General practitioners' HIV test offer to high-risk groups during STI consultations: an observational patient survey. Journal: BMJ Open Manuscript ID: bmjopen-0-00 Article Type: Research Date Submitted by the Author: -Jun-0 Complete List of Authors: Joore, Ivo; Academic Medical Centre, University of Amsterdam, General Practice Reukers, Daphne; National Institute for Public Health and the Environment, Epidemiology & Surveillance Unit, Centre for Infectious Disease Control Donker, G; NIVEL, Sentinel practice network Sighem, Ard; Foundation HIV Monitoring (Stichting HIV Monitoring), Op de Coul, Eline; National Institute for Public Health and the Environment, Epidemiology & Surveillance Unit, Centre for Infectious Disease Control Prins, Jan; Academic Medical Centre, University of Amsterdam, Internal Medicine; Division of Infectious Diseases Geerlings, Suzanne; Academic Medical Centre, University of Amsterdam, Internal Medicine; Division of Infectious Diseases Barth, Roos; Foundation HIV Monitoring (Stichting HIV Monitoring), van Bergen, Jan; Academic Medical Centre, University of Amsterdam, General Practice Broek, Ingrid; National Institute for Public Health and the Environment, Infectious Diseases Surveillance <b>primary Subject Heading</b>: Secondary Subject Heading: Keywords: HIV/AIDS Public health, General practice / Family practice, Infectious diseases, Sexual health INFECTIOUS DISEASES, HIV & AIDS < INFECTIOUS DISEASES, Public health < INFECTIOUS DISEASES, PUBLIC HEALTH - http://bmjopen.bmj.com/site/about/guidelines.xhtml
Page of BMJ Open 0 0 0 0 0 Copies of related papers, previous Editors and reviewers' comments, and responses to those comments can be submitted using the File Designation "Supplementary file for Editors only". Editors encourage authors to submit previous communications as doing so is likely to expedite the review process. Trienekens SC, van den Broek IV, Donker GA, et al. Consultations for sexually transmitted infections in the general practice in the Netherlands: an opportunity to improve STI/HIV testing. BMJ Open 0;:e00 - http://bmjopen.bmj.com/site/about/guidelines.xhtml
Page of 0 0 0 0 0 0 0 0 TITLE PAGE General practitioners HIV test offer to high-risk groups during STI consultations: an observational patient survey IK Joore, DFM Reukers, GA Donker, AI van Sighem, ELM Op de Coul, JM Prins, SE Geerlings, RE Barth, JEAM van Bergen, IV van den Broek Corresponding author Ivo K. Joore Meibergdreef 0 DE Amsterdam, The Netherlands Email: i.k.joore@amc.uva.nl Phone: +(0)0- Department of General Practice Division of Clinical Methods and Public Health Academic Medical Centre Amsterdam, The Netherlands Co-authors IK Joore Department of General Practice Division Clinical Methods and Public Health Academic Medical Centre Amsterdam, the Netherlands - http://bmjopen.bmj.com/site/about/guidelines.xhtml
Page of BMJ Open 0 0 0 0 0 0 0 0 DFM Reukers National Institute for Public Health and the Environment (RIVM) Epidemiology & Surveillance Unit, Centre for Infectious Disease Control Bilthoven, the Netherlands GA Donker NIVEL Primary Care Database, Sentinel Practices Utrecht, the Netherlands AI van Sighem Foundation HIV Monitoring Amsterdam, The Netherlands On behalf of the ATHENA national observational HIV cohort Amsterdam, The Netherlands ELM Op de Coul National Institute for Public Health and the Environment (RIVM) Epidemiology & Surveillance Unit, Centre for Infectious Disease Control Bilthoven, the Netherlands JM Prins Department of Internal Medicine Division of Infectious Diseases Academic Medical Centre Amsterdam, The Netherlands SE Geerlings Department of Internal Medicine Division of Infectious Diseases Academic Medical Centre Amsterdam, The Netherlands - http://bmjopen.bmj.com/site/about/guidelines.xhtml
Page of 0 0 0 0 0 0 0 0 RE Barth Foundation HIV Monitoring Amsterdam, The Netherlands On behalf of the ATHENA national observational HIV cohort Amsterdam, The Netherlands JEAM van Bergen Department of General Practice Division Clinical Methods and Public Health Academic Medical Centre Amsterdam, the Netherlands STI AIDS Netherlands (SOA AIDS Nederland) Amsterdam, the Netherlands National Institute for Public Health and the Environment (RIVM) Epidemiology & Surveillance Unit, Centre for Infectious Disease Control Bilthoven, the Netherlands. IV van den Broek National Institute for Public Health and the Environment (RIVM) Epidemiology & Surveillance Unit, Centre for Infectious Disease Control Bilthoven, the Netherlands Keyword (MESH terms): HIV, general practice, Primary Health Care, Guideline, Epidemiology, Diagnosis Word count: Abstract 00 Article: - http://bmjopen.bmj.com/site/about/guidelines.xhtml
Page of BMJ Open 0 0 0 0 0 0 0 ABSTRACT Objectives: Prior research has shown that Dutch general practitioners (GPs) often do not offer HIV testing, while 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 diagnosing HIV infections in the Netherlands. Design: Prospective observational patient survey. Setting: ) Dutch primary care network of - sentinel practices where questionnaires during STI-consultations were routinely collected, 00-0. ) Dutch observational cohort with medical data of HIV-positive patients in specialised HIV care, 00-0. Outcome measures: The proportion of patients tested for HIV during STIconsultations, with additional information requested from GPs on HIV-testing pre- or post-consultation for specific high-risk groups for whom HIV testing was indicated, but not performed. Information was collected on the profile of HIV-positive patients entering specialized HIV care diagnosed by GPs. Results: Initially, in 0% of STI consultations in high-risk groups an HIV-test was reported (0/0). In addition, in % of consultations in high-risk groups an HIV test had been done 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 reluctance of patients. The initiative of the patient was a strong determinant for HIV testing. One third of HIV-positive patients in specialized HIV care were diagnosed by GPs; these were on average older, and more often MSM or migrant than the patients tested for HIV in the network. Conclusions: In one third of the STI consultations from high-risk groups no HIV test was performed, which is lower than previously reported. GPs make individual decisions, based on patients risk and opinions. New additional strategies need to be developed, as the risk-based testing strategy alone is insufficient in reducing the number of undiagnosed HIV patients. - http://bmjopen.bmj.com/site/about/guidelines.xhtml
