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Niforatos JD, Nowacki AS, Avery A, Gripshover BM, Yax JA. Clinical knowledge of human immunodeficiency virus and sexually transmitted infections among emergency medicine providers. Int J STD AIDS 2019; 30:1290-1297. [PMID: 31718468 DOI: 10.1177/0956462419866052] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Introduction This study examines the association of the domains of knowledge for HIV and sexually transmitted infections (STIs) among emergency medicine providers (EP). Methods From February 2018 to March 2018, 75 EP (physicians, residents, and advanced practice providers) completed an anonymous, self-administered survey. The primary outcome of strength of correlation between HIV and STI sections of the survey was analyzed using Spearman’s rank-order coefficient. Results Respondents were physicians (54.6%), male (56%), Caucasian (83.7%), with eight years in practice (IQR: 2,16). Spearman’s correlation of HIV and STIs showed a weak positive correlation ( r = 0.35, p = 0.002). There was no association between HIV scores and provider type ( p = 0.67) or provider gender ( p = 0.89) as well as no association between STI scores and provider type ( p = 0.10) or provider gender ( p = 0.79). Conclusion The results of our study reveal that when presented with a patient at high risk for undiagnosed HIV or with undiagnosed symptomatic HIV infection, most providers either do not test or do not have HIV in the differential diagnosis. Similarly, knowledge of STIs is only weakly correlated with knowledge of HIV risk factors and symptomatic HIV infection. Further research and screening efforts may benefit by focusing on HIV education among emergency medicine providers.
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Affiliation(s)
- Joshua D Niforatos
- Cleveland Clinic Lerner College of Medicine, Case Western Reserve University, Cleveland, OH, USA.,Department of Emergency Medicine, The Johns Hopkins Hospital/The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Amy S Nowacki
- Cleveland Clinic Lerner College of Medicine, Case Western Reserve University, Cleveland, OH, USA.,Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, OH, USA
| | - Ann Avery
- Case Western Reserve University School of Medicine, Cleveland, OH, USA.,Department of Infectious Diseases, MetroHealth Medical Center, Cleveland, OH, USA
| | - Barbara M Gripshover
- Case Western Reserve University School of Medicine, Cleveland, OH, USA.,John T. Carey Special Immunology Unit, Department of Medicine, Division of Infectious Diseases and HIV Medicine, University Hospitals Cleveland Medical Center, Cleveland, OH, USA
| | - Justin A Yax
- Case Western Reserve University School of Medicine, Cleveland, OH, USA.,Department of Emergency Medicine, University Hospitals Cleveland Medical Center, Cleveland, OH, USA
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Tan R, Hugli O, Cavassini M, Darling K. Non-targeted HIV testing in the emergency department: not just how but where. Expert Rev Anti Infect Ther 2018; 16:893-905. [PMID: 30406726 DOI: 10.1080/14787210.2018.1545575] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
INTRODUCTION The emergency department (ED) has the potential to enhance early HIV diagnosis through HIV testing programs. How these are implemented is a subject of debate. Areas covered: We describe the main HIV testing approaches: diagnostic testing, targeted screening, and non-targeted screening, and review ED-based non-targeted HIV screening studies conducted after 2006 among ≥5000 patients. As well as examining how testing is offered, we focus on where it is offered, through the patient's journey from registration, via triage and the waiting room, to the bedside. Barriers to the testing offer, acceptance and performance were examined at each location. While testing offer rates were higher at registration and triage, compared to the waiting room and bedside, this was sometimes at the expense of testing acceptance and performance. Variables affecting testing rates included type of consent, employment of external staff and type of testing: fourth generation serological testing versus rapid testing. Expert commentary: These large studies shed light on the importance of where as well as how HIV testing is performed, and the ways in which the 'where' can influence non-targeted screening yields. This perspective enables testing approaches to be tailored to specific ED settings in order to maximize testing rates.
