Date Published: July 21, 2017
Publisher: Public Library of Science
Author(s): Noemy De Rossi, Nicolas Dattner, Matthias Cavassini, Solange Peters, Olivier Hugli, Katharine E. A. Darling, Etsuro Ito.
The emergency department (ED) is mentioned specifically in the Swiss HIV testing recommendations as a site at which patients can benefit from expanded HIV testing to optimise early HIV diagnosis. At our centre, where local HIV seroprevalence is 0.2–0.4%, 1% of all patients presenting to the ED are tested for HIV. Barriers to HIV testing, from the patient and doctor perspective, and patient acceptability of rapid HIV testing were examined in this study.
Between October 2014 and May 2015, 100 discrete patient-doctor encounter pairs undertook a survey in the ED of Lausanne University Hospital, Switzerland. Patients completed a questionnaire on HIV risk factors and were offered free rapid HIV testing (INSTI™). For every patient included, the treating doctor was asked if HIV testing had 1) been indicated according to the national testing recommendations, 2) mentioned, and 3) offered during the consultation.
Of 100 patients, 30 had indications for HIV testing through risk factors or a suggestive presenting complaint (PC). Fifty patients accepted rapid testing; no test was reactive. Of 50 patients declining testing, 82% considered themselves not at risk or had recently tested negative and 16% wished to focus on their PC. ED doctors identified 20 patients with testing indications, mentioned testing to nine and offered testing to six. The main reason for doctors not mentioning or not offering testing was the wish to focus on the PC.
Patients and doctors at our ED share the testing barrier of wishing to focus on the PC. Rapid HIV testing offered in parallel to the patient-doctor consultation increased the testing rate from 6% (offered by doctors) to 50%. Introducing this service would enable testing of patients not offered tests by their doctors and reduce missed opportunities for early HIV diagnosis.
Early diagnosis and treatment of HIV infection optimises the benefit of antiretroviral therapy and prevents onward transmission. In Switzerland, while 50.2% of patients presenting with HIV infection are diagnosed promptly, the remainder are diagnosed late, with CD4 counts below 350 cells/mm3 or an AIDS-defining event [1, 2].
This is the first study exploring patient and doctor barriers to HIV testing in the Swiss ED setting. Both patients and doctors wished to focus on the PC over discussing HIV. Whilst medically valid, this shared wish was also a shared barrier to testing, as 75% of doctors who identified testing indications failed to offer testing. A further doctor barrier was the low (30%) sensitivity for identifying patients with testing indications, despite training seminars and pocket information cards. These findings are concerning if doctors are expected to initiate testing in line with FOPH recommendations.