Proactive HIV testing strategies in primary care

After the introduction of therapy, HIV changed from a deadly disease to a chronic treatable infection, with those infected – if treated in time – having almost the same life expectancy as those not infected. Also, other studies have reported that early initiation of therapy greatly reduces the risk of transmission of HIV to sexual partners. Thus early detection is essential, but to date HIV testing of high-risk groups has not halted the progress of the epidemic in the Netherlands. The studies in this thesis were initiated with the goal of increasing our understanding of additional proactive HIV testing strategies in primary care and other healthcare settings. The results of this thesis contribute in particular to improve HIV testing programmes and assist in the implementation of these strategies in daily practice. General practitioners are key players in a proactive HIV testing policy. One of the main findings of this thesis is that HIV-infected patients frequently visit their general practitioner and a large group of these individuals present with HIV indicator conditions in the period prior to HIV diagnosis. HIV indicator condition-guided testing by general practitioners could be the starting point for more proactive provider-initiated HIV testing

The importance of registration of sexual orientation and recognition of indicator conditions for an adequate HIV risk-assessment

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. 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. 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. Documentation of sexual orientation and ethnicity, and IC-guided testing by GPs could be the starting point for more proactive provider-initiated HIV testin

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

textabstractBackground: 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

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. 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. 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%. 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 testin

Data from: Low prevalence of methicillin-resistant Staphylococcus aureus among men who have sex with men attending an STI clinic in Amsterdam, a cross-sectional study

Objective: Community-associated methicillin-resistant Staphylococcus aureus (CA-MRSA) is common among men who have sex with men (MSM) in the USA. It is unknown whether this is also the case in Amsterdam, the Netherlands. Design: Cross-sectional study. Setting: Sexually transmitted infection outpatient low- threshold clinic, Amsterdam, the Netherlands. Participants: Between October 2008 and April 2010, a total of 211 men were included, in two groups: (1) 74 MSM with clinical signs of a skin or soft tissue infection (symptomatic group) and (2) 137 MSM without clinical signs of such infections (asymptomatic group). Primary outcome measures: S aureus and MRSA infection and/or colonisation. Swabs were collected from the anterior nasal cavity, throat, perineum, penile glans and, if present, from infected skin lesions. Culture for S aureus was carried out on blood agar plates and for MRSA on selective chromagar plates after enrichment in broth. If MRSA was found, the spa- gene was sequenced. Secondary outcome measures: Associated demographic characteristics, medical history, risk factors for colonisation with S aureus and high-risk sexual behaviour were collected through a self- completed questionnaire. Results: The prevalence of S aureus colonisation in the nares was 37%, the pharynx 11%, the perianal region 12%, the glans penis 10% and in skin lesions 40%. In multivariable analysis adjusting for age, anogenital S aureus colonisation was significantly associated with the symptomatic group (p=0.01) and marginally with HIV ( p=0.06). MRSA was diagnosed in two cases: prevalence 0.9% (95% CI 0.1% to 3.4%)). Neither had CA-MRSA strains. Conclusions: CA-MRSA among MSM in Amsterdam is rare. Genital colonisation of S aureus is not associated with high-risk sexual behaviour