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Affiliation(s)
- Rainer Tan
- a Infectious Diseases Service , Lausanne University Hospital , Lausanne , Switzerland
| | - Olivier Hugli
- b Emergency Department , Lausanne University Hospital , Lausanne , Switzerland
| | - Matthias Cavassini
- a Infectious Diseases Service , Lausanne University Hospital , Lausanne , Switzerland
| | - Katharine Darling
- a Infectious Diseases Service , Lausanne University Hospital , Lausanne , Switzerland
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Lazzarino T, Martenet S, Mamin R, Du Pasquier RA, Peters S, Perreau M, Muller O, Hugli O, Cavassini M, Darling KEA. Effect of national HIV testing recommendations and local interventions on HIV testing practices in a Swiss university hospital: a retrospective analysis between 2012 and 2015. BMJ Open 2018; 8:e021203. [PMID: 30287667 PMCID: PMC6194398 DOI: 10.1136/bmjopen-2017-021203] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
OBJECTIVES Despite HIV testing recommendations published by the Federal Office of Public Health (FOPH) since 2007, many individuals living with HIV are diagnosed late in Switzerland. The aim of this study is to examine the effect of the 2013 FOPH HIV testing recommendations on HIV testing rates. SETTING Ten clinical services at Lausanne University Hospital, Lausanne, Switzerland. PARTICIPANTS Patients attending between 1 January 2012 and 31 December 2015. DESIGN Retrospective analysis using two existing hospital databases. HIV testing rates calculated as the percentage of tests performed (from the Immunology Service database) per number of patients seen (from the central hospital database). PRIMARY AND SECONDARY OUTCOME MEASURES The primary outcome was testing rate change following the 2013 FOPH testing recommendations, comparing testing rates 2 years before and 2 years after their publication. Secondary outcomes were demographic factors of patients tested or not tested for HIV. RESULTS 147 884 patients were seen during the study period of whom 9653 (6.5%) were tested for HIV, with 34 new HIV diagnoses. Mean testing rate increased from 5.6% to 7.8% after the recommendations (p=0.001). Testing rate increases were most marked in services involved in clinical trials on HIV testing, whose staff had attended training seminars on testing indications and practice. Testing rates were lower among older (aged >50 years), female and Swiss patients compared with younger, male and non-Swiss patients, both globally (p=0.001) and in specific clinical services. CONCLUSIONS This simple two-database tool demonstrates clinical services in which HIV testing practice can be optimised. Improved testing rates in services involved in clinical trials on testing suggest that local engagement complements the effect of national recommendations. While, overall, HIV testing rates increased significantly over time, testing rates were lower among patients with similar demographic profiles to individuals diagnosed late in Switzerland.
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Affiliation(s)
- Tosca Lazzarino
- Faculty of Biology and Medicine, University of Lausanne, Lausanne University Hospital, Lausanne, Switzerland
| | - Sebastien Martenet
- Information and Management Control, Lausanne University Hospital, Lausanne, Switzerland
| | - Rachel Mamin
- Service of Immunology and Allergy, Lausanne University Hospital, Lausanne, Switzerland
| | | | - Solange Peters
- Service of Oncology, Lausanne University Hospital, Lausanne, Switzerland
| | - Matthieu Perreau
- Service of Immunology and Allergy, Lausanne University Hospital, Lausanne, Switzerland
| | - Olivier Muller
- Cardiology Service, Lausanne University Hospital, Lausanne, Switzerland
| | - Olivier Hugli
- Emergency Department, Lausanne University Hospital, Lausanne, Switzerland
| | - Matthias Cavassini
- Infectious Diseases Service, Lausanne University Hospital, Lausanne, Switzerland
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Lhopitallier L, Moulin E, Hugli O, Cavassini M, Darling KEA. Missed opportunities for HIV testing among patients newly presenting for HIV care at a Swiss university hospital: a retrospective analysis. BMJ Open 2018; 8:e019806. [PMID: 29895647 PMCID: PMC6009466 DOI: 10.1136/bmjopen-2017-019806] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
Abstract