Page of 0 0 0 0 0 0 0 Strength and limitations of this study Study is carried out in a GP network covering a representative sample of the Dutch population consulting the GP. We obtained more in-depth information on previous or follow-up consultations and reasons for (not) testing for HIV, which were lacking in prior studies. Information collected is more detailed in consultation characteristics than information based on electronic records only, but the uncertainty of the completeness of reporting remains. - http://bmjopen.bmj.com/site/about/guidelines.xhtml
Page of BMJ Open 0 0 0 0 0 0 0 INTRODUCTION An estimated total of,000 individuals are living with HIV in the Netherlands, %- % of whom are undiagnosed. In 0,,0 HIV patients entered into specialized HIV-care, of whom % presented late for care (CD count < 0 cells/mm or AIDS-defining event regardless of CD count). In 0, Cohen et al. showed that early treatment achieved % reduction in the transmission between sero-discordant couples, paving the road for a new additional strategy now known as Treatment as prevention. Early testing is paramount to an integrated approach aimed at early treatment, reduced transmission and increased public and individual health benefits. The general practitioner (GP), who acts as a gatekeeper to care in the Netherlands, is an important point of entrance into care, also for the diagnosis of Sexual Transmitted Infections (STI). In the Netherlands, every person is registered at a general practice and % of the Dutch population contacts their GP at least once per year. Costs of consultations are covered by mandatory health insurance. However, insured persons have to pay a mandatory deductible amount out of their own pocket. According to the most recent GP guidelines, patients with STI questions or complaints, belonging to high-risk groups should be advised to get an HIV test. Previously, we explored STI testing at general practices in the Netherlands using questionnaire data on STI consultations in the GP sentinel practices between 00 and 0. The study showed that HIV tests were not carried out in the majority of STI consultations of patients at higher risk for HIV. Especially, men who have sex with men (MSM) and persons from STI-endemic countries were frequently not tested. However, in this study only limited patient information was available from questionnaires on individual consultations whereas circumstantial information on potential previous HIV testing was not available. In our current study, we aimed to further investigate the frequency and reasons for (not) testing for HIV and the contribution of GPs in diagnosing HIV infections in the Netherlands. We therefore collected additional information from the GPs to find out more about HIV testing in high-risk groups. Offering HIV tests is most relevant for groups who have the highest risk to be diagnosed with HIV or are known to be diagnosed at a late stage of disease. We therefore also compared the profile of - http://bmjopen.bmj.com/site/about/guidelines.xhtml
Page of 0 0 0 0 0 patients tested for HIV in general practice with the characteristics of HIV-positive patients referred by GPs to specialised HIV care. - http://bmjopen.bmj.com/site/about/guidelines.xhtml
Page of BMJ Open 0 0 0 0 0 00 0 0 0 0 0 0 0 0 0 0 0 METHODS Data on HIV testing and diagnosis was retrieved from two data sources in 00 to 0: ) a consultation-based dataset from the sentinel practices of NIVEL Primary Care Database, which provided information on HIV testing in STI-related consultations of GPs in - general practices in the Netherlands. For every STI- consultation from specific high-risk groups where HIV testing was indicated (according to the guidelines) but not performed, an additional questionnaire was sent to the GP to retrieve additional information on HIV-testing pre- or post-consultation. ) The ATHENA national observational HIV cohort from the Dutch Stichting HIV Monitoring (HMF, HIV Monitoring Foundation) provided information on HIV-positive persons receiving specialized HIV care. National Dutch STI guidelines for GPs: High-risk groups Populations at higher risk for STI, including HIV (high-risk groups), are defined in Dutch national guidelines as: MSM, commercial sex workers (CSW), clients of CSW, people from countries where STIs are endemic, people with three or more partners in the last months, and people with a partner in one of these high-risk groups. STIendemic areas are defined as countries where the general population is known to have a higher percentage of STI, which include almost all non-western countries. Data collection NIVEL Primary Care Database - sentinel practices The patient population of the sentinel practices of NIVEL Primary Care Database covers approximately 0.% of the Dutch population and is nationally representative for age, gender, regional distribution and population density. Since 00, GPs are requested to routinely complete a questionnaire for each registered new disease episode in a patient s electronic record with an ICPC-code concerning STI issues. Questionnaires are collected by NIVEL and completed forms are sent annually to the National Institute for Public Health and the Environment (RIVM) with anonymous identification numbers. The questionnaire contains information on STI testing and diagnosis, patient demographics, reason for consultation and sexual risk behaviour, - http://bmjopen.bmj.com/site/about/guidelines.xhtml
