Missed opportunities to offer HIV tests to high-risk groups during general practitioners’ STI-related consultations: an observational study

Abstract

ObjectivesPrior research has shown that Dutch general practitioners (GPs) do not always offer HIV testing and the number of undiagnosed HIV patients remains high. We aimed to further investigate the frequency and reasons for (not) testing for HIV and the contribution of GPs to the diagnosis of HIV infections in the Netherlands.DesignObservational study.Setting(1) Dutch primary care network of 42–45 sentinel practices where report forms during sexually transmitted infection (STI)-related consultations were routinely collected, 2008–2013. (2) Dutch observational cohort with medical data of HIV-positive patients in HIV care, 2008–2013.Outcome measuresThe proportion of STI-related consultations in patients from high-risk groups tested for HIV, with additional information requested from GPs on HIV testing preconsultation or postconsultation for whom HIV testing was indicated, but not performed. Next, information was collected on the profile of HIV-positive patients entering specialised HIV care following diagnosis by GPs.ResultsInitially, an HIV test was reported (360/907) in 40% of STI-related consultations in high-risk groups. Additionally, in 26% of consultations an HIV test had been performed in previous or follow-up consultations or at different STI-care facilities. The main reasons for not testing were perceived insignificant risk; ‘too’ recent risk according to GPs or the reluctance of patients. The initiative of the patient was a strong determinant for HIV testing. GPs diagnosed about one third of all newly found cases of HIV. Compared with STI clinics, HIV-positive patients diagnosed in general practice were more likely to be older, female, heterosexual male or sub-Saharan African.ConclusionsIn one-third of the STI-related consultations of persons from high-risk groups, no HIV test was performed in primary care, which is lower than previously reported. Risk-based testing has intrinsic limitations and implementation of new additional strategies in primary care is warranted.

The need to scale up HIV indicator condition-guided testing for early case-finding: a case-control study in primary care

“…This implies that all patients in the general population with an unspecified STI diagnosis should be tested for HIV. In the Netherlands, persons who are diagnosed with an STI in primary care should be evaluated in terms of patient’s risk-assessment and symptoms to determine whether they should be further tested for STIs [11, 17]. Chlamydia is highly prevalent among Dutch patients who are in groups that are presumed to have a low risk of HIV.…”

“…In the Netherlands, STI care is provided by GPs and STI clinics [7, 17]. Results from STI clinics are not always sent to the GP, which could cause an underestimation of the number of ICs [11]. For the same reason, the proportion not tested for HIV after an STI diagnosis may have been overestimated, since HIV tests may be performed at STI clinics.…”

“…One third of all HIV infections in the Netherlands are diagnosed by GPs [2]. A Dutch study also showed that GPs reach groups of persons at risk of HIV that are not reached by STI clinics, which underlines the important role of primary care in fighting the HIV epidemic [2, 11]. In several European countries, primary care is a setting for creating opportunities to detect HIV as early as possible [11–14].…”

“…Dutch GP guidelines already promote provider-initiated HIV testing among high-risk populations, but this strategy alone shows limits in the implementation to detect HIV-infected people [11]. For example, GPs may find it difficult to have complex conversations about sexual risk behaviour [15, 16].…”

HIV testing for key populations in Europe: A decade of technological innovation and patient empowerment complement the role of health care professionals

“…In the traditional HIV testing approach, health care professionals need to stay updated about the local epidemiology of HIV (‘who to test’), and indicator conditions for an HIV test to avoid ‘missed opportunities’ . A guide for health care providers, listing key populations and medical conditions that may mask an underlying HIV‐infection, can be used as guideline for testing .…”