RESUMEN
BACKGROUND: Indicator condition guided HIV testing is a proven effective strategy for increasing HIV diagnosis in health care facilities. As part of the INTEGRATE Joint Action, we conducted four pilot studies, aiming to increase integrated testing for HIV/HCV/HBV and sexually transmitted infections, by introducing and expanding existing indicator condition guided HIV testing methods. METHODS: Pilot interventions included combined HIV/HCV testing in a dermatovenerology clinic and a clinic for addictive disorders in Lithuania; Increasing HIV testing rates in a tuberculosis clinic in Romania by introducing a patient information leaflet and offering testing for HIV/HCV/sexually transmitted infections to chemsex-users in Barcelona. Methods for implementing indicator condition guided HIV testing were adapted to include integrated testing. Testing data were collected retrospectively and prospectively. Staff were trained in all settings, Plan-do-study-act cycles frequently performed and barriers to implementation reported. RESULTS: In established indicator conditions, HIV absolute testing rates increased from 10.6 to 71% in the dermatovenerology clinic over an 18 months period. HIV testing rates improved from 67.4% at baseline to 94% in the tuberculosis clinic. HCV testing was added to all individuals in the dermatovenerology clinic, eight patients of 1701 tested positive (0.47%). HBV testing was added to individuals with sexually transmitted infections with a 0.44% positivity rate (2/452 tested positive). The Indicator condition guided HIV testing strategy was expanded to offer HIV/HCV testing to people with alcohol dependency and chemsex-users. 52% of chemsex-users tested positive for ≥ 1 sexually transmitted infection and among people with alcohol dependency 0.3 and 3.7% tested positive for HIV and HCV respectively. CONCLUSIONS: The four pilot studies successfully increased integrated testing in health care settings, by introducing testing for HBV/HCV and sexually transmitted infections along with HIV testing for established indicator conditions and expanding the strategy to include new indicators; alcohol dependency and chemsex. HCV testing of individuals with alcohol abuse showed high positivity rates and calls for further implementation studies. Methods used for implementing indicator condition guided HIV Testing have proven transferable to implementation of integrated testing.
Asunto(s)
Infecciones por VIH , Hepatitis C , Enfermedades de Transmisión Sexual , Instituciones de Atención Ambulatoria , Atención a la Salud , Infecciones por VIH/diagnóstico , Infecciones por VIH/epidemiología , Hepatitis C/diagnóstico , Hepatitis C/epidemiología , Humanos , Lituania , Estudios Retrospectivos , Rumanía , Enfermedades de Transmisión Sexual/diagnóstico , Enfermedades de Transmisión Sexual/epidemiología , EspañaRESUMEN
BACKGROUND: People living with HIV experience burdensome multidimensional symptoms and concerns requiring person-centred care. Routine use of patient reported outcome measures can improve outcomes. There is no brief patient reported outcome measure (PROM) that currently reflects the breadth of concerns for people living with HIV. This study aimed to develop and cognitively test a brief novel patient reported outcome measure for use within routine adult HIV care- the "Positive Outcomes" HIV PROM. METHODS: Development followed the COSMIN taxonomy and guidance for relevance and comprehensiveness, and Rothrock guidance on development of valid patient reported outcome measures. The Positive Outcomes HIV PROM was developed by a steering group (people living with HIV, HIV professionals and health services researchers) using findings from a previously reported qualitative study of priority outcomes for people living with HIV. The prototype measure was cognitively tested with a purposive sample of people living with HIV. RESULTS: The Positive Outcomes HIV PROM consists of 23 questions (22 structured, and one open question) informed by the priorities of key stakeholders (n = 28 people living with HIV, n = 21 HIV professionals and n = 8 HIV commissioners) to ensure face and content validity, and refined through cognitive testing (n = 6 people living with HIV). Cognitive testing demonstrated high levels of acceptability and accessibility. CONCLUSIONS: The Positive Outcomes HIV PROM is the first brief patient reported outcome measure reflecting the diverse needs of people living with HIV designed specifically for use in the clinical setting to support patient assessment and care, and drive service quality improvement. It is derived from primary data on the priority outcomes for people living with HIV and is comprehensive and acceptable. Further psychometric testing is required to ensure reliability and responsiveness.