Page of 0 0 0 0 0 0 0 0 including an additional laboratory report of test results. For all new consultations regarding HIV (risk), extra questions about who initiated discussing HIV during this consultation and reasons for testing or not testing for HIV are included. As part of our study, an additional questionnaire was sent to GPs for those STI-consultations in which no HIV test was performed, but limited (to avoid too much workload for the participating GPs) to the most important high-risk groups responsible for the HIV epidemic in our country: MSM or persons originating from an STI-endemic country. This questionnaire addressed whether patients were tested in a recent previous or follow-up consultation (within a time window of months) or at a different STI-care facility and, if not, reasons for not testing for HIV. Patient number, birth date and consultation date were patient identifiers based on which the GP could elicit the required information of the specific consultations from his/her patient records. HMF/ATHENA national observational HIV cohort In order to examine the proportion of all newly HIV diagnoses registered in specialized HIV care originating from the general practice and compare the characteristics of this group to those of the patients who were tested in the sentinel practices, data on HIV-positive patients who entered into care between 00-0 after diagnosis by the GP, was obtained from the HMF/ATHENA (HIV Monitoring Foundation, AIDS Therapy Evaluation in the Netherlands) cohort, which monitors all registered HIV-infected persons from the HIV treatment centres, including four paediatric centres. The anonymized dataset includes age, gender, region of origin (country of birth), location of referral/diagnosis and route of transmission. Data analysis HMF/ATHENA data were used for descriptive analyses of HIV-positive patients in care diagnosed in general practice. NIVEL primary care data were pooled over six years, from 00 till 0, to increase statistical power. Univariate and multivariate logistic regression was performed to identify main determinants of receiving an HIV test in the general practice. We used SPSS.0 software (IBM, USA) for statistical analysis. - http://bmjopen.bmj.com/site/about/guidelines.xhtml
Page of BMJ Open 0 0 0 0 0 0 0 0 RESULTS HIV testing in general practice From 00 to 0,,0 STI-related consultations were registered in the NIVEL database, during which 0 persons were tested for HIV (0%). HIV testing during STI consultations by patient group The majority of the HIV tests, %, were performed in people of Dutch origin, and % in females. Patients originating from STI endemic were tested at similar rates as Dutch patients, with some variation among groups (Table ). The highest percentage of HIV tests was done in patients reporting paid sex contacts (aor., % CI.-. compared to persons in a steady partnership; Table ) and in patients giving as the reason for consultation 'coming for a periodical check-up' (aor., % CI.-. compared to persons coming with STI symptoms), '(ex)partner was unfaithful' (aor., % CI.-.) or fear of STI (aor., % CI.-.). The majority (%) of people who were notified for an STI by a partner were not tested for HIV (aor., % CI.-., compared to persons coming with STI complaints) even if they belonged to a high-risk group; MSM who were notified for STI were tested in % of consultations and notified persons from STI endemic countries in % of consultations. In total, STI consultations were linked to a positive HIV result, patients were known HIV positive while received a positive test result in the current STI consultation. - http://bmjopen.bmj.com/site/about/guidelines.xhtml
Page of 0 0 0 0 0 Table Number of HIV tests and odds of receiving HIV testing during an STI related consultation by demographics and behavioural risk factors in the sentinel practices of the NIVEL Primary Care database, 00-0. Age HIV testing n(%) in STI related consultations N STI consultations Gender and sexual preference Ethnicity Relationships (< months) Reason of STI consultation Number of partners (< months) HIV tests Univariate Multivariate N n (%) OR (%CI) AOR (%CI) <0 (.0%) Ref Ref 0- (.%). (. -.). (.-.)* 0- (.%). (. - ). (.-.0)* >0 (.%). (. -.). (0.-.) Missing # (.%) - Female (.%) Ref Ref Heterosexual Male* (.%). (. -.). (.0 -.) MSM** 0 (.%). (. -.). (. -.0) Missing # (.%) - Dutch 0 (0.0%) Ref ns Sub-Saharan African 0 (0.0%). (.0 -.) Antillean/Surinamese (.%) 0. (0. -.) Turkish/Moroccan 0 (.%). (0. -.) Other Non-Western (.0%) 0. (0. -.) Other Western (.%). (. - ) Missing # (.%) - Steady partner (.%) Ref Ref Incidental steady/casual partners (.%). (. -.). (.0-.) Concurrent sexual partner (.%). (. -.).0 (.-.) Paid sex contacts (.%).0 (. - ). (. -.) Missing # 0 (.%) - STI symptoms (.%) Ref Ref Notified by partner (.%).0 (.-.). (.-.) Periodic check-up 0 (.0%). (.-.). (.-.) Partner unfaithful (.0%). (.-.). (.-.) Recent risk (.%). (.-.). (.-.) Fear of STI (.0%). (.-.0). (.-.) Referred (.%).0 (0.-.).0 (0.-.) Missing # (.%) - 0- (.%) Ref Ref (.%). (.0-.) 0. (0.-.) or more (.%). (.-.).0 (.-.) Missing # 0 0 (.%). (.-. 0. (0.-0.) Statistical significance, p <0.0 of the odds ratio, tested with the Wald test. AOR: adjusted odds ratio from multivariate logistic regression. CI: confidence interval. MSM: men who have sex with men. Ref: reference category, ns: not significant. * For men and 0 women information on sexual preference was not given; these men are classified as heterosexual. ** MSM were not tested because they were already known HIV-positive. # Missing: questionnaires were not complete for all variables; missing were included as a category in univariate and multivariate analyses; OR s are not reported for this group except in the case where there was a significant association (Number of partners). - http://bmjopen.bmj.com/site/about/guidelines.xhtml
