Intention of physicians to implement guidelines for screening and treatment of latent tuberculosis infection in HIV-infected patients in The Netherlands: a mixed-method design

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.

Latent tuberculosis infection screening in persons newly-diagnosed with HIV infection in Italy: A multicentre study promoted by the Italian Society of Infectious and Tropical Diseases

“…In the present study, it was found that LTBI screening among PLWH was performed significantly more frequently in foreignborn individuals coming from high TB incidence countries. This is in agreement with what has been observed in other European countries, such as the Netherlands (Evenblij et al, 2016), Belgium (Wyndham-Thomas et al, 2016), and Switzerland (Elzi et al, 2007), as well as in non-European countries, such as Australia (Doyle et al, 2014). In contrast, a study performed in the United States demonstrated an association between the request for screening for LTBI diagnosis and poverty (Reaves et al, 2017).…”

“…This is a very interesting issue; however this parameter was not evaluated in our survey. The low implementation of LTBI screening is likely due to the low perception of TB risk in PLWH (Evenblij et al, 2016), and to the awareness of the inaccuracy of LTBI tests, which can give falsenegative results in immunosuppressed persons (Goletti et al, 2014;Goletti et al, 2007;Vincenti et al, 2007) and are inadequate to predict progression to disease (Diel et al, 2011;Petruccioli et al, 2016a;Goletti et al, 2018a;Goletti et al, 2018b). The accuracy of LTBI tests improves if a selected population known to have a higher probability to progress to active disease is identified, as recommended in the recent guidelines of the British HIV Association (BHIVA) (BHIVA, 2018).…”

“…In spite of the existing recommendations, there is evidence that even in resource-rich countries, a significant proportion of PLWH are not screened for LTBI diagnosis (WHO, 2019;Evenblij et al, 2016;Wyndham-Thomas et al, 2016). This may be due to the low accuracy of LTBI tests to predict the development of active TB (Diel et al, 2011;Petruccioli et al, 2016a;Goletti et al, 2018a;Goletti et al, 2018b), to the awareness of the reduction in TB risk in those on combined antiretroviral therapy (cART) (Girardi et al, 2004;Girardi et al, 2012), and to the lack of availability of LTBI tests in clinical centres (CDC, 2011;Web site, 2018).…”

Tuberculosis Case Finding Practice: The Intention of Cadres in East Nusa Tenggara, Indonesia

“…However, engaging the community in TB detection has several challenges, including inadequate public knowledge regarding TB surveillance, insufficient ability to diagnose TB, limited geographical coverage, social economic barriers, low public awareness, and high stigma among healthcare workers and in communities (Ministry of Health Republic of Indonesia, 2018). In addition, a previous study pointed out that the barriers could be derived from internal factors of individual health workers; although individual health workers have received optimal education and training, their intention to perform TB case finding is not optimal (Evenblij, Verbon, & Van Leth, 2016). In supporting the duty of cadres to implement TB case finding, enhancing the intention of cadres to find TB cases at their community is important.…”

Guidance for programmatic management of latent tuberculosis infection in the European Union/European Economic Area

“…We acknowledge that physicians will be confronted with the challenge of assessing the patient-level risk and benefits while implementing these population-level public health activities [23,24]. Educational Selection of LTBI treatment regimen from the following treatment regimens based on an individual risk assessment: isoniazid alone (for 6-9 months) rifampicin alone (for 3-4 months) isoniazid and rifapentine (for 3 months) isoniazid and rifampicin (for 3-4 months) Programmatic issues Implementation of patient-centred strategies for service delivery Implementation of an integrated strategy including: material incentives and enablers counselling and education peer-based support culturally sensitive approaches…”