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Fármacos Anti-VIH/uso terapéutico , Cognición/efectos de los fármacos , Infecciones por VIH/tratamiento farmacológico , Evaluación de Resultado en la Atención de Salud/estadística & datos numéricos , Medición de Resultados Informados por el Paciente , Atención Dirigida al Paciente/métodos , Calidad de Vida/psicología , Adulto , Femenino , Humanos , Masculino , Persona de Mediana Edad , Psicometría/métodos , Investigación Cualitativa , Reproducibilidad de los ResultadosAsunto(s)
Antibacterianos/uso terapéutico , Tamizaje Masivo/métodos , Serodiagnóstico de la Sífilis/métodos , Sífilis/diagnóstico , Sífilis/tratamiento farmacológico , Cumplimiento y Adherencia al Tratamiento/estadística & datos numéricos , Adulto , Trazado de Contacto/estadística & datos numéricos , Femenino , Humanos , Masculino , Auditoría Médica , Penicilinas/uso terapéutico , Parejas Sexuales , Sífilis/epidemiología , Reino Unido/epidemiologíaRESUMEN
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.
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Infecciones por VIH/diagnóstico , Promoción de la Salud/métodos , Cuerpo Médico/educación , Educación del Paciente como Asunto/métodos , Diagnóstico Precoz , Unión Europea , Femenino , Prueba de VIH , Servicios de Salud , Humanos , Masculino , Aceptación de la Atención de Salud , Guías de Práctica Clínica como AsuntoRESUMEN
OBJECTIVES: In recent years, new technologies and new approaches to scale up HIV testing have emerged. The objective of this paper was to synthesize the body of recent evidence on strategies aimed at increasing the uptake and coverage of HIV testing outside of health care settings in the European Union (EU)/European Economic Area (EEA). METHODS: Systematic searches to identify studies describing effective HIV testing interventions and barriers to testing were run in five databases (2010-2017) with no language restrictions; the grey literature was searched for similar unpublished studies (2014-2017). Study selection, data extraction and critical appraisal were performed by two independent reviewers following Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. RESULTS: Eighty studies on HIV testing in non-health care settings were identified, the majority set in Northern Europe. Testing was implemented in 65 studies, with men who have sex with men the risk group most often targeted. Testing coverage and positivity/reactivity rates varied widely by setting and population group. However, testing in community and outreach settings was effective at reaching people who had never previously been tested and acceptability of HIV testing, particularly rapid testing, outside of health care settings was found to be high. Other interventions aimed to increase HIV testing identified were: campaigns (n = 8), communication technologies (n = 2), education (n = 3) and community networking (n = 1). CONCLUSIONS: This review has identified several strategies with potential to achieve high HIV testing coverage outside of health care settings. However, the geographical spread of studies was limited, and few intervention studies reported before and after data, making it difficult to evaluate the impact of interventions on test coverage.
Asunto(s)
Infecciones por VIH/diagnóstico , Prueba de VIH/métodos , Homosexualidad Masculina/estadística & datos numéricos , Relaciones Comunidad-Institución , Diagnóstico Precoz , Unión Europea , Femenino , Humanos , Masculino , Guías de Práctica Clínica como AsuntoRESUMEN
OBJECTIVES: Since 2013, the London HIV Mortality Review Group has conducted annual reviews of deaths among people with HIV to reduce avoidable mortality. METHODS: All London HIV care Trusts reported data on 2016 patient deaths in 2017. Deaths were submitted using a modified Causes of Death in HIV reporting form and categorized by a specialist HIV pathologist and two HIV clinicians. RESULTS: There were 206 deaths reported; 77% were among men. Median age at death was 56 years. Cause was established for 82% of deaths, with non-AIDS-related malignancies and AIDS-defining illnesses being the most common causes reported. Risk factors in the year before death included: tobacco smoking (37%), excessive alcohol consumption (19%), non-injecting drug use (10%), injecting drug use (7%) and opioid substitution therapy (6%). Thirty-nine per cent of patients had a history of depression, 33% chronic hypertension, 27% dyslipidaemia, 17% coinfection with hepatitis B virus and/or hepatitis C virus and 14% diabetes mellitus. At the time of death, 81% of patients were on antiretroviral therapy (ART), 61% had a CD4 count < 350 cells/µL, and 24% had a viral load ≥ 200 HIV-1 RNA copies/mL. Thirty-six per cent of deaths were unexpected; 61% of expected deaths were in hospital. Two-thirds of expected deaths had a prior end-of-life care discussion documented. CONCLUSIONS: In 2016, most deaths were attributable to non-AIDS-related conditions and the majority of patients were on ART and virally suppressed. However, several potentially preventable deaths were identified and underlying risk factors were common. As London HIV patients are not representative of people with HIV in the UK, a national mortality review is warranted.