Page of BMJ Open 0 0 0 0 0 0 00 0 0 0 0 0 0 0 0 0 0 HIV testing: initiative and reason In % of the HIV-related consultations the GP initiated the discussion on testing for HIV (/0). HIV tests were more commonly performed when the initiative to address HIV was taken by the patient (%) than by the GP (%). The most common reason for HIV testing, reported by the GP, was for reassurance of the patient (%; /0), while in % of consultations the reason given was a potential risk of infection (0/0). HIV testing in high-risk groups As shown in the flowchart (Figure ), % (n=0) of STI consultations were performed in high-risk groups who should be tested for HIV according to guidelines. Of these, 0% (/0) was not tested for HIV during the consultation: persons originating from an STI endemic country (n=), MSM (), persons who had three or more sex partners in the last months () or partners at risk (), and a few persons reporting paid sex contacts () (Figure ). Additional questionnaires sent to GPs For the additional questionnaires to obtain more information on STI consultations without immediate HIV test, we selected the patients from the high-risk groups MSM or persons originating from an STI endemic country. STI consultations were eligible, but were excluded because they were from GPs who had withdrawn from the sentinel practices of NIVEL Primary Care Database (N=), had incomplete questionnaires (N=) or the reason for not offering an HIV test had already been reported (N=, see figure ). The response to this questionnaire was 0% (/), but (%) could not be traced back in the patient records, leaving questionnaires for analysis. The GPs reported that in % (N=) of patients an HIV test had been done in a previous or follow-up consultation, or at a different STI-care facility. Six of the patients (%) had tested HIV-positive earlier. Combining the reported HIV-tests from the additional questionnaire with those reported in the original questionnaire, the total proportion of all high-risk group patients with an HIV test on or around the time of STI consultation was %: 0% in the same consultation and a further % before or after that consultation or in another STI-care facility (% of the 0% initially not tested). - http://bmjopen.bmj.com/site/about/guidelines.xhtml
Page of 0 0 0 0 0 0 0 0 Reasons for not testing in high-risk groups In the group of consultations for which a reason for not testing was given in the original questionnaire, the main reasons given were that the patient had not been at risk for STI transmission (0%) or that the time of the risk exposure was too recent (%). GPs also mentioned that the patient needed time to think (%) or the patient refused the test (%). In the additional questionnaires, reasons given (n=) for not testing were, according to the GP, insignificant risk of HIV infection (%), risk of HIV infection was too recent but no HIV test was performed in follow-up consultation (%), HIV was discussed but not tested (%), while in % of consultations no HIV test was performed because the patient had not brought up the subject of HIV. HIV-positive patients in care diagnosed in general practice Of all HIV-positive patients registered in care in the HMF/ATHENA cohort between 00 and 0, % (N=0) were referred from a general practice, % from an STI clinic and % from a hospital. Most patients diagnosed by the GP were between 0 and 0 years of age (N=, %). The majority were MSM (N=, %) and/or originated from STI-endemic countries (N=, %) of which the largest groups were sub-saharan Africans (N=0, %), or Antilleans or Surinamese (N=0, %; Table ). These HIV-positive patients in care referred by the GP were on average older and more often MSM or migrant than the patients who were tested for HIV in the sentinel practices, of whom % were 0-0 years old, % were MSM, and % were from an STI-endemic country (see Table ). - http://bmjopen.bmj.com/site/about/guidelines.xhtml
Page of BMJ Open 0 0 0 0 0 0 Table HIV positive patients in Dutch specialized HIV care referred by the GP and HIV testing during STI related consultations by age, gender and ethnicity, 00-0. *The ATHENA national observational HIV cohort from the Dutch monitoring foundation (HMF) + NIVEL Primary Care Database, sentinel practices Age Transmission group HIV positive patients in care diagnosed by GPs * STI consultations where an HIV test is performed at GP STI - related consultations + N % N % <0.%.% 0-.%.% 0-.%.% >0.0%.% Female.%.% Heterosexual Male.% 0.% Ethnicity MSM.0%.% Dutch.%.% Sub-Saharan African 0.%.0% Antillean/Surinamese 0.%.% Turkish/Moroccan.%.% Other Western.%.% Other Non-Western.0%.0% Total 0 0% 0 0% Age not recorded for STI consultation at the GP; Gender not reported for consultations; sexual preference not recorded for 0 men, classified here under heterosexual Ethnicity not recorded in consultations - http://bmjopen.bmj.com/site/about/guidelines.xhtml
Page of 0 0 0 0 0 0 0 0 DISCUSSION GPs diagnosed more than one third of HIV patients who came in care in the Netherlands between 00-0. The GP guidelines on HIV-testing in high-risk groups were implemented better than reported in our previous study. but still in % of the STI consultations from high-risk groups no HIV test was performed although this was indicated. The main reasons for not testing for HIV were that the GP judged the individual risk for HIV infection as low or the patient did not discuss the topic of HIV during the STI consultation. This indicates that GPs evaluate the situation of individual patients to determine whether patients classified in a high-risk group should be tested for HIV. On the other hand, the initiative or the opinion of the patient is also of influence for either or not receiving an HIV test. One third of HIV-positive patients in specialized HIV care were diagnosed by GPs; these were on average older, and more often MSM or migrant than the patients tested for HIV in the network. This study was carried out in a GP network covering a representative sample of the Dutch population consulting the GP. We obtained in-depth information on previous or follow-up consultations and reasons for (not) testing for HIV, which were lacking in prior studies. The preceding study, using the same source of initial questionnaire data on STI -consultations of the GP sentinel surveillance network, found that % of the patients in high-risk groups were not tested according to national guidelines in place between 00 and 0, but contextual information was lacking. Our study observed that the proportion of STI related consultations in high-risk groups not tested for HIV was lower (%), as HIV tests were performed in previous or follow-up consultations or at a different facility such as an STI clinic, showing the importance of validating routinely collected data. A limitation of the present study is the uncertainty of the completeness of reporting. The more in-depth HIV related information on previous or follow-up consultations was obtained from 0% of patients; 0% of additional questionnaires were not returned and % could not be traced back in patient records. Underreporting may potentially have led to overestimation of the proportion of patients tested for HIV or the - http://bmjopen.bmj.com/site/about/guidelines.xhtml
