Provider-initiated HIV testing in rural Haiti: low rate of missed opportunities for diagnosis of HIV in a primary care clinic

Louise C Ivers,Kenneth A Freedberg,Joia S Mukherjee

doi:10.1186/1742-6405-4-28

Abstract

As HIV treatment is scaled-up in resource-poor settings, the timely identification of persons with HIV infection remains an important challenge. Most people with HIV are unaware of their status, and those who are often present late in the course of their illness. Free-standing voluntary counseling and testing sites often have poor uptake of testing. We aimed to evaluate a 'provider-initiated' HIV testing strategy in a primary care clinic in rural resource-poor Haiti by reviewing the number of visits made to clinic before an HIV test was performed in those who were ultimately found to have HIV infection. In collaboration with the Haitian Ministry of Health, a non-governmental organization (Partners In Health) scaled up HIV care in central Haiti by reinforcing primary care clinics, instituting provider-initiated HIV testing and by providing HIV treatment in the context of primary medical care, free of charge to patients. Among a cohort of people with HIV infection, we assessed retrospectively for delays in or 'missed opportunities' for diagnosis of HIV by the providers in one clinic. Of the first 117 patients diagnosed with HIV in one clinic, 100 (85%) were diagnosed at the first medical encounter. Median delay in diagnosis for the remaining 17 was only 62 days (IQR 19 – 122; range 1 – 272). There was no statistical difference in CD4 cell count between those with and without a delay. 3787 HIV tests were performed in the period reviewed. Provider-initiated testing was associated with high volume uptake of HIV testing and minimal delay between first medical encounter and diagnosis of HIV infection. In scale up of HIV care, provider-initiated HIV testing at primary care clinics can be a successful strategy to identify patients with HIV infection.

Highlights

5–8% of individuals with Human Immunodeficiency Virus (HIV) infection globally are aware of their diagnosis [1]
Much of the HIV testing in the developing world is done through maternity clinics offering antiretroviral drugs for the prevention of maternal to child transmission of HIV or specialty voluntary counseling and testing (VCT) clinics to which people come desiring knowledge of their status
US and African studies have identified high rates of "missed opportunities" for making the diagnosis of HIV among primary care clinicians who did not offer HIV tests to their patients even if they had clinical syndromes associated with HIV infection or if they were from a high-risk sociodemographic group [5,6,7,8,9,10]

Summary

Introduction

5–8% of individuals with Human Immunodeficiency Virus (HIV) infection globally are aware of their diagnosis [1]. In 2002, when the Global Fund to Fight AIDS, TB and Malaria called for applications, Partners In Health – a non-profit organization affiliated with Harvard Medical School – began a collaborative program with the Haiti Ministry of Health with the goal of improving access to primary care as an avenue to provide HIV prevention, testing and treatment To achieve this goal, staffing levels were improved for general patient care and non-HIV related essential medicines were provided free of charge to patients seeking care. All health care providers – including doctors, nurses, social workers and community health workers were educated about the signs and symptoms of HIV, the importance of active case finding and contact tracing and the urgency for testing those who appeared ill even if they did not present for HIV testing To determine whether this approach was effective in identifying patients with HIV in a timely manner, we reviewed the number of clinic visits that a patient had prior to testing HIV positive in one of our clinics

Objectives

Methods

Results

Conclusion