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Terapia Antirretroviral Altamente Activa/estadística & datos numéricos , Causas de Muerte , Coinfección/mortalidad , Infecciones por VIH/mortalidad , Síndrome de Inmunodeficiencia Adquirida , Adulto , Recuento de Linfocito CD4 , Enfermedades Cardiovasculares/mortalidad , Diabetes Mellitus/mortalidad , Femenino , Encuestas Epidemiológicas , Hepatitis Viral Humana/mortalidad , Humanos , Londres/epidemiología , Masculino , Persona de Mediana Edad , Neoplasias/mortalidad , Factores de Riesgo , Trastornos Relacionados con Sustancias/mortalidad , Carga ViralRESUMEN
OBJECTIVES: People living with HIV (PLWH) have multidimensional concerns requiring person-centred care. Routine use of patient-reported outcome measures (PROMs) improves outcomes. No brief PROM currently reflects the breadth of concerns for PLWH. This study sought to identify priority outcomes for PLWH, model current practice, explore views on introducing PROMs into routine care, and devise a model for person-centred care incorporating the PROM. METHODS: A cross-national multi-centre study (London, Brighton and Dublin) was carried out. Semi-structured qualitative interviews with adult PLWH, HIV health care professionals and HIV commissioners (responsible for planning and commissioning services) were performed. Interviews were analysed using thematic and framework analysis. RESULTS: PLWH (n = 28), professionals (n = 21) and commissioners (n = 8) described concerns related to living with HIV across six domains: physical (e.g. pain and gastrointestinal symptoms), cognitive (e.g. memory and sleep), psychological (e.g. anxiety and depression), social (e.g. isolation and intimacy), welfare (e.g. finances and fears regarding change of immigration status), and information (e.g. long-term outcomes) needs. Themes were highly inter-related, impacting across domains of need (e.g. physical and cognitive problems impacting on psychological and social wellbeing). Perceived benefits of using PROMs in routine HIV care included improved person-centredness, patient empowerment, fewer missed concerns, increased engagement with services, and informed planning of services. Potential challenges included heterogeneity of PLWH, literacy, and utility for those who struggle to engage with care. CONCLUSIONS: This study presents a novel model of person-centred care incorporating an HIV-specific PROM. The model reflects priorities of key stakeholders. Explicit use of PROMs in routine HIV care could afford benefits for PLWH, clinical teams and commissioners.
Asunto(s)
Infecciones por VIH/terapia , Medición de Resultados Informados por el Paciente , Atención Dirigida al Paciente/métodos , Adulto , Anciano , Anciano de 80 o más Años , Femenino , Infecciones por VIH/psicología , Personal de Salud , Humanos , Masculino , Persona de Mediana Edad , Investigación Cualitativa , Reino Unido , Adulto JovenRESUMEN
This national audit of 142 clinics demonstrated that the majority of clinics surveyed had policies and agreed clinical practice for alcohol and recreational drug enquiry, as well as documentation of HIV test refusal, although this was not the case in 24% of clinics as regards alcohol usage, 21% of clinics as regards recreational drugs use and 43% of clinics as regards chemsex usage. Regarding management of HIV test refusal, there was no policy or agreed practice in 13% of clinics with respect to men having sex with men (MSM) attenders, and in 18% of clinics for heterosexual attenders. Seventy percent of clinics had HIV point of care tests (POCT) available. Recommendations include: all clinics should have a policy of routine enquiry about alcohol, recreational drugs and chemsex, all clinics should record reasons for HIV test refusal and all clinics should provide testing alternatives to improve uptake, e.g. point of care testing or home sampling.