OBJECTIVES To determine the frequency of missed opportunities (MOs) among patients newly diagnosed with HIV, risk factors for presenting MOs and the association between MOs and late presentation (LP) to care. DESIGN Retrospective analysis. SETTING HIV outpatient clinic at a Swiss tertiary hospital. PARTICIPANTS Patients aged ≥18 years newly presenting for HIV care between 2010 and 2015. MEASURES Number of medical visits, up to 5 years preceding HIV diagnosis, at which HIV testing had been indicated, according to Swiss HIV testing recommendations. A visit at which testing was indicated but not performed was considered an MO for HIV testing. RESULTS Complete records were available for all 201 new patients of whom 51% were male and 33% from sub-Saharan Africa. Thirty patients (15%) presented with acute HIV infection while 119 patients (59%) were LPs (CD4 counts <350 cells/mm3 at diagnosis). Ninety-four patients (47%) had presented at least one MO, of whom 44 (47%) had multiple MOs. MOs were more frequent among individuals from sub-Saharan Africa, men who have sex with men and patients under follow-up for chronic disease. MOs were less frequent in LPs than non-LPs (42.5% vs 57.5%, p=0.03). CONCLUSIONS At our centre, 47% of patients presented at least one MO. While our LP rate was higher than the national figure of 49.8%, LPs were less likely to experience MOs, suggesting that these patients were diagnosed late through presenting late, rather than through being failed by our hospital. We conclude that, in addition to optimising provider-initiated testing, access to testing must be improved among patients who are unaware that they are at HIV risk and who do not seek healthcare.
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Affiliation(s)
- Loïc Lhopitallier
- Infectious Diseases Service, Lausanne University Hospital, Lausanne, Switzerland
| | - Estelle Moulin
- Infectious Diseases Service, Lausanne University Hospital, Lausanne, Switzerland
| | - Olivier Hugli
- Emergency Department, Lausanne University Hospital, Lausanne, Switzerland
| | - Matthias Cavassini
- Infectious Diseases Service, Lausanne University Hospital, Lausanne, Switzerland
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Gillet C, Darling KEA, Senn N, Cavassini M, Hugli O. Targeted versus non-targeted HIV testing offered via electronic questionnaire in a Swiss emergency department: A randomized controlled study. PLoS One 2018. [PMID: 29513659 PMCID: PMC5841645 DOI: 10.1371/journal.pone.0190767] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Background In Switzerland, the national HIV testing recommendations propose targeted testing. Although the emergency department (ED) is mentioned specifically as a site where HIV testing should take place, the testing rate in our ED is 1% of patients seen. The aim of this study was to use electronic tablets to offer testing to ED patients and to examine whether non-targeted screening increased testing rates compared to targeted testing. Methods This randomised, cross-over design study took place at Lausanne University Hospital, Switzerland, between August and November 2015. Eligible patients were randomised to a targeted testing or a non-targeted screening arm. Using electronic tablets, targeted arm patients completed a risk factor assessment; patients with risk factors were offered free rapid HIV testing. Non-targeted arm patients received information about HIV and HIV testing on their tablet and were then offered testing. In a second step, patients who declined testing were crossed over to the other strategy. The primary endpoint was the HIV testing rate per arm. Results Eighty patients were recruited to each study arm. In the targeted arm, 17 patients (of 80, 21%) had at least one risk factor and were offered testing, of whom eight (of 17, 47%) accepted. HIV testing rate in the targeted arm was 10% (8/80) compared to 48% (38/80) in the non-targeted arm (P<0.001). Secondary cross–screening, where targeted arm patients without risk factors were offered non-targeted screening, increased the testing rate in the targeted arm to 45% (36/80). Among patients offered testing, the acceptance rate did not differ between targeted and non-targeted arms, at 48% and 53%, respectively (P = 0.9) Discussion In our centre, non-targeted HIV screening resulted in a higher testing rate than targeted testing due to more patients being offered a test. The acceptance rate of testing offered did not differ between targeted and non-targeted arms. Electronic tablets were well-received by patients and easy to use. We conclude that non-targeted HIV screening using electronic tablets would increase the HIV testing rate in our ED. Trial registration ClinicalTrials.gov NCT03038724
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Affiliation(s)
- Cleo Gillet
- Faculty of Biology and Medicine, University of Lausanne, Lausanne, Switzerland
