HIV testing: the boundaries. A survey of HIV testing practices and barriers to more widespread testing in a British teaching hospital

Blood-borne virus testing in emergency departments - a systematic review of seroprevalence, feasibility, acceptability and linkage to care

BACKGROUND

Blood-borne viruses (BBVs) cause significant morbidity and mortality worldwide. Emergency departments (EDs) offer a point of contact for groups at increased risk of BBVs who may be less likely to engage with primary care. We reviewed the literature to evaluate whether BBV testing in this setting might be a viable option to increase case finding and linkage to care.

METHODS

We searched PubMed database for English language articles published until June 2019 on BBV testing in EDs. Studies reporting seroprevalence surveys, feasibility, linkage to care, enablers and barriers to testing were included. Additional searches for grey literature were performed.

RESULTS

Eight-nine articles met inclusion criteria, of which 14 reported BBV seroprevalence surveys in EDs, 54 investigated feasibility and acceptability, and 36 investigated linkage to care. Most studies were HIV-focused and conducted in the USA. Seroprevalence rates were in the range 1.5-17% for HCV, 0.7-1.6% for HBV, and 0.8-13% for HIV. For studies that used an opt-in study design, testing uptake ranged from 2% to 98% and for opt-out it ranged from 16% to 91%. There was a wide range of yield: 13-100% of patients received their test result, 21-100% were linked to care, and 50-91% were retained in care. Compared with individuals diagnosed with HIV, linkage to and retention in care were lower for those diagnosed with hepatitis C. Predictors of linkage to care was associated with certain patient characteristics.

CONCLUSIONS

Universal opt-out BBV testing in EDs may be feasible and acceptable, but linkage to care needs to be improved by optimizing implementation. Further economic evaluations of hepatitis testing in EDs are needed.

HIV testing in secondary care: a multicentre longitudinal mixed methods electronic survey of non-HIV specialist hospital physicians in South-East Scotland and Northern England

BACKGROUND

Increasing the uptake of HIV testing in people who may have undiagnosed HIV is essential to reduce the morbidity associated with late HIV diagnosis.

METHODS

We conducted a multicentre, longitudinal, mixed-methods study, surveying the attitudes, knowledge and practice of non-HIV specialist hospital physicians in South-East Scotland and North-East England with respect to HIV testing.

RESULTS

We found that although awareness of indications for HIV testing had improved over time, only 13% of clinicians recognised all of the surveyed HIV indicator conditions. Physicians were better at recognising the indicator conditions relevant to their specialty. The perception of working with a low-risk patient population was the most frequently cited barrier to offering an HIV test. Only a third of study respondents had requested more than 10 HIV tests in the preceding year.

CONCLUSIONS

Our study supports a need for targeted and sustained educational initiatives to increase rates of HIV testing in secondary care.

Seroprevalence of HCV, HBV and HIV in two inner-city London emergency departments

SUMMARY

In this paper we build on work investigating the feasibility of human immunodeficiency virus (HIV) testing in emergency departments (EDs), estimating the prevalence of hepatitis B, C and HIV infections among persons attending two inner-London EDs, identifying factors associated with testing positive in an ED. We also undertook molecular characterisation to look at the diversity of the viruses circulating in these individuals, and the presence of clinically significant mutations which impact on treatment and control.Blood-borne virus (BBV) testing in non-traditional settings is feasible, with emergency departments (ED) potentially effective at reaching vulnerable and underserved populations. We investigated the feasibility of BBV testing within two inner-London EDs. Residual samples from biochemistry for adults (⩾18 years) attending The Royal Free London Hospital (RFLH) or the University College London Hospital (UCLH) ED between January and June 2015 were tested for human immunodeficiency virus (HIV)Ag/Ab, anti-hepatitis C (HCV) and HBsAg. PCR and sequence analysis were conducted on reactive samples. Sero-prevalence among persons attending RFH and UCLH with residual samples (1287 and 1546), respectively, were 1.1% and 1.0% for HBsAg, 1.6% and 2.3% for anti-HCV, 0.9% and 1.6% for HCV RNA, and 1.3% and 2.2% for HIV. For RFH, HBsAg positivity was more likely among persons of black vs. white ethnicity (odds ratio 9.08; 95% confidence interval 2.72-30), with anti-HCV positivity less likely among females (0.15, 95% CI 0.04-0.50). For UCLH, HBsAg positivity was more likely among non-white ethnicity (13.34, 95% CI 2.20-80.86 (Asian); 8.03, 95% CI 1.12-57.61 (black); and 8.11, 95% CI 1.13-58.18 (other/mixed)). Anti-HCV positivity was more likely among 36-55 year olds vs. ⩾56 years (7.69, 95% CI 2.24-26.41), and less likely among females (0.24, 95% CI 0.09-0.65). Persons positive for HIV-markers were more likely to be of black vs. white ethnicity (4.51, 95% CI 1.63-12.45), and less likely to have one ED attendance (0.39, 95% CI 0.17-0.88), or female (0.12, 95% CI 0.04-0.42). These results indicate that BBV-testing in EDs is feasible, providing a basis for further studies to explore provider and patient acceptability, referral into care and cost-effectiveness.