Asunto(s)
Auditoría Clínica , Infecciones por VIH , Política de Salud , Homosexualidad Masculina , Drogas Ilícitas/efectos adversos , Guías de Práctica Clínica como Asunto , Instituciones de Atención Ambulatoria , Adhesión a Directriz , Infecciones por VIH/diagnóstico , Infecciones por VIH/prevención & control , Humanos , Masculino , Salud Reproductiva , Medición de Riesgo , Salud Sexual , Reino UnidoRESUMEN
OBJECTIVES: The aims of this study were to to assess the feasibility of simultaneous testing for the blood-borne viruses (BBV), HIV, hepatitis C (HCV) and hepatitis B (HBV), in the Emergency Department (ED) and ascertain the seroprevalence for these three viruses in this setting. METHODS: A pilot BBV testing program was undertaken as part of routine clinical care in the ED. All ED attendees aged between 16 and 65 years old who were able to consent were tested over a 55 week period on an opt out basis. Patients with positive test results were linked to clinical services. Interventions aimed at improving testing rates were implemented and evaluated by quality improvement (QI) methodology. RESULTS: Of 25,520 age-eligible ED attendees, 6108 (24%) underwent BBV testing; an additional 1160 (4.5%) underwent a standalone HIV test (total of 7268 (28%) individuals).There were 83/7268 (1.1%) non-negative (ie reactive or equivocal) results for HIV and 103/6108 (1.7%) and 32/6108 (0.52%) for anti-HCV IgG and HBsAg, respectively. Of these, 12 (0.17%), 16 (0.26%) and 8 (0.13%) were new reactive tests for HIV, HCV and HBV, respectively, which were able to be confirmed on a second test. Specific QI interventions led to temporary increases in testing rates. CONCLUSIONS: An opt out BBV testing program in the ED is feasible and effective at finding new cases. However, the testing rate was low at 24%. Although QI interventions led to some improvement in testing rates, further studies are required to identify ways to achieve sustained increases in testing in this setting.
Asunto(s)
Servicios de Diagnóstico/organización & administración , Servicios Médicos de Urgencia/métodos , Infecciones por VIH/diagnóstico , Hepatitis B/diagnóstico , Hepatitis C/diagnóstico , Adolescente , Adulto , Anciano , Servicio de Urgencia en Hospital , Femenino , Infecciones por VIH/epidemiología , Hepatitis B/epidemiología , Hepatitis C/epidemiología , Humanos , Masculino , Persona de Mediana Edad , Estudios Retrospectivos , Estudios Seroepidemiológicos , Adulto JovenRESUMEN
OBJECTIVES: European guidelines recommend HIV testing for individuals presenting with indicator conditions (ICs) including AIDS-defining conditions (ADCs). The extent to which non-HIV specialty guidelines recommend HIV testing in ICs and ADCs is unknown. Our aim was to pilot a methodology in the UK to review specialty guidelines and ascertain if HIV was discussed and testing recommended. METHODS: UK and European HIV testing guidelines were reviewed to produce a list of 25 ADCs and 49 ICs. UK guidelines for these conditions were identified from searches of the websites of specialist societies, the National Institute of Clinical Excellence (NICE) website, the NICE Clinical Knowledge Summaries (CKS) website, the Scottish Intercollegiate Guidance Network (SIGN) website and the British Medical Journal Best Practice database and from Google searches. RESULTS: We identified guidelines for 12 of 25 ADCs (48%) and 36 of 49 (73%) ICs. In total, 78 guidelines were reviewed (range 0-13 per condition). HIV testing was recommended in six of 17 ADC guidelines (35%) and 24 of 61 IC guidelines (39%). At least one guideline recommended HIV testing for six of 25 ADCs (24%) and 16 of 49 ICs (33%). There was no association between recommendation to test and publication year (P = 0.62). CONCLUSIONS: The majority of guidelines for ICs do not recommend testing. Clinicians managing ICs may be unaware of recommendations produced by HIV societies or the prevalence of undiagnosed HIV infection among these patients. We are piloting methods to engage with guideline development groups to ensure that patients diagnosed with ICs/ADCs are tested for HIV. We then plan to apply our methodology in other European settings as part of the Optimising Testing and Linkage to Care for HIV across Europe (OptTEST) project.