| | | | - Nicolas Senn
- Department of Ambulatory Care and Community Medicine, University of Lausanne, Lausanne, Switzerland
| | - Matthias Cavassini
- Infectious Disease Service, Lausanne University Hospital, Lausanne, Switzerland
| | - Olivier Hugli
- Emergency Department, Lausanne University Hospital, Lausanne, Switzerland
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Kang H, Cui Z, Chia JTN, Khorsandi Zardoshti A, Barrios R, Lima VD, Guillemi S. Innovative Multimodal Training Program for Family Physicians Leads to Positive Outcomes Among Their HIV-Positive Patients. THE JOURNAL OF CONTINUING EDUCATION IN THE HEALTH PROFESSIONS 2018; 38:60-65. [PMID: 29369268 DOI: 10.1097/ceh.0000000000000189] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
CME programs can increase physicians' uptake and adherence to clinical guidelines for chronic diseases. We developed an intensive multimodal training program for family physicians to increase their competency in the management and treatment of HIV, through group learning and via close interactions with expert clinicians in HIV. We trained 51 physicians from September 2010 to June 2015 and compared their adherence to clinical guidelines 1 year before and 1 year after the program. We observed significant increases in the physicians' HIV-related clinical competencies, in accordance with clinical guidelines, and an increase in the number of HIV-positive patients seen by these physicians and the number of combination antiretroviral therapies prescribed by these physicians. By combining various pedagogical approaches, as well as creating and encouraging communities of practice, we were able to make a durable impact on physician performance and patient-specific outcomes.
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Affiliation(s)
- Helen Kang
- Dr. Kang: Independent Scholar. Ms. Cui: Biostatistician, BC Centre for Excellence in HIV/AIDS. Mr. Chia: Data Analyst, BC Centre for Excellence in HIV/AIDS. Ms. Khorsandi Zardoshti: Clinical Education Program Coordinator, BC Centre for Excellence in HIV/AIDS. Dr. Barrios: Senior Medical Director, Vancouver Community Health Services, Vancouver Coastal Health Authority. Dr. Lima: Research Scientist/Senior Statistician, Epidemiology and Population Health Program, BC Centre for Excellence in HIV/AIDS. Dr. Guillemi: Director of Clinical Education, BC Centre for Excellence in HIV/AIDS
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Patient and doctor perspectives on HIV screening in the emergency department: A prospective cross-sectional study. PLoS One 2017; 12:e0180389. [PMID: 28732088 PMCID: PMC5521743 DOI: 10.1371/journal.pone.0180389] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2017] [Accepted: 06/14/2017] [Indexed: 11/26/2022] Open
Abstract
Background The emergency department (ED) is mentioned specifically in the Swiss HIV testing recommendations as a site at which patients can benefit from expanded HIV testing to optimise early HIV diagnosis. At our centre, where local HIV seroprevalence is 0.2–0.4%, 1% of all patients presenting to the ED are tested for HIV. Barriers to HIV testing, from the patient and doctor perspective, and patient acceptability of rapid HIV testing were examined in this study. Methods Between October 2014 and May 2015, 100 discrete patient-doctor encounter pairs undertook a survey in the ED of Lausanne University Hospital, Switzerland. Patients completed a questionnaire on HIV risk factors and were offered free rapid HIV testing (INSTI™). For every patient included, the treating doctor was asked if HIV testing had 1) been indicated according to the national testing recommendations, 2) mentioned, and 3) offered during the consultation. Results Of 100 patients, 30 had indications for HIV testing through risk factors or a suggestive presenting complaint (PC). Fifty patients accepted rapid testing; no test was reactive. Of 50 patients declining testing, 82% considered themselves not at risk or had recently tested negative and 16% wished to focus on their PC. ED doctors identified 20 patients with testing indications, mentioned testing to nine and offered testing to six. The main reason for doctors not mentioning or not offering testing was the wish to focus on the PC. Discussion Patients and doctors at our ED share the testing barrier of wishing to focus on the PC. Rapid HIV testing offered in parallel to the patient-doctor consultation increased the testing rate from 6% (offered by doctors) to 50%. Introducing this service would enable testing of patients not offered tests by their doctors and reduce missed opportunities for early HIV diagnosis.