Page of BMJ Open 0 0 0 0 0 00 0 0 0 0 0 0 0 0 0 0 importance of determinants of receiving HIV testing, if selection was biased towards patients in whom a test was performed. Nevertheless, the information collected in this study is more complete and detailed in patient and consultation characteristics than information based on electronic patient records only. A study in France estimated that % of the MSM did not receive HIV testing when visiting their health care provider. Similar results (%) were obtained in our study. These studies highlight the limitations of risk based testing and illustrate that the rate of missed opportunities for HIV testing remains high. Of all high-risk groups, especially the proportion tested among the group of persons originating from HIV-endemic countries remains low (not above average), whereas this group is relatively large among the HIV patients in care. This group is known to enter later in care and to be more often unaware of their HIV diagnosis. GPs have access to this group and may therefore play an important role in reaching this group. A study using the national STI database from STI clinics in the Netherlands showed a high overall STI positivity rate among notified sexual partners of MSM, heterosexual male and female. Of the notified MSM, % was newly diagnosed with HIV. Remarkably, in our study only % of the notified MSM during an STI consultation were tested for HIV. Apparently, notification for another STI in high-risk groups does not automatically lead to an HIV test as well. The patient s opinion could be an underlying reason for the fact that notified high-risk patients were not tested for HIV. In the Netherlands, provider-initiated testing is less common, although this has increased slowly in the period from to 00 (from % in to % in 00). In our study the GP took the initiative to discuss HIV in only % of the HIVrelated consultations, which indicates that a higher rate of testing might be achieved if provider-initiated strategies are more stimulated. One of the most common reasons given for not testing in high-risk groups during an STI consultation was that the risk of HIV infection was too recent, but data showed that the patient was usually not tested at a later moment. According to the national guidelines, GPs should have tested for HIV in the same consultation and repeated the HIV test after three months. Recently, new HIV tests have been introduced on the market to detect HIV much earlier after point of infection. However, guidelines are not adjusted yet, because more insight is needed into the characteristics and limitations of these new HIV tests. - http://bmjopen.bmj.com/site/about/guidelines.xhtml
Page of 0 0 0 0 0 0 0 0 0 A revised GP guideline for STI was released in September 0. This updated guideline addresses HIV testing in high-risk groups more clearly than before, so the situation may have improved by now. The revised Dutch GP guideline for STI consultations advising more provider-initiated HIV testing focuses on HIV testing in high-risk groups. An in-depth sexual history taking to estimate the risk for HIV including sexual identity, country of origin and number of partners at present and in the past six months is important for adequate risk-assessment. Patients from high- risk groups are advised to have an HIV test during an STI consultation and GPs are recommended to pro-actively discuss HIV testing, regardless of the reason for consultation in MSM and patients who originate from HIV-endemic regions. Patients who are diagnosed with another STI (chlamydia, gonorrhoea, syphilis, hepatitis B) should also be advised to get an HIV test. In our study it was shown that the GPs may not always follow the guideline to the letter, but they take the patients' sexual behaviour and opinions into account to determine whether they should be tested for HIV. The choice between rigid testing according to the guidelines and personal, individual patient care with more flexible implementation of guidelines rightfully remains a matter to be decided by GPs and patients themselves and can probably not be changed easily. In the future, GPs may be supported by evidence for the effectiveness of new additional provider-initiated HIV testing strategies, to enhance early case finding. Details of two new, targeted HIV testing strategies have recently been published: ) offering an HIV test to individuals with HIV indicator conditions and ) routine HIV testing in primary care settings where the HIV prevalence exceeds per,000 among to -year-olds. - New cost-effective strategies with risk-based testing might be a way to reduce the number of undiagnosed HIV patients. GP in the Netherlands are important test providers, diagnosing about one third of the HIV patients in care. The proportion of STI consultations in high-risk groups not tested for HIV is lower than previously reported, an estimated % of those at risk. GPs make individual decisions for testing the high-risk groups, based on patients risk and opinions. Risk-based testing has intrinsic limitations and therefore is insufficient in reducing the number of undiagnosed HIV patients alone. Combining new additional HIV testing strategies with risk-based testing may help to curb the ongoing epidemic. - http://bmjopen.bmj.com/site/about/guidelines.xhtml
Page of BMJ Open 0 0 0 0 0 0 0 Acknowledgements All general practitioners who participated in the Dutch sentinel GP network from 00-0 and all participants of the ATHENA national observational HIV cohort are gratefully acknowledged. Contributors DR was involved in the data collection, statistical analyses and first draft of the manuscript. IKJ and IvB were involved in the data collection, performed further statistical analyses and wrote the final manuscript. All authors contributed to the design and/or interpretation, provided feedback and approved the final submitted version of the manuscript. Funding This work was supported by Aids Fonds grant number: 00, Amsterdam, the Netherlands. Competing interests The authors declare they have no competing interests. Ethics approval Ethical approval for the study was not necessary following Dutch law as the study used anonymous patient data collected for routine surveillance. Data sharing statement No additional data are available. - http://bmjopen.bmj.com/site/about/guidelines.xhtml