Asunto(s)
Infecciones por VIH/diagnóstico , Infecciones por VIH/epidemiología , Tamizaje Masivo/métodos , Guías de Práctica Clínica como Asunto , Humanos , Reino UnidoRESUMEN
These guidelines are an update for 2015 of the 2008 UK guidelines for the management of syphilis. The writing group have piloted the new BASHH guideline methodology, notably using the GRADE system for assessing evidence and making recommendations. We have made significant changes to the recommendations for screening infants born to mothers with positive syphilis serology and to facilitate accurate and timely communication between the teams caring for mother and baby we have developed a birth plan. Procaine penicillin is now an alternative, not preferred treatment, for all stages of syphilis except neurosyphilis, but the length of treatment for this is shortened. Other changes are summarised at the start of the guideline.
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Guías de Práctica Clínica como Asunto , Serodiagnóstico de la Sífilis , Sífilis , Manejo de la Enfermedad , Humanos , Sífilis/diagnóstico , Sífilis/tratamiento farmacológico , Treponema pallidum/inmunología , Reino UnidoRESUMEN
Patients diagnosed with lymphogranuloma venereum have high rates of co-infection with HIV, syphilis and hepatitis C. The aim of this enhanced surveillance was to screen all men who have sex with men (MSM) newly diagnosed with HIV, syphilis or hepatitis C for co-infection with asymptomatic lymphogranuloma venereum as part of the recommended sexual health screen. Of the 145 patients screened, 21 patients were diagnosed with rectal Chlamydia trachomatis, one with both rectal and urethral chlamydia and six with urethral chlamydia. One rectal chlamydia-positive sample, when tested, was equivocal for lymphogranuloma venereum. Our data suggested that there was not a pool of asymptomatic lymphogranuloma venereum infection in MSM recently diagnosed with HIV, hepatitis C and syphilis. However, there have been recent reports of an increased incidence of asymptomatic lymphogranuloma venereum, raising the question whether lymphogranuloma venereum should be screened for in high risk asymptomatic MSM. The prevalence of asymptomatic rectal chlamydia infections was 19%.
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Infecciones Asintomáticas/epidemiología , Coinfección/epidemiología , Infecciones por VIH/diagnóstico , Hepatitis C/diagnóstico , Homosexualidad Masculina , Linfogranuloma Venéreo/diagnóstico , Sífilis/diagnóstico , Adulto , Chlamydia trachomatis/aislamiento & purificación , Infecciones por VIH/epidemiología , Hepatitis C/epidemiología , Humanos , Incidencia , Linfogranuloma Venéreo/epidemiología , Linfogranuloma Venéreo/microbiología , Masculino , Tamizaje Masivo , Prevalencia , Factores de Riesgo , Sífilis/epidemiología , Reino Unido/epidemiologíaRESUMEN
OBJECTIVE: Since 2003, over 2000 cases of lymphogranuloma venereum (LGV) have been diagnosed in the U.K. in men who have sex with men (MSM). Most cases present with proctitis, but there are limited data on how to differentiate clinically between LGV and other pathology. We analysed the clinical presentations of rectal LGV in MSM to identify clinical characteristics predictive of LGV proctitis and produced a clinical prediction model. DESIGN: A prospective multicentre case-control study was conducted at six U.K. hospitals from 2008 to 2010. Cases of rectal LGV were compared with controls with rectal symptoms but without LGV. METHODS: Data from 98 LGV cases and 81 controls were collected from patients and clinicians using computer-assisted self-interviews and clinical report forms. Univariate and multivariate logistic regression was used to compare symptoms and signs. Clinical prediction models for LGV were compared using receiver operating curves. RESULTS: Tenesmus, constipation, anal discharge and weight loss were significantly more common in cases than controls. In multivariate analysis, tenesmus and constipation alone were suggestive of LGV (OR 2.98, 95% CI 0.99 to 8.98 and 2.87, 95% CI 1.01 to 8.15, respectively) and that tenesmus alone or in combination with constipation was a significant predictor of LGV (OR 6.97, 95% CI 2.71 to 17.92). The best clinical prediction was having one or more of tenesmus, constipation and exudate on proctoscopy, with a sensitivity of 77% and specificity of 65%. CONCLUSIONS: This study indicates that tenesmus alone or in combination with constipation makes a diagnosis of LGV in MSM presenting with rectal symptoms more likely.
