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.

HIV indicator condition-guided testing to reduce the number of undiagnosed patients and prevent late presentation in a high-prevalence area: a case-control study in primary care.

OBJECTIVES: Recent guidelines advocate accelerated provider-initiated HIV testing by general practitioners (GPs). We aimed to identify the number of patient consultations in six general practices in the South-East of Amsterdam, and the incidence of HIV indicator conditions reported in their medical files prior to diagnosis. METHODS: A cross-sectional search in an electronic general practice database. We used a case-control design to identify those conditions most associated with an HIV-positive status. RESULTS: We included 102 HIV cases diagnosed from 2002 to 2012, and matched them with 299 controls. In the year prior to HIV diagnosis, 61.8% of cases visited their GP at least once, compared with 38.8% of controls. In the 5 years prior to HIV diagnosis, 58.8% of HIV cases had exhibited an HIV indicator condition, compared with 7.4% of controls. The most common HIV-related conditions were syphilis and gonorrhoea. The most common HIV-related symptoms were weight loss, lymphadenopathy and peripheral neuropathy. During this period, average HIV prevalence among people aged 15-59 years increased from 0.4% to 0.9%. CONCLUSIONS: This study revealed many opportunities for HIV indicator condition-guided testing in primary care. As yet, however, HIV indicator conditions are not exploited as triggers for early HIV testing.

[A young man with extensive skin abnormalities]. / Een jongeman met uitgebreide huidafwijkingen.

A 26-year-old man who has sex with men visited the STI clinic because of increasing skin abnormalities since four months. The patient had macular skin lesions on his penis and scrotum, condylomata lata in the anal region, cutaneous lesions on the feet, and a widespread papular rash. A secondary stage of syphilis was diagnosed.

General practitioners' barriers and facilitators towards new provider-initiated HIV testing strategies: a qualitative study.

European guidelines recommend offering an HIV test to individuals who display HIV indicator conditions (ICs). UK guidelines recommend performing a 'routine offer of HIV testing' in primary care where HIV prevalence exceeds 2 in 1000. Implementation of new provider-initiated HIV testing strategies in general practice is limited, while the numbers of undiagnosed and late for care HIV patients remain high. We have explored Dutch general practitioners' barriers to and facilitators of both strategies. We combined semi-structured in-depth interviews with focus groups. Nine general practitioners - key informants of sexually transmitted infection/HIV prevention and control - were selected for the interviews. Additionally, we organised focus groups with a broad sample of general practitioners (n = 81). Framework analysis was used to analyse the data. Various barriers were found, related to (1) the content of the guidelines (testing the right group and competing priorities in general practice), (2) their organisational implementation (lack of time, unclear when to repeat the HIV test and overlong list of ICs) and (3) the patient population (creating fear among patients, stigmatising them and fear regarding financial costs). Multiple general practitioners stated that performing a sexual risk assessment of patients is important before applying either strategy. Also, they recommended implementing the IC-guided approach only in high-prevalence areas and combining HIV tests with other laboratory blood tests. General practitioners tend to cling to old patterns of risk-based testing. Promoting awareness of HIV testing and educating general practitioners about the benefits of new provider-initiated HIV testing strategies is important for the actual uptake of HIV testing.