Auditing HIV Testing Rates across Europe: Results from the HIDES 2 Study

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.

Rationales for indicator condition-based HIV testing data from the Hospital for Infectious Diseases in Warsaw – one-year observation

“…Undoubtedly, it confirms the benefits arising from the routine testing of all patients with mononucleosis-like syndrome [17]. Currently, the tests for the detection of HIV are not routinely performed in hospitals' emergency departments, in Poland or in the rest of Europe.…”

“…The scientific research should be continued, which will verify in general the benefits of routine indicator condition-based HIV testing for patients with the specific indicator conditions such as pneumonia or a newly diagnosed HCV infection [17,31].…”

Late presenters among newly diagnosed HIV-infected in Poland in 2006-2008

“…It is worth emphasising that carried-out studies like the European project HIDES 1 and 2 (HIV Indicator Disease Across Europe Study) have shown that the testing model based on the routine indicator condition-guided HIV testing, the prevalence of which in the population amounts to > 0.1%, is very effective [34,35].…”

New HIV Diagnoses among Older Adults in the EU/EEA: Missed Opportunities and Barriers to Testing

“…universal testing) [13,40,75] to automatic pop-up alert for medical charts [37]. Certain testing approaches have been shown to successfully target older adults, such as opt-out testing in primary health care or in emergency departments [30,49,76,77] and the indicator-condition guided testing, a very promising approach [78,79], that may warrant scale-up in this population group [24,26,80].…”