Asunto(s)
Estreñimiento/etiología , Homosexualidad Masculina , Linfogranuloma Venéreo/diagnóstico , Dolor/etiología , Enfermedades del Recto/diagnóstico , Pérdida de Peso , Adulto , Estudios de Casos y Controles , Hemorragia Gastrointestinal/etiología , Infecciones por VIH/complicaciones , Humanos , Modelos Logísticos , Linfogranuloma Venéreo/complicaciones , Linfogranuloma Venéreo/fisiopatología , Masculino , Persona de Mediana Edad , Análisis Multivariante , Proctitis/etiología , Proctoscopía , Estudios Prospectivos , Enfermedades del Recto/complicaciones , Enfermedades del Recto/fisiopatología , Sensibilidad y Especificidad , Reino UnidoRESUMEN
OBJECTIVE: To identify risk factors for rectal lymphogranuloma venereum (rLGV) in men who have sex with men (MSM). DESIGN: A case-control study at 6 U.K. hospitals compared MSM with rLGV (cases) with rLGV-negative controls: MSM without potential rLGV symptoms (CGa) and separately, MSM with such symptoms (CGs). METHODS: Between 2008 and 2010, there were 90 rLGV cases, 74 CGa and 69 CGs recruited. Lifestyles and sexual behaviours in the previous 3â months were reported using internet-based computer-assisted self-interviews. Logistic regression was used to investigate factors associated with rLGV. RESULTS: Cases were significantly more likely to be HIV-positive (89%) compared with CGa (46%) and CGs (64%). Independent behavioural risks for rLGV were: unprotected receptive anal intercourse (adjusted OR (AOR)10.7, 95% CI 3.5 to 32.8), fisting another (AOR=6.7, CI 1.8 to 25.3), sex under the influence of gamma-hydroxybutyrate (AOR=3.1, CI 1.3 to 7.4) and anonymous sexual contacts (AOR=2.7, CI 1.2 to 6.3), compared with CGa; unprotected insertive anal intercourse (AOR=4.7, CI 2.0 to 10.9) and rectal douching (AOR=2.9 CI 1.3 to 6.6), compared with CGs. An incubation period from exposure to symptoms of 30â days was indicated. CONCLUSIONS: Unprotected receptive anal intercourse is a key risk factor for rectal LGV with the likelihood that rectal-to-rectal transmission is facilitated where insertive anal sex also occurs. The association between HIV and rLGV appears linked to HIV-positive men seeking unprotected sex with others with the same HIV status, sexual and drug interests. Such men should be targeted for frequent STI screening and interventions to minimise associated risks.
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Infecciones por VIH/epidemiología , Homosexualidad Masculina/estadística & datos numéricos , Linfogranuloma Venéreo/epidemiología , Enfermedades del Recto/epidemiología , Sexo Inseguro/estadística & datos numéricos , Adulto , Estudios de Casos y Controles , Humanos , Modelos Logísticos , Masculino , Persona de Mediana Edad , Análisis Multivariante , Estudios Prospectivos , Factores de Riesgo , Conducta Sexual/estadística & datos numéricos , Oxibato de Sodio , Irrigación Terapéutica/estadística & datos numéricos , Reino Unido/epidemiología , Adulto JovenRESUMEN
Effective asymptomatic screening for sexually transmitted infections is an important public health service because a significant proportion of sexually transmitted infections do not present with symptoms. In 2009, the National Audit Group of the British Association of Sexual Health and HIV (BASHH) audited the management of asymptomatic patients and recommended increased documentation about oral and anal sex, regional strategies for nucleic acid amplification test (NAAT) use for gonorrhoea, improved screening for hepatitis B in men who have sex with men and an increase in screening for HIV. The 2012 audit used web-based forms to collect submissions from 180 consultant-led centres (65% response rate) that included episodes of care from 6669 asymptomatic patients. An improvement was demonstrated for all the areas measured during the 2009 audit. A doubling of gonorrhoea testing using NAATs was seen and yet 10% of asymptomatic patients continued to have microscopy despite these tests not being recommended by BASHH guidelines. This audit recommends universal adoption of gonorrhoea NAATs across the United Kingdom.
