Abstract
BackgoundAll newly diagnosed HIV-infected patients in the Netherlands should be screened for latent tuberculosis infection (LTBI) and offered preventive therapy if infected without evidence of active tuberculosis. This guideline, endorsed by the national professional body of HIV physicians is in line with international recommendations, and based on the increased risk of progression from LTBI to active tuberculosis in HIV-infected patients. The objective of the study is to assess the intention of HIV physicians to implement this national guideline.MethodsA mixed method design triangulating results from two surveys among all (n = 80) HIV physicians in The Netherlands and qualitative interviews among 11 Dutch HIV physicians performed in 2014.ResultsThe majority of physicians used a risk-stratification approach based on individual a priori risk of tuberculosis to identify HIV-infected patients for LTBI screening, rather than screening all new HIV-infected patients. The intended and actual provision of preventive treatment was low, due to expressed doubts on the accuracy of diagnostic tools for LTBI. Interviewees reported that the guidelines did not match their clinical experience and lacked evidence for the recommendations. Screening for and treatment of LTBI was approached at a patient-level only. None of the interviewees referred to potential public health implications of the guidelines.ConclusionsIntended implementation of the national HIV-TB guidelines in the Netherlands is poor, due to a disconnect between clinical practice and evidence-based recommendations in the guideline. There is an urgent need to reconcile the views of HIV-physicians, public health experts, and guideline committee members, regarding the best strategy to address HIV-TB co-infection in the Netherlands.Electronic supplementary materialThe online version of this article (doi:10.1186/s12889-016-3539-2) contains supplementary material, which is available to authorized users.
Highlights
In an attempt to reduce the risk of active tuberculosis (TB), international guidelines stipulate screening HIVinfected individuals for latent TB infection (LTBI), and to offer preventive treatment if found infected and without evidence of active TB [1, 2]
Low CD4 count is a risk for progression from LTBI to active TB, respondents from both countries were less likely to be screened for LTBI in this setting (SC II: 27/51, 53 %, SC IV 15/51, 20 %), compared to those with high CD4 counts (SC I: 38/51, 75 %, and SC III: 40/51, 78 % and SC V: 23/51, 40 %, respectively)
Of the HIVphysicians who intended to screen for LTBI, less than 25 % would use both screening tests, as stipulated in the guideline, in any of the SCs (Fig. 2 Upper right)
Summary
In an attempt to reduce the risk of active tuberculosis (TB), international guidelines stipulate screening HIVinfected individuals for latent TB infection (LTBI), and to offer preventive treatment if found infected and without evidence of active TB [1, 2]. In a large European cohort study with more than 1700 patients with a wide variety of types of immunosuppression such superiority of IGRA over TST was not observed [6]. This equipoise makes that several international guidelines recommend either a two-step procedure (IGRA when TST-positive), or using both test simultaneously [7, 8]
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