Date Published: July 2, 2019
Publisher: Public Library of Science
Author(s): Javier Martínez Sanz, María Jesús Pérez Elías, Alfonso Muriel, Cristina Gómez Ayerbe, María Jesús Vivancos Gallego, Matilde Sánchez Conde, Margarita Herrero Delgado, Pilar Pérez Elías, Lidia Polo Benito, Yolanda de la Fuente Cortés, Rafael Barea, Ann K. Sullivan, Maria Jose Fuster Ruiz de Apodaca, María José Galindo, Santiago Moreno, Kwasi Torpey.
Late HIV diagnosis remains one of the challenges in combating the epidemic. Primary care providers play an important role in screening for HIV infection. Our study aims to evaluate the relationship between knowledge and barriers to HIV testing and screening outcomes. The impact of an education program for primary care providers, towards improving HIV testing and late diagnosis rates, is also assessed.
A self-administered questionnaire that was developed within the framework of the European project OptTEST was used to examine HIV knowledge and barriers to HIV testing scores before and after being involved in an HIV education program. A quasi-experimental design with pre- and post-intervention measures was performed to investigate its impact. We performed multivariable logistic regression analysis to assess the relationship between variables for the HIV testing offer.
A total of 20 primary care centers and 454 primary care staff were included. Baseline OptTEST results showed that more knowledgeable staff offered an HIV test more frequently (OR 1.07; CI 95% 1.01–1.13; p = 0.027) and had lower barrier scores (OR 0.89; CI 95% 0.77–0.95; p = 0.005). Nurses had lower scores in knowledge-related items (OR 0.28; CI 95% 0.17–0.46; p<0.001), but higher scores in barrier-related items than physicians (OR 3.28; CI 95% 2.01–5.46; p<0.001). Specific centers with more knowledgeable staff members had a significant association with a greater level of new HIV diagnosis rates (OR 1.61; CI 95% 1.04–2.49; p = 0.032). After the intervention, we found that 12 out of 14 individual questions showed improved scores. In the 6 months after the training program, we similarly found a higher HIV testing rate (OR 1.19; CI 1.02–1.42; p = 0.036). This study highlights the association between knowledge and barriers to HIV testing, including HIV testing rates. It shows that it is possible to modify knowledge and reduce perceived barriers through educational programs, subsequently improving HIV screening outcomes.
Spain is one of the European countries with the highest estimated number of people living with HIV, and it still has a high rate of new HIV diagnoses [1,2]. Of an estimated 150,000 people living with HIV in Spain, 18% remain undiagnosed . The annual HIV incidence is 18 cases per 100,000, and almost half are diagnosed at a late stage . Late HIV diagnosis has a profound individual implication in terms of HIV-related morbidity and mortality [4–6], as well as population implications, since it increases the risk of onward HIV transmission [7,8]. Despite this, several studies have shown that primary care providers frequently miss opportunities to test for HIV [9–11]. Primary care providers are required to perform different preventive care tasks to achieve better quality care, one of which is screening for HIV infection. There is increasing evidence that this testing is acceptable to patients in a primary care environment and is also operationally feasible , even though implementation requires training and staff support . There is a need to assess the primary care providers’ knowledge about HIV, and to better understand barriers to HIV testing, with the aim of contributing to a decrease in the number of undiagnosed people [14,15]. To achieve effective control of the HIV epidemic, medical education is necessary, including updated information to primary care providers .
The DRIVE study (Diagnóstico Rápido de la Infección por VIH en España, or in English ‘Rapid HIV testing in Spain’) was designed to investigate different aspects of HIV testing, and the FOCO study (Formación Concienciación, in English ‘Education Awareness’) was developed with the aim of improving the HIV screening in primary care through the promotion of educational programs. The current analysis, which is part of the FOCO and DRIVE03 studies, was approved by the research Ethics Committee at the Hospital Clínico Universitario of Valencia and Hospital Universitario Ramón y Cajal. It was carried out from January 2016 to December 2017 in 20 primary care centers of the University Hospital Ramón y Cajal: its basic health area has an estimated population of 555,655, with 373,180 aged 15- to 65-years-old.
Among 630 primary care providers working in the 20 primary care centers of the Ramón y Cajal basic health area, 454 (72%) attended the training sessions (mean of 23 for each primary care center). Of these, 344 (76%) filled out the initial questionnaire, with women making up 91.7% of respondents, having a median age of 51 years (IQR 43–56). In addition, 59% were medical doctors, 39% were nurses, and 2% were nursing assistants. Of the total who completed at least one questionnaire, 75.1% offered an HIV test in the past (96.7% doctors, 39.5% nurses, and 14.3% nursing assistants), and 98.4% reported acceptance by patients. Moreover, 98% answered that it would be useful to have a tool to identify patients with an indication for HIV testing. The mean score of the question relating to HIV risk assessment in daily practice was 3.18 (3.07–3.29), while only 25% (20–29%) of respondents are aware of national HIV testing guidelines. Lack of time was considered to be one of the least perceived barriers, with a mean score of 1.89 (1.80–1.98), and difficulty with foreign languages was considered to be one of the most perceived barriers, with a mean score of 3.31 (3.20–3.42).
This study highlights how rates of HIV testing and new diagnoses are influenced by providers’ knowledge about the disease itself and the barriers in testing it. Furthermore, it demonstrates the possibility of modifying knowledge and reducing perceived barriers through educational programs. This research was carried out in the Ramón y Cajal basic health area, with broad participation of the total primary care staff, which sees adequate levels of knowledge in most items of the OptTEST questionnaire, yet some barriers to HIV testing are still seen in this setting. Almost all respondents report good acceptance after offering the HIV test, similar to other studies in primary care ; this is more positive than indicated in other settings, such as emergency services . Despite this, low HIV testing rates are still seen in primary care centers of this health area