Page 0 of 0 0 0 0 0 0 00 0 0 0 0 0 0 0 0 0 References. Op de Coul, ELM, Schreuder I, Conti S, et al. Changing patterns of undiagnosed HIV infection in the Netherlands: who benefits most from intensified HIV test and treat policies? [under review]. Van Sighem AI, Gras LA, Smith CJ, et al. Monitoring Report 0: Human Immunodeficiency Virus (HIV) Infection in the Netherlands. Stichting HIV Monitoring, 0.. Cohen MS, Chen YQ, McCauley M, et al. Prevention of HIV- infection with early antiretroviral therapy. N Engl J Med 0;:-0.. Van den Broek IV, Verheij RA, van Dijk CE, et al. Trends in sexually transmitted infections in the Netherlands, combining surveillance data from general practices and sexually transmitted infection centers. BMC Fam Pract 0;:.. Donker G, Dorsman S, Spreeuwenberg P, et al. Twenty-two years of HIV-related consultations in Dutch general practice: a dynamic cohort study. BMJ Open 0;:e00.. Cardol M, van Dijk L, de Jong JD, et al. Second National Study into disease and treatment in family practice. Family practitioner: what does the gatekeeper do? [Tweede nationale studie naar ziekten en verrichtingen in de huisartspraktijk. Huisartsenzorg: wat doet de poortwachter?]. NIVEL/RIVM, 00. (Kernrapport ) http://www.nivel.nl/sites/default/files/bestanden/ns_rapport.pdf (accessed May 0) [In Dutch]. Meyboom-de Jong B, Smith RJ, Hiddema-van-der Wal A, et al. The family physician's sentinel function studied with reference to referrals and referral cards. Ned Tijdschr Geneeskd ;0:-0.. Government of the Netherlands. Health Insurance. http://www.government.nl/issues/health-insurance/contents (accessed May 0) [Dutch] 0 - http://bmjopen.bmj.com/site/about/guidelines.xhtml
Page of BMJ Open 0 0 0 0 0 0 0 0. Van Bergen J, Dekker J, Boeke A, et al. Dutch College of General Practitioners guideline STD consultation (first revision) [NHG standaard: Het soa-consult (eerste herziening)]. Huisarts Wet 0;:0-.. Trienekens SC, van den Broek IV, Donker GA, et al. Consultations for sexually transmitted infections in the general practice in the Netherlands: an opportunity to improve STI/HIV testing. BMJ Open 0;:e00.. Donker GA. Continuous morbidity registration GP sentinel surveillance, annual report 0, NIVEL (Netherlands Institute for Health Services Research), 0. http://www.nivel.nl/sites/default/files/peilstations%0jaarverslag%00%0engels. pdf (accessed May 0). Boesten J, Braaksma L, Klapwijk-Strumpler S, et al. Adequate record keeping in electronic patient records [Adequate dossiervorming met het Elektronisch Patiëntendossier]. Dutch College of General Practitioners [Nederlands Huisartsgenootschap], 0. https://www.nhg.org/sites/default/files/content/nhg_org/uploads/richtlijn_adequate_do ssiervorming_met_het_elektronisch_patientendossier_.pdf (accessed May 0) [In Dutch]. Champenois K, Cousien A, Cuzin L, et al. Missed opportunities for HIV testing in newly-hiv-diagnosed patients, a cross sectional study. BMC Infect Dis 0;:00.. Op de Coul ELM, van Sighem AI, Brinkman K, et al. Factors associated with presenting late or with advanced HIV disease in the Netherlands, -0. [under review]. van Aar F, van Weert Y, Spijker R, et al. Partner notification among men who have sex with men and heterosexuals with STI/HIV: different outcomes and challenges. Int J STD Aids 0 ;:-.. Cornett JK, Kirn TJ. Laboratory diagnosis of HIV in adults: a review of current methods. Clin Infect Dis 0;:-. - http://bmjopen.bmj.com/site/about/guidelines.xhtml
Page of 0 0 0 0 0 0 0 0. Donker G, Wolters I, van Bergen J. Care in general practices in numbers: GPs must test the high-risk groups for HIV. [Huisartsenzorg in cijfers: huisartsen moeten risicogroepen testen op hiv.] Huisarts Wet 00;,. [In Dutch]. Donker GA, Van den Broek IVF. Sexual anamnesis crucial in STI-consultations. [Seksuele anamnese cruciaal bij soa- consult] Huisarts Wet 0;:. [In Dutch]. National Institute for Health and Care Excellence (NICE). Increasing the uptake of HIV testing to reduce undiagnosed infection and prevent transmission among black African communities living in England. Public Health Guidance,, 0. https://www.nice.org.uk/guidance/ph (accessed May 0) 0. National Institute for Health and Care Excellence (NICE). Increasing the uptake of HIV testing to reduce undiagnosed infection and prevent transmission among men who have sex with men. Public Health Guidance,, 0. https://www.nice.org.uk/guidance/ph (accessed May 0). HIV in Europe. HIV Indicator Conditions: Guidance for implementing HIV testing in Adults in Health Care Settings, 0. http://hiveurope.eu/portals/0/guidance.pdf.pdf (accessed May 0). Jones A, Cremin I, Abdullah F, et al. Transformation of HIV from pandemic to low-endemic levels: a public health approach to combination prevention. Lancet 0;:-. - http://bmjopen.bmj.com/site/about/guidelines.xhtml
Page of BMJ Open 0 0 0 0 0 xmm (00 x 00 DPI) - http://bmjopen.bmj.com/site/about/guidelines.xhtml
Page of 0 0 0 Section/Topic Item # STROBE 00 (v) Statement Checklist of items that should be included in reports of cross-sectional studies Recommendation Reported on page # Title and abstract (a) Indicate the study s design with a commonly used term in the title or the abstract, Introduction (b) Provide in the abstract an informative and balanced summary of what was done and what was found Background/rationale Explain the scientific background and rationale for the investigation being reported, Objectives State specific objectives, including any prespecified hypotheses, Methods Study design Present key elements of study design early in the paper, Setting Describe the setting, locations, and relevant dates, including periods of recruitment, exposure, follow-up, and data collection Participants (a) Give the eligibility criteria, and the sources and methods of selection of participants, Variables Clearly define all outcomes, exposures, predictors, potential confounders, and effect modifiers. Give diagnostic criteria, if Data sources/ measurement applicable * For each variable of interest, give sources of data and details of methods of assessment (measurement). Describe comparability of assessment methods if there is more than one group Bias Describe any efforts to address potential sources of bias,, Study size Explain how the study size was arrived at Quantitative variables Explain how quantitative variables were handled in the analyses. If applicable, describe which groupings were chosen and why Statistical methods (a) Describe all statistical methods, including those used to control for confounding, Results (b) Describe any methods used to examine subgroups and interactions, (c) Explain how missing data were addressed,, (d) If applicable, describe analytical methods taking account of sampling strategy (e) Describe any sensitivity analyses - http://bmjopen.bmj.com/site/about/guidelines.xhtml,,,, NA NA
