Investigating Barriers in HIV-Testing Oncology Patients: The IBITOP Study, Phase I

Clinical decision support systems to guide healthcare providers on HIV testing

OBJECTIVE

To understand the impact of clinical decision support systems (CDSSs) on improving HIV testing and diagnosis.

DESIGN

An original global systematic review (PROSPERO Number: CRD42020175576) of peer-reviewed articles reporting on electronic CDSSs that generate triggers encouraging healthcare providers to perform an HIV test.

METHODS

Medline, Embase, Cochrane CENTRAL and CINAHL EBSCOhost were searched up to 17 November 2020 and reference lists of included articles were checked. Qualitative and quantitative syntheses (using meta-analyses) of identified studies were performed.

RESULTS

The search identified 1424 records. Twenty-two articles met inclusion criteria (19 of 22 non-HIV endemic settings); 18 clinical and four laboratory-driven reminders. Reminders promoted 'universal' HIV testing for all patients without a known HIV infection and no recent documented HIV test, or 'targeted' HIV testing in patients with clinical risk-factors or specific diagnostic tests. CDSSs increased HIV testing in hospital and nonhospital setting, with the pooled risk-ratio amongst studies reporting comparable outcome measures in hospital settings (n = 3) of 2.57 [95% confidence interval (CI) 1.53-4.33, random-effect model] and in nonhospital settings (n = 4) of 2.13 (95% CI 1.78-4.14, random effect model). Results of the clinical impact of CDSSs on HIV diagnosis were mixed.

CONCLUSION

CDSSs improve HIV testing and may, potentially, improve diagnosis. The data support the broader study of CDSSs in low- and high prevalent HIV settings to determine their precise impact on UNAIDS goals to reach universal HIV testing and treatment coverage.

Patterns of HIV Self-Disclosure in the Oncology Setting

Higher rates of cancer treatment toxicity and uniquely poor outcomes following a cancer diagnosis have been reported for persons living with HIV (PLWH). This highlights the importance of active HIV status ascertainment in the oncology setting. Self-disclosure of HIV via electronic questionnaire at patient intake is a low-cost option that has not been thoroughly evaluated. We examined 10 years (2009-2019) of patient intake questionnaire data at Moffitt Cancer Center. Self-disclosure of an HIV diagnosis was not uniform, with 36.1% (n = 299, 95% confidence interval [CI] = 32.8% to 39.4%) of 828 patients disclosing. Identification of HIV through this method was highest for anal cancer patients (66.7%, 95% CI = 57.8% to 74.7%). Self-disclosure among patients with hematopoietic malignancies, the most common diagnosis among PLWH at our institution, was lower (19.4%, 95% CI = 14.6% to 25.0%). Patient characteristics associated with HIV self-disclosure included cancer site, natal gender, and race and ethnicity. Findings highlight gaps to motivate future efforts to increase HIV ascertainment prior to initiating cancer care.

Latent infection screening and prevalence in cancer patients born outside of Australia: a universal versus risk-based approach?

PURPOSE

Contention surrounds how best to screen patients for latent and undiagnosed infection prior to cancer treatment. Early treatment and prophylaxis against reactivation may improve infection-associated morbidity. This study sought to examine rates of screening and prevalence of latent infection in overseas-born patients receiving cancer therapies.

METHODS

A single-centre retrospective audit of 952 overseas-born patients receiving chemotherapy, targeted agents and immunotherapy between January 1 and December 31 2019 was undertaken at Peter MacCallum Cancer Centre. Pre-treatment screening for hepatitis B (HBV), hepatitis C (HCV), human immunodeficiency virus (HIV), latent tuberculosis (LTBI), toxoplasmosis and strongyloidiasis was audited.

RESULTS

Approximately half of our overseas-born patients were screened for HBV (58.9%) and HCV (50.7%). Fewer patients were screened for HIV (30.5%), LTBI (18.3%), strongyloidiasis (8.6%) or toxoplasmosis (8.1%). Although 59.7% of our patients were born in countries with high epidemiological risk for latent infection, according to World Health Organization data, 35% were not screened for any infection prior to commencement of therapy.

CONCLUSION

The prevalence of latent infections amongst overseas-born patients with cancer, and complexities associated with risk-based screening, likely supports universal latent infection screening amongst this higher-risk cohort.

[Survey on HIV, HBV and HCV screening practices in cancerology, France]

HIV testing is recommended at time of cancer diagnosis, HBV and HCV screening because of the risk of reactivation with certain anticancer drugs.This is a cross-sectional study. The objectives were to assess the screening practices in cancer patients and the satisfaction of professionals in the event of use of the CancerHIV network. A questionnaire drafted by the CancerHIV expert and the OncoPaca-Corse Regional Cancer Network (RCN) was distributed in the region at the end of 2018 (part 1: V1) before being extended to the national level via the CancerHIV network (part 2: V2). Participation reached 160 and 130 respondents (V1 and V2, respectively). At the initial cancer assessment, 23% of respondents declared that they systematically screened for HIV at V1 (V2: 17%), 25% for HBV (V2: 20%) and 24% for HCV (V2: 19%). Before immunotherapy, the rates were 54% for HIV in V1 (V2: 52%), 57% for HBV (V2: 60%) and 55% for HCV (V2: 57%). Among the respondents, satisfaction when requesting a regional or national remedy was high (almost 100%). Screening for HIV, HBV and HCV allows supervised prescription of immunosuppressive or cytotoxic treatment to a potentially immunosuppressed patient. This study, resulting of an original collaboration between a RCN and a national expert network, underlines the lack of screening at the 2 examined stages of patient care, and the need for raising practitioners' awareness to recommendations.

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

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.

Missed opportunities for HIV testing among patients newly presenting for HIV care at a Swiss university hospital: a retrospective analysis

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.

Impact and barriers of an HIV rapid test program implementation at an oncological referral center in Mexico

The aim of this study was to evaluate the implementation of human immunodeficiency virus (HIV) screening with rapid tests in an oncologic center in Mexico City, report the HIV prevalence, and describe contacts screening and linkage to HIV care while identifying barriers to the performance of the program. In 2014, an HIV rapid test program was implemented in four departments of the hospital "Instituto Nacional de Cancerología". From 2014 to 2016, 3032 HIV rapid tests were performed in the hospital. The overall HIV prevalence was 0.8%, with the highest prevalence in the Hematology Department (2.4%). In the Gynecology Department, prevalence was 0.05%. Only 25 and 22 tests were performed in the lung cancer and germ cell tumor clinic, respectively, with one positive test. The health staff not offering the test was the main limitation to the full implementation of the program in those departments. The contacts screening led to three positive cases. The acceptance of the test was 99%. Patients who tested positive were seen by an infectious diseases physician on the same day the test was performed. Rapid HIV tests are a useful tool to expand HIV diagnosis in patients with cancer and to establish a rapid linkage to HIV care. Staff education needs to be improved to raise awareness of the health staff for a successful scale up of the program.