Abstract
European guidelines recommend the routine offer of an HIV test in patients with a number of AIDS-defining and non-AIDS conditions believed to share an association with HIV; so called indicator conditions (IC). Adherence with this guidance across Europe is not known. We audited HIV testing behaviour in patients accessing care for a number of ICs. Participating centres reviewed the case notes of either 100 patients or of all consecutive patients in one year, presenting for each of the following ICs: tuberculosis, non-Hodgkins lymphoma, anal and cervical cancer, hepatitis B and C and oesophageal candidiasis. Observed HIV-positive rates were applied by region and IC to estimate the number of HIV diagnoses potentially missed. Outcomes examined were: HIV test rate (% of total patients with IC), HIV test accepted (% of tests performed/% of tests offered) and new HIV diagnosis rate (%). There were 49 audits from 23 centres, representing 7037 patients. The median test rate across audits was 72% (IQR 32–97), lowest in Northern Europe (median 44%, IQR 22–68%) and highest in Eastern Europe (median 99%, IQR 86–100). Uptake of testing was close to 100% in all regions. The median HIV+ rate was 0.9% (IQR 0.0–4.9), with 29 audits (60.4%) having an HIV+ rate >0.1%. After adjustment, there were no differences between regions of Europe in the proportion with >0.1% testing positive (global p = 0.14). A total of 113 patients tested HIV+. Applying the observed rates of testing HIV+ within individual ICs and regions to all persons presenting with an IC suggested that 105 diagnoses were potentially missed. Testing rates in well-established HIV ICs remained low across Europe, despite high prevalence rates, reflecting missed opportunities for earlier HIV diagnosis and care. Significant numbers may have had an opportunity for HIV diagnosis if all persons included in IC audits had been tested.
Highlights
Late-stage diagnosis of HIV and undiagnosed HIV continue to be features of many European HIV epidemics [1]
Six HIV indicator conditions were selected for auditing of HIV testing: tuberculosis (TB), hepatitis B and C (HEP), non-Hodgkin lymphoma (NHL), anal and cervical cancer (ACCAN) and oesophageal candidiasis (ECAN)
The results show that persons presenting to healthcare settings with conditions widely accepted as indicator conditions (IC) are not routinely HIV tested
Summary
Late-stage diagnosis of HIV and undiagnosed HIV continue to be features of many European HIV epidemics [1]. As described elsewhere [9], the pilot phase of the HIDES Study (HIV Indicator Diseases across Europe Study) surveyed eight indicator conditions (ICs)–with 3588 individuals presenting with either sexually transmitted infections, malignant lymphoma, anal or cervical cancer, herpes zoster, hepatitis B and C, ongoing mononucleosis-like illness, unexplained leukocytopenia and thrombocytopenia and seborrheic dermatitis offered an HIV test. All eight ICs individually fulfilled the study’s criteria of demonstrating an HIV prevalence of >0.1%, for malignant lymphoma and anal and cervical cancer, 0.1 fell within the 95% confidence interval. In line with ECDC (European Centre for Disease Prevention and Control) guidance, the study demonstrated that individuals presenting to any healthcare setting with HIV indicator conditions (ICs) should be strongly recommended to have an HIV test [9,10,11]
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