Page of BMJ Open 0 0 0 Participants * (a) Report numbers of individuals at each stage of study eg numbers potentially eligible, examined for eligibility, -, table and confirmed eligible, included in the study, completing follow-up, and analysed figure. (b) Give reasons for non-participation at each stage NA Descriptive data (c) Consider use of a flow diagram Figure. * (a) Give characteristics of study participants (eg demographic, clinical, social) and information on exposures and potential confounders Table, - (b) Indicate number of participants with missing data for each variable of interest - Figure. Outcome data * Report numbers of outcome events or summary measures NA Main results (a) Give unadjusted estimates and, if applicable, confounder-adjusted estimates and their precision (eg, % confidence - interval). Make clear which confounders were adjusted for and why they were included (b) Report category boundaries when continuous variables were categorized NA (c) If relevant, consider translating estimates of relative risk into absolute risk for a meaningful time period NA Other analyses Report other analyses done eg analyses of subgroups and interactions, and sensitivity analyses - Discussion Key results Summarise key results with reference to study objectives Limitations Discuss limitations of the study, taking into account sources of potential bias or imprecision. Discuss both direction and magnitude of any potential bias Interpretation 0 Give a cautious overall interpretation of results considering objectives, limitations, multiplicity of analyses, results from - similar studies, and other relevant evidence Generalisability Discuss the generalisability (external validity) of the study results - Other information Funding Give the source of funding and the role of the funders for the present study and, if applicable, for the original study on which the present article is based *Give information separately for cases and controls in case-control studies and, if applicable, for exposed and unexposed groups in cohort and cross-sectional studies. Note: An Explanation and Elaboration article discusses each checklist item and gives methodological background and published examples of transparent reporting. The STROBE checklist is best used in conjunction with this article (freely available on the Web sites of PLoS Medicine at http://www.plosmedicine.org/, Annals of Internal Medicine at http://www.annals.org/, and Epidemiology at http://www.epidem.com/). Information on the STROBE Initiative is available at www.strobe-statement.org. - http://bmjopen.bmj.com/site/about/guidelines.xhtml
Missed opportunities to offer HIV tests to high-risk groups during general practitioners STI consultations: an observational study. Journal: BMJ Open Manuscript ID bmjopen-0-00.r Article Type: Research Date Submitted by the Author: -Sep-0 Complete List of Authors: Joore, Ivo; Academic Medical Center, University of Amsterdam, General Practice Reukers, Daphne; National Institute for Public Health and the Environment, Epidemiology & Surveillance Unit, Centre for Infectious Disease Control Donker, G; NIVEL Primary Care Database, Sentinel practices Sighem, Ard; On behalf of the ATHENA national observational HIV cohort, Stichting HIV Monitoring, Op de Coul, Eline; National Institute for Public Health and the Environment, Epidemiology & Surveillance Unit, Centre for Infectious Disease Control Prins, Jan; Academic Medical Center, University of Amsterdam, Internal Medicine; Division of Infectious Diseases Geerlings, Suzanne; Academic Medical Center, University of Amsterdam, Internal Medicine; Division of Infectious Diseases Barth, Roos; On behalf of the ATHENA national observational HIV cohort, University Medical Center Utrecht, Internal Medicine; Division of Infectious Diseases van Bergen, Jan; Academic Medical Center, University of Amsterdam, General Practice; Soa Aids Nederland (STI AIDS Netherlands), Broek, Ingrid; National Institute for Public Health and the Environment, Infectious Diseases Surveillance <b>primary Subject Heading</b>: Secondary Subject Heading: Keywords: HIV/AIDS Public health, General practice / Family practice, Infectious diseases, Sexual health INFECTIOUS DISEASES, HIV & AIDS < INFECTIOUS DISEASES, Public health < INFECTIOUS DISEASES, PUBLIC HEALTH - http://bmjopen.bmj.com/site/about/guidelines.xhtml
Page of BMJ Open 0 0 0 0 0 Copies of related papers, previous Editors and reviewers' comments, and responses to those comments can be submitted using the File Designation "Supplementary file for Editors only". Editors encourage authors to submit previous communications as doing so is likely to expedite the review process. Trienekens SC, van den Broek IV, Donker GA, et al. Consultations for sexually transmitted infections in the general practice in the Netherlands: an opportunity to improve STI/HIV testing. BMJ Open 0;:e00 - http://bmjopen.bmj.com/site/about/guidelines.xhtml
Page of 0 0 0 0 0 0 0 0 TITLE PAGE Missed opportunities to offer HIV tests to high-risk groups during general practitioners STI consultations: an observational study. IK Joore, DFM Reukers, GA Donker, AI van Sighem, ELM Op de Coul, JM Prins, SE Geerlings, RE Barth, JEAM van Bergen, IV van den Broek Corresponding author Ivo K. Joore Meibergdreef 0 DE Amsterdam, The Netherlands Email: i.k.joore@amc.uva.nl Phone: +(0)0- Department of General Practice Division of Clinical Methods and Public Health Academic Medical Center Amsterdam, the Netherlands Co-authors IK Joore Department of General Practice Division Clinical Methods and Public Health - http://bmjopen.bmj.com/site/about/guidelines.xhtml