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Tominski D, Katchanov J, Driesch D, Daley MB, Liedtke A, Schneider A, Slevogt H, Arastéh K, Stocker H. The late-presenting HIV-infected patient 30 years after the introduction of HIV testing: spectrum of opportunistic diseases and missed opportunities for early diagnosis. HIV Med 2016; 18:125-132. [PMID: 27478058 DOI: 10.1111/hiv.12403] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/24/2016] [Indexed: 11/27/2022]
Abstract
OBJECTIVES The aim of the study was to describe the characteristics of HIV-infected late presenters, opportunistic diseases at diagnosis and missed opportunities to diagnose HIV infection earlier. METHODS In a retrospective cohort study, we reviewed the medical records of all adults with newly diagnosed HIV infection admitted to the Department of Infectious Diseases of the Vivantes Auguste-Viktoria Hospital, Berlin, Germany. RESULTS In the 5-year period from 2009 to 2013, 270 late presenters were identified. The most common AIDS-defining conditions were oesophageal candidiasis (n = 136; 51%), wasting syndrome (n = 106; 40%) and pneumocystis pneumonia (n = 91; 34%). Fifty-five patients (21%) had presented with at least one HIV indicator condition on prior contact with health care services without being offered testing for HIV. Female patients and heterosexual men [not men who have sex with men ('non-MSM')] had a significantly higher chance of being among patients previously presenting with indicator conditions and not being tested [odds ratio (OR) 4.7; 95% confidence interval (CI) 2.2-10.0; P < 0.001; and OR 2.4; 95% CI 1.2-5.1; P < 0.01, respectively]. The most commonly missed indicator conditions were leucocytopenia (n = 13; 24%), thrombocytopenia (n = 12; 22%), oral candidiasis (n = 9; 16%), unexplained weight loss (n = 7; 13%), herpes zoster (n = 5; 9%) and cervical dysplasia/cancer (n = 4; 20% of women). The median time between presentation with an indicator condition and the diagnosis of HIV infection was 158.5 days [interquartile range (IQR) 40-572 days]. Patients with oral candidiasis and unexplained weight loss had the shortest time between the "missed opportunity" and the diagnosis of HIV infection. Fifty-five hospital admissions with a total cost of over EUR 500 000 and - most importantly - six in-hospital deaths might have been prevented if HIV testing had been performed in patients with documented indicator conditions. CONCLUSIONS Indicator conditions are still missed by clinicians. Women and 'non-MSM' are at highest risk of presenting with an indicator condition but not being tested for HIV infection.