Timeliness of diagnosis of HIV in Newfoundland and Labrador, Canada: A mixed-methods study

BACKGROUND

Late diagnosis of HIV is associated with poor outcomes and increased cost. Novel HIV testing promotion strategies may reduce late diagnosis. The purpose of this study was to determine the timeliness of HIV testing in Newfoundland and Labrador (NL), missed opportunities for testing, and barriers to HIV testing.

METHODS

Demographic and clinical information from individuals diagnosed with HIV in NL from 2006-2016 was retrospectively reviewed. Patients were also invited to participate in semi-structured interviews regarding knowledge about HIV transmission, risk associated with their behaviour, testing decision making, and testing opportunities.

RESULTS

Fifty-eight new HIV diagnoses occurred during the study period: 53/58 (91.4%) were male and 33/58 (56.9%) were men who have sex with men. The mean age at diagnosis was 40.6 (SD 11.05) years. CD4 count at diagnosis ranged from 2 to 1,408 cells/mm³, with a mean of 387 cells/mm³. For 39/58 (67.2%) of individuals, the first-ever HIV test was positive. Of the 58 patients, 55 (94.8%) had had health care contact within the 5 years prior to diagnosis (mean 13.7 contacts). Heterosexual men were more likely to present with a late diagnosis (p = 0.049). Ten (17.2%) individuals agreed to an interview. Thematic analysis revealed that barriers to testing were stigma, negative health care interactions, denial, and fear of the diagnosis.

CONCLUSIONS

HIV diagnosis is made later in NL than in other Canadian provinces. Late diagnosis may be prevented if HIV testing became a routine testing procedure.

Attitudes to rapid HIV testing among Spanish General Practitioners

OBJECTIVES

The objectives of this study were to investigate the acceptability of rapid HIV testing among general practitioners in Spain and to identify perceived barriers and needs in order to implement rapid testing in primary care settings.

METHODS

An anonymous questionnaire was distributed online to all members of the two largest Spanish scientific medical societies for family and community medicine. The study took place between 15th June and 31st October 2010.

RESULTS

Completed questionnaires were returned by 1308 participants. The majority (90.8%) of respondents were General Practitioners (GP). Among all respondents, 70.4% were aware of the existence of rapid tests for the diagnosis of HIV but they did not know how to use them. Nearly 80% of participants would be willing to offer rapid HIV testing in their practices and 74.7% would be confident of the results obtained by these tests. The barriers most commonly identified by respondents were a lack of time and a need for training, both in the use of rapid tests (44.3% and 56.4%, respectively) and required pre- and post-test counselling (59.2% and 34.5%, respectively).

CONCLUSIONS

This study reveals a high level of acceptance and willingness on the part of GPs to offer rapid HIV testing in their practices. Nevertheless, the implementation of rapid HIV testing in primary care will not be possible without moving from comprehensive pre-test counselling towards brief pre-test information and improving training in the use of rapid tests.

Low levels of HIV test coverage in clinical settings in the U.K.: a systematic review of adherence to 2008 guidelines

Objectives

To quantify the extent to which guideline recommendations for routine testing for HIV are adhered to outside of genitourinary medicine (GUM), sexual health (SH) and antenatal clinics.

Methods

A systematic review of published data on testing levels following publication of 2008 guidelines was undertaken. Medline, Embase and conference abstracts were searched according to a predefined protocol. We included studies reporting the number of HIV tests administered in those eligible for guideline recommended testing. We excluded reports of testing in settings with established testing surveillance (GUM/SH and antenatal clinics). A random effects meta-analysis was carried out to summarise level of HIV testing across the studies identified.

Results

Thirty studies were identified, most of which were retrospective studies or audits of testing practice. Results were heterogeneous. The overall pooled estimate of HIV test coverage was 27.2% (95% CI 22.4% to 32%). Test coverage was marginally higher in patients tested in settings where routine testing is recommended (29.5%) than in those with clinical indicator diseases (22.4%). Provider test offer was found to be lower (40.4%) than patient acceptance of testing (71.5%).

Conclusions

Adherence to 2008 national guidelines for HIV testing in the UK is poor outside of GUM/SH and antenatal clinics. Low levels of provider test offer appear to be a major contributor to this. Failure to adhere to testing guidelines is likely to be contributing to late diagnosis with implications for poorer clinical outcomes and continued onwards transmission of HIV. Improved surveillance of HIV testing outside of specialist settings may be useful in increasing adherence testing guidelines.