Asunto(s)
Tamizaje Masivo/métodos , Auditoría Médica , Anamnesis , Técnicas de Amplificación de Ácido Nucleico/métodos , Enfermedades de Transmisión Sexual/diagnóstico , Infecciones por Chlamydia/diagnóstico , Chlamydia trachomatis , Femenino , Gonorrea/diagnóstico , Infecciones por VIH/diagnóstico , Investigación sobre Servicios de Salud , Humanos , Masculino , Neisseria gonorrhoeae , Salud Reproductiva , Reino UnidoRESUMEN
OBJECTIVES: Routine HIV testing in nonspecialist settings has been shown to be acceptable to patients and staff in pilot studies. The question of how to embed routine HIV testing, and make it sustainable, remains to be answered. METHODS: We established a service of routine HIV testing in an emergency department (ED) in London, delivered by ED staff as part of routine clinical care. All patients aged 16 to 65 years were offered an HIV test (latterly the upper age limit was removed). Meetings were held weekly and two outcome measures examined: test offer rate (coverage) and test uptake. Sustainability methodology (process mapping; plan-do-study-act (PDSA) cycles) was applied to maximize these outcome measures. RESULTS: Over 30 months, 44,582 eligible patients attended the ED. The mean proportion offered an HIV test was 14%, varying from 6% to 54% per month over the testing period. The mean proportion accepting a test was 63% (range 33-100%). A total of 4327 HIV tests have been performed. Thirteen patients have been diagnosed with HIV infection (0.30%). PDSA cycles having the most positive and sustained effects on the outcome measures include the expansion to offer blood-based HIV tests in addition to the original oral fluid tests, and the engagement of ED nursing staff in the programme. CONCLUSIONS: HIV testing can be delivered in the ED, but constant innovation and attention have been required to maintain it over 30 months. Patient uptake remains high, suggesting acceptability, but time will be required before true embedding in routine clinical practice is achieved.
Asunto(s)
Servicio de Urgencia en Hospital/organización & administración , Infecciones por VIH/diagnóstico , Tamizaje Masivo/métodos , Evaluación de Programas y Proyectos de Salud/estadística & datos numéricos , Adolescente , Adulto , Anciano , Diagnóstico Tardío/prevención & control , Femenino , Humanos , Londres/epidemiología , Masculino , Persona de Mediana Edad , Reino Unido , Adulto JovenRESUMEN
OBJECTIVES: UK guidelines recommend routine HIV testing in general clinical settings when the local HIV prevalence is > 0.2%. During pilot programmes evaluating the guidelines, we used laboratory-based testing of oral fluid from patients accepting tests. Samples (n = 3721) were tested manually using the Bio-Rad Genscreen Ultra HIV Ag-Ab test (Bio-Rad Laboratories Ltd, Hemel Hempstead, UK). This was a methodologically robust method, but handling of samples was labour intensive. We performed a validation study to ascertain whether automation of oral fluid HIV testing using the fourth-generation HIV test on the Abbott Architect (Abbott Diagnostics, Maidenhead, UK) platform was possible. METHODS: Oral fluid was collected from 143 patients (56 known HIV-positive volunteers and 87 others having contemporaneous HIV serological tests) using the Oracol+ device (Malvern Medicals, Worcester, UK). Samples were tested concurrently: manually using the Genscreen Ultra test and automatically on the Abbott Architect. RESULTS: For oral fluid, the level of agreement of results between the platforms was 100%. All results agreed with HIV serology. The use of the Oracol+ device produced high-quality samples. Subsequent field use of the test has shown a specificity of 99.97% after nearly 3000 tests. CONCLUSIONS: Laboratory-based HIV testing of oral fluid requires less training of local staff, with fewer demands on clinical time and space than near-patient testing. It is acceptable to patients. The validation exercise and subsequent clinical experience support automation, with test performance preserved. Automation reduces laboratory workload and speeds up the release of results. Automated oral fluid testing is thus a viable option for large-scale HIV screening programmes.
