Promoting indicator condition-guided testing for HIV in the hospital setting

In our global efforts to finish the ‘last mile’ towards ending the HIV epidemic, timely diagnosis remains a key focus point. In Europe, an estimated third of the people living with HIV (PLHIV) is unaware of their diagnosis and late diagnosis (CD4 count at diagnosis < 350 cells/uL) is still reported in over half of all new cases.
In the last decade, more and more research on improving HIV testing focuses on implementing indicator condition-guided testing. Indicator conditions (ICs) are defined as those conditions that are AIDS-defining, those associated with an undiagnosed HIV prevalence of > 0.1%, or conditions where failure to identify an HIV infection may have significant adverse implications for the patient’s clinical management. In 2014, the HIV in Europe-initiative published a guidance on indicator condition-guided HIV testing in adults in health care settings. It was a novel approach to HIV testing strategies based on the HIV Indicator Diseases across Europe Study (HIDES) and its subsequent study HIDES II. These studies identified various ICs associated with a HIV prevalence of over 0.1%. The guideline now contains a list of over 50 ICs.
Numerous studies since have shown that IC-guided HIV testing is an effective approach to track down those yet undiagnosed. Additionally, IC-guided testing has the advantage of bypassing the patient- and provider-level barrier of discussing risk factors for HIV. As a consequence, many national and international guidelines now recommend IC-guided HIV testing. However, many recent studies on IC-guided HIV testing show poor awareness of this approach and low adherence to these guidelines; they confirm either high prevalence of HIV in ICs or high incidence of ICs in newly diagnosed HIV cases but consistently show missed opportunities for earlier HIV diagnosis due to lack of adherence and/or absence of local protocols on IC-guided HIV testing.

This study aims to take the next step towards promoting and implementing IC-guided HIV testing. We will measure baseline HIV-testing rates in all patients presenting with one of seven selected ICs (i.e. tuberculosis, cervical cancer, vulva cancer, malignant lymphoma, hepatitis B, hepatitis C and peripheral neuropathy of unknown cause) to assess adherence to recommendations on IC-guided HIV testing. Subsequently we will assess barriers and facilitators to adherence to this approach through qualitative research methods to design a targeted intervention. We will also determine if performing an HIV-test is included in the local- and national diagnostic/therapeutic guidelines for these ICs. With this integrated approach, we will identify opportunities for intervention on both provider-level and organization-level so as to design a comprehensive approach to address the various determinants of successful innovation in healthcare. These interventions will be executed in the intervention-phase. We will measure the effect with a repeat-measure of HIV-testing rates in all patients presenting with the same selected ICs. Our main outcome will be change in HIV-test rates for the selected ICs; we hypothesise our intervention will increase the HIV-testing rates for indicator conditions amongst different medical specialisms. Furthermore, it will generate awareness about all HIV-indicator conditions and the importance of testing for HIV in patients presenting with an indicator condition. This will ultimately facilitate earlier identification of HIV infection and therefore ultimately help stop HIV.

Interventions to promote indicator condition-guided testing for HIV in the hospital will facilitate earlier identification of HIV infection and therefore ultimately help stop HIV

Baseline measurement (pre-intervention HIV-test rates), exploration of barriers and facilitators, tailor made intervention, post-intervention measurement of HIV-test rates

Explore possibilities to include HIV-testing recommendations in medical specialist guidelines for indicator conditions where this is lacking and map barriers and facilitators to HIV-testing at the level of patient, health care provider, department and organisation. Use these to execute a tailor-made intervention to ameliorate indicator condition-guided testing for HIV in the hospital