Acceptability of rapid HIV diagnosis technology among primary healthcare practitioners in Spain

This study investigated the acceptability of rapid HIV testing among general practitioners (GP) and aimed to identify perceived barriers and needs in order to implement rapid testing in primary care settings. An anonymous questionnaire was distributed online to all members of the two largest Spanish scientific medical societies for family and community medicine. The study took place between 15 June 2012 and 31 October 2010. Completed questionnaires were returned by 1308 participants. The majority (90.8%) of respondents were GP. Among all respondents, 70.4% were aware of the existence of rapid tests for the diagnosis of HIV but they did not know how to use them. Nearly 80% of participants would be willing to offer rapid HIV testing in their practices and 74.7% would be confident of the result obtained by these tests. The barriers most commonly identified by respondents were a lack of time and a need for training, both in the use of rapid tests (44.3% and 56.4%, respectively) and required pre- and post-test counselling (59.2% and 34.5%, respectively). This study reveals a high level of acceptance and willingness on the part of GPs to offer rapid HIV testing in their practices. Nevertheless, the implementation of rapid HIV testing in primary care will not be possible without moving from comprehensive pre-test counselling towards brief pre-test information and improving training in the use of rapid tests.

"It is not easy": challenges for provider-initiated HIV testing and counseling in Flanders, Belgium

This study identified physicians' HIV testing practices and their barriers toward implementing provider-initiated HIV testing and counseling (PITC) for Sub-Saharan African migrants (SAM) in Flanders, Belgium. In-depth interviews were conducted on a purposive sample of 20 physicians (ten GPs and ten internists). GPs performed mainly patient-initiated tests, while internists carried out tests based on disease indicators and risk behavior. For the most part, World Health Organization (WHO) guidelines were not followed. Study participants were not in favor of implementing PITC. Reasons included lack of information on the HIV epidemic among SAM, fear of stigmatizing patients, perceiving testing as unethical for undocumented patients, questionable relevance of pre-test counseling, lack of expertise in discussing sexuality, language barriers, lack of time, and the absence of a national or regional HIV testing policy. Implementing PITC will require appropriate training of service providers. Also, supporting policies should be developed with the participation of stakeholders encouraging "normalization" of HIV testing.

Factors that affect HIV testing and counseling services among heterosexuals in Canada and the United Kingdom: an integrated review

OBJECTIVE

To examine factors that affect the utilization of HIV testing and counseling (HTC) services among heterosexual populations in Canada and the U.K.

METHODS

We conducted an integrated review of published and unpublished literature (1996-September 2010) using Scopus, OVID-EMBASE, CSA illumina, CINHAL, PROQuest, Web of Science, and Google.

RESULTS

Twenty-seven studies met the inclusion criteria. We identified and categorized the key factors into three broad categories depending on their source. Personal-related factors included socio-demographic characteristics, risk perception, illness, HIV-related stigma, level of HIV and testing knowledge, and culture. Provider-related factors included provider-recommended HIV testing, provision of culturally and linguistically appropriate services, and doctor-patient relationship. System-related factors included integrating HIV testing with other health care services, anonymity of testing services, suitability of testing venues, technical aspects of HIV testing, and funding for immigrant health services.

CONCLUSION

The findings from our review indicate that HTC behaviors of heterosexuals in the Canada and the U.K. are likely influenced by several unchangeable (socio-demographic characteristics) and amenable factors. There is need to step-up research to confirm whether these associations are causal using stronger research designs. PRACTICAL IMPLICATION: We have made several recommendations that could be used to improve existing services in Canada.

Patterns of HIV testing at a London teaching hospital between 2004 and 2007

The aims of this study were to observe trends in testing for HIV between 2004 and 2007 in one London, UK, hospital and to observe the seroprevalence of HIV within subgroups. Tests were grouped according to source and reason for testing. A total of 58,720 tests were considered (HIV-1 seroprevalence 0.9%). The majority (75.4%) of tests were performed as part of routine and opt-out protocols including antenatal and genitourinary (GU) screening. Among people specifically seeking HIV testing, the HIV seroprevalence was 3.5%. Medical specialties performed fewer tests but a high HIV seroprevalence was observed, including infectious disease (seroprevalence 4.4%) and other medical specialties (seroprevalence 3.4%). A small number of specialties performed few HIV tests. HIV testing was cost-effective in virtually all settings. This study suggests that more HIV tests could be performed, for example, in acute medicine, and training might increase the number of tests offered in some settings. The most effective way of increasing testing appears to be opt-out testing.

Patterns of HIV testing at a London teaching hospital between 2004 and 2007

To observe trends in testing for HIV between 2004 and 2007 in a London hospital and to observe the seroprevalence of HIV within subgroups. Tests were grouped according to source and reason for testing; 58,720 tests were considered (HIV-1 seroprevalence = 0.9%). The majority (75.4%) of tests were performed as part of routine and opt-out protocols including antenatal and genitourinary screening. Among people specifically seeking HIV testing, the HIV seroprevalence was 3.5%. Medical specialties performed fewer tests but a high HIV seroprevalence was observed, including infectious disease (seroprevalence 4.4%) and other medical specialties (seroprevalence 3.4%). A small number of specialties performed few HIV tests. HIV testing was cost-effective in virtually all settings. This study suggests that more HIV tests could be performed, for example, in acute medicine, and training might increase the number of tests offered in some settings. The most effective way of increasing testing appears to be opt-out testing.

Barriers to the implementation of the UK HIV testing guidelines in secondary care: how many are medical?

A survey of consultants in Plymouth Teaching Hospital was performed to identify barriers to HIV testing in secondary care. Testing practices were compared with those recommended by the UK HIV testing guidelines and barriers to testing described.