Page of BMJ Open 0 0 0 0 0 0 0 Academic Medical Center Amsterdam, the Netherlands DFM Reukers National Institute for Public Health and the Environment (RIVM) Epidemiology & Surveillance Unit, Centre for Infectious Disease Control Bilthoven, the Netherlands GA Donker NIVEL Primary Care Database, Sentinel Practices Utrecht, the Netherlands AI van Sighem Stichting HIV Monitoring Amsterdam, the Netherlands On behalf of the ATHENA national observational HIV cohort Amsterdam, the Netherlands ELM Op de Coul National Institute for Public Health and the Environment (RIVM) Epidemiology & Surveillance Unit, Centre for Infectious Disease Control Bilthoven, the Netherlands - http://bmjopen.bmj.com/site/about/guidelines.xhtml
Page of 0 0 0 0 0 0 0 JM Prins Department of Internal Medicine Division of Infectious Diseases Academic Medical Center Amsterdam, the Netherlands SE Geerlings Department of Internal Medicine Division of Infectious Diseases Academic Medical Center Amsterdam, the Netherlands RE Barth University Medical Center Utrecht Utrecht, the Netherlands On behalf of the ATHENA national observational HIV cohort Amsterdam, the Netherlands JEAM van Bergen Department of General Practice Division Clinical Methods and Public Health - http://bmjopen.bmj.com/site/about/guidelines.xhtml
Page of BMJ Open 0 0 0 0 0 0 0 Academic Medical Center Amsterdam, the Netherlands STI AIDS Netherlands (SOA AIDS Nederland) Amsterdam, the Netherlands National Institute for Public Health and the Environment (RIVM) Epidemiology & Surveillance Unit, Centre for Infectious Disease Control Bilthoven, the Netherlands. IV van den Broek National Institute for Public Health and the Environment (RIVM) Epidemiology & Surveillance Unit, Centre for Infectious Disease Control Bilthoven, the Netherlands Keyword (MESH terms): HIV, General practice, Primary Health Care, Guideline, Epidemiology, Diagnosis Word count: Abstract Article: - http://bmjopen.bmj.com/site/about/guidelines.xhtml
Page of 0 0 0 0 0 0 0 ABSTRACT Objectives: Prior 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. Design: Observational study Setting: ) Dutch primary care network of - sentinel practices where report forms during STI consultations were routinely collected, 00-0. ) Dutch observational cohort with medical data of HIV-positive patients in HIV care, 00-0. Outcome measures: The proportion of STI consultations in patients from high-risk groups tested for HIV, with additional information requested from GPs on HIV testing pre- or post-consultation for whom HIV testing was indicated, but not performed. Secondly, information was collected on the profile of HIV-positive patients entering specialised HIV care following diagnosis by GPs. Results: Initially, an HIV test was reported (0/0) in 0% of STI consultations in high-risk groups. In addition, in % 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 to STI clinics, HIV positive patients diagnosed in general practice were more likely to be older, female, heterosexual male or Sub-Saharan African. Conclusions: In one third of the STI 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. - http://bmjopen.bmj.com/site/about/guidelines.xhtml
Page of BMJ Open 0 0 0 0 0 0 0 Strength and limitations of this study Study is carried out in a GP network covering a representative sample of the Dutch population. Report forms had limited circumstantial information on potential previous HIV testing. We obtained additional information by questionnaire on previous or follow-up consultations and reasons for (not) testing for HIV, which were lacking in prior studies. - http://bmjopen.bmj.com/site/about/guidelines.xhtml
Page of 0 0 0 0 0 0 0 INTRODUCTION In the Netherlands an estimated total of,000 individuals are infected with HIV, %-% of whom are undiagnosed. In 0,,0 HIV patients entered into specialised HIV care, of whom % were late for care (CD count < 0 cells/mm or AIDS-defining event regardless of CD count). In 0, Cohen et al. showed that early treatment achieved % reduction in transmission between sero-discordant couples, paving the road for a new additional strategy now known as Treatment as Prevention. Early testing is paramount to an integrated approach aimed at early treatment, reduced transmission and increased public and individual health benefits. The general practitioner (GP), who acts as a gatekeeper to care in the Netherlands, is an important point of entrance into care, including the diagnosis of sexually transmitted infections (STIs). In the Netherlands, more than % of the population is registered at a general practice and % of the Dutch population contacts the GP at least once per year. Treatment of STIs and care is mainly provided by GPs and STI clinics. According to the most recent GP guidelines, patients who belong to high-risk groups with STI-related questions or symptoms, should be advised to undergo an HIV test. Previously, we explored STI testing at general practices in the Netherlands using questionnaire data on STI consultations in the GP sentinel practices between 00 and 0. The study showed that HIV tests were not carried out in % of STI consultations involving patients at higher risk for HIV. Especially, men who have sex with men (MSM) and persons from STI-endemic countries were frequently not tested. However, for this study, limited circumstantial information was available from report forms on individual consultations and potential previous HIV testing. For our current study, we aimed to further investigate the frequency and reasons for (not) testing for HIV as well as the contribution of GPs in the diagnosis of HIV infections in the Netherlands. We therefore collected additional information from GPs to find out more about HIV testing in high-risk groups during STI-related consultations. Secondly, we compared the profile of HIV-positive patients referred by GPs to specialised HIV care with the characteristics of HIV-positive patients diagnosed in STI clinics. - http://bmjopen.bmj.com/site/about/guidelines.xhtml