living with HIV in the French DAT'AIDS cohort between 2010 and 2015

Background

Although antiretroviral therapy (ART) has reduced the risk of Kaposi sarcoma (KS), KS cases still occur in HIV‐infected people.

Objective

To describe all KS cases observed between 2010 and 2015 in a country with high ART coverage.

Methods

Retrospective study using longitudinal data from 44 642 patients in the French Dat’AIDS multicenter cohort. Patients’ characteristics were described at KS diagnosis according to ART exposure and to HIV‐plasma viral load (HIV‐pVL) (≤50 or >50) copies/mL.

Results

Among the 209 KS cases diagnosed during the study period, 33.2% occurred in ART naïve patients, 17.3% in ART‐experienced patients and 49.5% in patients on ART, of whom 23% for more than 6 months. Among these patients, 24 (11.5%) had HIV‐pVL ≤50 cp/mL, and 16 (66%) were treated with a boosted‐PI‐based regimen. The distribution of KS localization did not differ by ART status nor by year of diagnosis.

Limitations

Data on human herpesvirus 8, treatment modalities for KS and response rate were not collected.

Conclusion

Half of KS cases observed in the study period occurred in patients not on ART, reflecting the persistence of late HIV diagnosis. Factors associated with KS in patients on ART with HIV‐pVL ≤50 cp/mL remain to be explored.

Estimates of the HIV undiagnosed population in Belgium reveals higher prevalence for MSM with foreign nationality and for geographic areas hosting big cities

Introduction

Increasing our knowledge on geographic areas and key populations most affected by HIV is essential to improve prevention and care and to ensure a more focused HIV response. Here, we estimated the prevalence of undiagnosed HIV infections in Belgium and its distribution across geographic areas and exposure groups.

Methods

We used surveillance data on newly diagnosed HIV cases and a previously developed back‐calculation model to estimate number and prevalence rates (per 10000) of undiagnosed HIV infections by exposure group at national and subnational levels. Belgium consists of three regions: Flanders, Brussels‐Capital Region and Wallonia. We produced estimates for Brussels‐Capital Region and Wallonia. For Flanders, we produced estimates for two sub‐regional areas: the province of Antwerp and the other provinces, because Antwerp is the second largest city after Brussels. Population sizes were determined using data from the Belgian Statistical Office and surveys on sexual behaviour and drug use.

Results

In Belgium, in 2015, an estimated 2818 (95% confidence interval: 2494 to 3208) individuals were living with undiagnosed HIV, that is, 15% of individuals living with HIV. The Brussels‐Capital Region and the province of Antwerp, which host the two biggest cities, accounted for ~60% of the undiagnosed infections, and had the highest undiagnosed prevalence rates per 10000: 12.0 (9.4 to 15.3) and 7.4 (5.6 to 9.8) respectively. Individuals with foreign nationality accounted for 56% of the total number of undiagnosed infections, and were the most affected populations in all areas in terms of undiagnosed prevalence rates. Specifically, men who have sex with men (MSM) with non‐European nationality were the most affected population in the province of Antwerp (853.4 (408.2 to 1641.9) undiagnosed infections per 10000), the Brussels‐Capital Region (543.9 (289.1 to 1019.1)), and the other provinces of Flanders (691.7 (235.5 to 1442.2)), while in Wallonia, it was heterosexual women with Sub‐Saharan African nationality (132.2 (90.6 to 178.5)).

Conclusions

Geographic areas hosting the biggest cities in Belgium accounted for the vast majority of undiagnosed HIV infections and individuals with foreign nationality were the most affected, especially MSM with non‐European nationality. This should be accounted for when tailoring prevention and testing programs. Furthermore, MSM with foreign nationality require more attention in Belgium, and certainly more generally in Europe.

HIV testing strategies employed in health care settings in the European Union/European Economic Area (EU/EEA): evidence from a systematic review

OBJECTIVES

Despite the availability of HIV testing guidelines to facilitate prompt diagnosis, late HIV diagnosis remains high across Europe. The study synthesizes recent evidence on HIV testing strategies adopted in health care settings in the European Union/European Economic Area (EU/EEA).

METHODS

Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were followed and systematic searches were run in five databases (2010-2017) to identify studies describing HIV testing interventions in health care settings in the EU/EEA. The grey literature was searched for unpublished studies (2014-2017). Two reviewers independently performed study selection, data extraction and critical appraisal.

RESULTS

One hundred and thirty intervention and/or feasibility studies on HIV testing in health care settings were identified. Interventions included testing provision (n = 94), campaigns (n = 14) and education and training for staff and patients (n = 20). HIV test coverage achieved through testing provision varied: 2.9-94% in primary care compared to 3.9-66% in emergency departments. HIV test positivity was lower in emergency departments (0-1.3%) and antenatal services (0-0.05%) than in other hospital departments (e.g. inpatients: 0-5.3%). Indicator condition testing programmes increased HIV test coverage from 3.9-72% before to 12-85% after their implementation, with most studies reporting a 10-20% increase. There were 51 feasibility and/or acceptability studies that demonstrated that HIV testing interventions were generally acceptable to patients and providers in health care settings (e.g. general practitioner testing acceptable: 77-93%).

CONCLUSIONS

This review has identified several strategies that could be adopted to achieve high HIV testing coverage across a variety of health care settings and populations in the EU/EEA. Very few studies compared the intervention under investigation to a baseline, but, where this was assessed, data suggested increases in testing.

The role of mobility in sexual risk behaviour and HIV acquisition among sub-Saharan African migrants residing in two European cities

BACKGROUND

Migrants from high endemic countries accounted for 18% of newly diagnosed HIV infections in Europe in 2017. Knowledge on the link between HIV risk and post-migration travels and their impact on HIV acquisition is scarce, but critical to inform prevention. This study aims to explore risky sexual behaviour and HIV-acquisition among sub-Saharan African migrants, and to assess post-migration mobility as a determinant of sexual risk behaviour.

METHODS

Data from two cross-sectional bio-behavioural surveys to assess HIV-prevalence conducted in Lisbon and Antwerp were analysed to explore migration-related characteristics, travel patterns, and sexual risk taking in the host country and abroad. Bi- and multivariate associations were estimated through adjusted odds ratios and 95% confidence intervals; multivariable logistic regression determined factors associated with condomless sexual intercourse.

RESULTS

Among N = 1508 participants above 18 years (58% males), 68% travelled post-migration (49.2% reported intercourse abroad). The overall proportion of condomless sex at last sexual intercourse was high (68.1%). The odds of condomless sex in the host country was five times higher when the last sexual intercourse abroad was also condomless [OR:5.32; 95%CI:2.98-9.25]. About half of the travellers reported concurrency, i.e. a regular partner in the host country while having other sexual partners abroad. Almost three percent of the participants reported being HIV+, but 5% had a reactive HIV test-result, with similar proportions among travellers and non-travellers. Also, among the n = 75 participants with reactive HIV test-results, condomless sex occurred (n = 40) and was associated with mobility.

CONCLUSIONS

Sub-Saharan African migrants are mobile and engage in sexual risk behaviours in the countries of residence and while travelling, increasing risk of post-migration HIV-acquisition. A transnational perspective on HIV prevention and sexual health promotion is needed for effectively reducing migrants' HIV risk related to their mobility.