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Affiliation(s)
- D Tominski
- Department of Infectious Diseases, Vivantes Auguste-Viktoria Hospital, Berlin, Germany
| | - J Katchanov
- Department of Infectious Diseases, Vivantes Auguste-Viktoria Hospital, Berlin, Germany
| | | | - M B Daley
- Department of Infectious Diseases, Vivantes Auguste-Viktoria Hospital, Berlin, Germany
| | - A Liedtke
- Department of Infectious Diseases, Vivantes Auguste-Viktoria Hospital, Berlin, Germany
| | - A Schneider
- Department of Infectious Diseases, Vivantes Auguste-Viktoria Hospital, Berlin, Germany
| | - H Slevogt
- Septomics Research Center, Jena University Hospital, Jena, Germany
| | - K Arastéh
- Department of Infectious Diseases, Vivantes Auguste-Viktoria Hospital, Berlin, Germany
| | - H Stocker
- Department of Infectious Diseases, Vivantes Auguste-Viktoria Hospital, Berlin, Germany
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Merz L, Zimmermann S, Peters S, Cavassini M, Darling KEA. Investigating Barriers in HIV-Testing Oncology Patients: The IBITOP Study, Phase I. Oncologist 2016; 21:1176-1182. [PMID: 27440062 DOI: 10.1634/theoncologist.2016-0107] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2016] [Accepted: 06/02/2016] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Although the prevalence of non-AIDS-defining cancers (non-ADCs) among people living with HIV is rising, we observed HIV testing rates below 5% at our oncology center, against a regional HIV prevalence of 0.2%-0.4%. We performed the Investigating Barriers in HIV-Testing Oncology Patients (IBITOP) study among oncology physicians and patients. METHODS Between July 1 and October 31, 2013, patients of unknown HIV status newly diagnosed with solid-organ non-ADCs referred to Lausanne University Hospital Oncology Service, Switzerland, were offered free HIV testing as part of their oncology work-up. The primary endpoints were (a) physician willingness to offer and patient acceptance of HIV testing and (b) physicians' reasons for not offering testing. RESULTS Of 239 patients of unknown HIV status with a new non-ADC diagnosis, 43 (18%) were offered HIV testing, of whom 4 declined (acceptance rate: 39 of 43; 91%). Except for 21 patients tested prior to oncology consultation, 175 patients (of 239; 73%) were not offered testing. Testing rate declined among patients who were >70 years old (12% versus 30%; p = .04); no non-European patients were tested. Physicians gave reasons for not testing in 16% of cases, the main reason being patient follow-up elsewhere (10 patients; 5.7%). HIV testing during the IBITOP study increased the HIV testing rate to 18%. CONCLUSION Although the IBITOP study increased HIV testing rates, most patients were not tested. Testing was low or nonexistent among individuals at risk of late HIV presentation (older patients and migrants). Barriers to testing appear to be physician-led, because patient acceptance of testing offered was very high (91%). In November 2013, the Swiss HIV testing recommendations were updated to propose testing in cancer patients. Phase II of the IBITOP study is examining the effect of these recommendations on HIV testing rates and focusing on physician-led testing barriers. IMPLICATIONS FOR PRACTICE Patients of unknown HIV status newly diagnosed with solid-organ non-AIDS-defining cancers were offered free HIV testing. Physician and patient barriers to HIV testing were examined. Most patients (82%) were not offered testing, and testing of individuals at risk of late HIV presentation (older patients and migrants) was low or nonexistent. Conversely, patient acceptance of testing offered was very high (91%), suggesting that testing barriers in this setting are physician-led. Since this study, the Swiss HIV testing recommendations now advise testing cancer patients before chemotherapy. Phase II of the Investigating Barriers in HIV-Testing Oncology Patients study is examining the effect of these recommendations on testing rates and physician barriers.
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Affiliation(s)
- Laurent Merz
- Infectious Diseases Service, Department of Medicine, Lausanne University Hospital, Lausanne, Switzerland
| | - Stefan Zimmermann
- Oncology Centre, Department of Oncology, Lausanne University Hospital, Lausanne, Switzerland
| | - Solange Peters
- Oncology Centre, Department of Oncology, Lausanne University Hospital, Lausanne, Switzerland
| | - Matthias Cavassini
- Infectious Diseases Service, Department of Medicine, Lausanne University Hospital, Lausanne, Switzerland
| | - Katharine E A Darling
- Infectious Diseases Service, Department of Medicine, Lausanne University Hospital, Lausanne, Switzerland
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