Asunto(s)
Serodiagnóstico del SIDA/métodos , Anticuerpos Anti-VIH/análisis , Infecciones por VIH/diagnóstico , Tamizaje Masivo/métodos , Serodiagnóstico del SIDA/normas , Infecciones por VIH/inmunología , VIH-1 , VIH-2 , Humanos , Tamizaje Masivo/economía , Tamizaje Masivo/normas , Reproducibilidad de los Resultados , Saliva/inmunología , Saliva/virologíaRESUMEN
A national audit of practice performance against the key performance indicators in the British Association for Sexual Health and HIV (BASHH) and HIV Medical Foundation for AIDS Sexual Health Standards for the Management of Sexually Transmitted Infections (STIs) was conducted in 2011. Approximately 60% and 8% of level 3 and level 2 services, respectively, participated. Excluding partner notification performance, the five lowest areas of performance for level 3 clinics were the STI/HIV risk assessment, care pathways linking care in level 2 clinics to local level 3 services, HIV test offer to patients with concern about STIs, information governance and receipt of chlamydial test results by clinicians within seven working days (the worst area of performance). The five lowest areas of performance for level 2 clinics were participating in audit, having an audit plan for the management of STIs for 2009-2010, the STI/HIV risk assessment, HIV test offer to patients with concern about STIs and information governance. The results are discussed with regard to the importance of adoption of the standards by commissioners of services because of their relevance to other national quality assurance drivers, and the need for development of a national system of STI management quality assurance measurement and reporting.
Asunto(s)
Infecciones por VIH/terapia , Auditoría Médica , Salud Reproductiva/normas , Enfermedades de Transmisión Sexual/terapia , Instituciones de Atención Ambulatoria/normas , Instituciones de Atención Ambulatoria/estadística & datos numéricos , Competencia Clínica , Trazado de Contacto , Manejo de la Enfermedad , Fundaciones , Infecciones por VIH/prevención & control , Humanos , Programas Nacionales de Salud/normas , Programas Nacionales de Salud/estadística & datos numéricos , Calidad de la Atención de Salud/normas , Calidad de la Atención de Salud/estadística & datos numéricos , Salud Reproductiva/estadística & datos numéricos , Enfermedades de Transmisión Sexual/prevención & control , Reino Unido/epidemiologíaRESUMEN
This paper reports on chlamydial partner notification (PN) performance in the 2011 BASHH national audit against the British Association for Sexual Health and HIV (BASHH) Medical Foundation for AIDS Sexual Health (MedFASH) Sexually Transmitted Infection Management Standards (STIMS). There was wide regional variation in level 3 clinic PN performance against the current standard of index case-reported chlamydial PN, with 43% (regional range 0-80%) of clinics outside London meeting the ≥0.6 contacts seen per index standard, and 85% of clinics (regional range 82-88%) in London meeting the ≥0.4 standard. For level 2 clinics, 39% (regional range 0-100%) of clinics outside London met the ≥0.6 standard, and 43% (regional range 40-50%) of clinics in London met the ≥0.4 standard. Performance for health-care worker (HCW)-verified contact attendance is also reported. New standards for each of these performance measures are proposed for all level 3 clinics: ≥0.6 contacts seen per index case based on index case report, and ≥0.4 contacts seen per index case based on HCW verification, both within four weeks of the first partner notification interview. The results are discussed with regard to the importance of adoption of standards by commissioners of services, relevance to national quality agendas, and the need for development of a national system of PN quality assurance measurement and reporting.
Asunto(s)
Infecciones por Chlamydia/prevención & control , Trazado de Contacto , Auditoría Médica , Salud Reproductiva/estadística & datos numéricos , Instituciones de Atención Ambulatoria/normas , Instituciones de Atención Ambulatoria/estadística & datos numéricos , Infecciones por Chlamydia/epidemiología , Atención a la Salud/normas , Atención a la Salud/estadística & datos numéricos , Manejo de la Enfermedad , Fundaciones/normas , Adhesión a Directriz/estadística & datos numéricos , Infecciones por VIH/epidemiología , Infecciones por VIH/prevención & control , Humanos , Londres/epidemiología , Salud Reproductiva/normasRESUMEN
This guideline provides evidence-based guidance on the content of safer sex advice and the provision of brief behaviour change interventions deliverable in genitourinary (GU) medicine clinics. Much of the advice is applicable to other healthcare settings including general practice and clinics providing HIV care. Advice on condom use and effectiveness, oral sex and other sexual practices, testing for sexually transmitted infections (STI) and partner reduction is provided. Advice specific to the transmission of HIV infection including seroadaptive behaviours and negotiated safety is also included. An accompanying review of the evidence supporting the guideline with a complete reference list is available online. A patient information leaflet based on the advice statements developed is also available through the BASHH website.