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Call for quicker HIV testing of Africans in UK
 
 
  Friday, 07 Dec 2007 16:03
http://www.inthenews.co.uk
 
GPs and other patient services must be more proactive in offering HIV testing to higher-risk groups, a new study suggests.
 
Researchers from University College London found that some doctors are missing opportunities to diagnose HIV early in Africans living in the UK.
 
HIV-positive individuals who are diagnosed late are about 14 times more likely to die within one year of diagnosis than those diagnosed early.
 
Dr Fiona Burns and colleagues surveyed 263 HIV-positive patients from Africa.
 
Writing in the journal Aids today, they say that half were diagnosed late despite above average use of primary and secondary healthcare services such as GPs and clinics.
 
In more than 80 per cent of cases of people who were later diagnosed as HIV-positive, the researchers say HIV testing was never discussed by the GP.
 
This was in spite of the fact the individuals were coming from countries with high HIV prevalence.
 
There are an estimated 63,500 adults living with HIV in the UK and the majority of heterosexually-acquired cases are found in African communities.
 
"What we are seeing here is a failing to utilise opportunities for earlier diagnosis of HIV," said Dr Burns.
 
"People are dying because they are not being tested early enough. We need to be in a position where GPs are prepared to discuss HIV risks and offer HIV tests as a matter of course to people from at-risk communities."
 
She added that African communities must also increase their awareness of the risks they face and the importance of HIV-testing.
 
Rhon Reynolds, senior policy officer and deputy chief executive officer of the African HIV Policy Network, said the group welcomed "the important findings from this study".
 
"It is clear that African people in the UK need to be informed of the benefits of early testing," he added.
 
"We need to seize every opportunity to combat the dire consequences of a late diagnosis. Simultaneously we need to be aware of the social, political and cultural barriers that make it hard for African people to test."
 
Missed opportunities for earlier HIV diagnosis within primary and secondary healthcare settings in the UK
 
AIDS:Volume 22(1)2 January 2008p 115-122
 
Burns, Fiona Ma; Johnson, Anne Ma; Nazroo, Jamesb; Ainsworth, Jonathanc; Anderson, Janed; Fakoya, Adee; Fakoya, Ibiduna; Hughes, Andyf; Jungmann, Evag; Sadiq, S Tariqh; Sullivan, Ann Ki; Fenton, Kevin Aa; on behalf of the SONHIA Collaboration Group
 
From the aCentre for Sexual Health and HIV Research, Department of Primary Care
and Population Sciences, UK
bDepartment of Epidemiology & Public Health, University College London, UK cNorth Middlesex University Hospital NHS Trust, UK
dHomerton Hospital NHS Trust, UK
eNewham University Hospital NHS Trust, UK
fSt. Mary's NHS Trust, UK
gCamden Primary Care Trust, UK
hSt. George's University of London, UK
iChelsea & Westminster Healthcare NHS Trust, London, UK.
 
Abstract
Objective: To identify opportunities for earlier HIV diagnosis within primary and secondary care settings in the UK in Africans with newly diagnosed HIV infection.
 
Methods: A survey of newly diagnosed HIV-positive Africans attending 15 HIV treatment centres across London was conducted between April 2004 and February 2006. The survey consisted of a confidential self-completed questionnaire linked to clinician-completed clinical records.
 
Results: A total of 263 questionnaires were completed, representing an uptake rate of 79.5% of patients approached and 49.8% (131/263) of participants presented with advanced HIV disease (CD4 cell count < 200 cells/μl at diagnosis). In the year prior to HIV diagnosis 76.4% (181/237) had seen their GP, 38.3% (98/256) had attended outpatient services, and 15.2% (39/257) inpatient services, representing missed opportunities for earlier HIV diagnosis. Of those attending GP services the issue of HIV and/or HIV testing was raised for 17.6% (31/176) and 37.1% (78/210) had a previous negative HIV test, 32.5% of these within the UK. Medical attention was sought for wide ranging reasons, often not obviously connected to underlying HIV status. Despite the population predominantly coming from countries of high HIV prevalence personal appreciation of risk was comparatively low and knowledge of benefits of testing lacking.
 
Conclusion: Africans are accessing health services but clinicians are failing to use these opportunities effectively for preventive and diagnostic purposes with regards to HIV infection. Comparatively low appreciation of personal risk and lack of perceived ill health within this community means clinicians need to be more proactive in addressing HIV.
 
Introduction
It is known that Africans with HIV infection in the UK access HIV services at a later stage of HIV disease than non-Africans [1-3], which denies them optimal therapeutic options and may hinder prevention efforts. The extent of missed opportunities within primary and secondary healthcare settings for earlier diagnosis within Britain is not known. The term 'secondary care' refers to services provided by medical specialists who generally do not have first contact with patients (e.g., cardiologists, urologists, dermatologists). In the UK patients must first seek care from primary care providers (general practitioners) and are then referred to secondary and/or tertiary providers, as needed.
 
In the UK there are now more heterosexually acquired HIV infections diagnosed than those acquired through sex between men. The majority of heterosexually acquired HIV is within the African communities [4]. Whereas the proportion of men who have sex with men who present late (CD4 cell count < 200 cells/μl) to HIV services has gradually reduced from approximately 30 to 20% over the past decade, there has been no such decline within the heterosexual community with between 40 and 50% continuing to present late [4]. HIV-infected individuals diagnosed late were approximately 8-10 times more likely to die within 1 year of diagnosis than those not diagnosed late [5,6]. Research in men who have sex with men suggests that earlier diagnosis could reduce short-term mortality by 56 to 84% and all mortality by 32% [5,6]. Late diagnosis not only denies an individual optimum therapy options, but also reflects missed opportunities to limit onward transmission. Work exploring missed opportunities for earlier diagnosis within the UK is extremely limited [7,8]. We sought to identify opportunities for earlier HIV diagnosis within primary and secondary care settings in the UK, and to identify factors related to these missed opportunities, in Africans with newly diagnosed HIV infection.
 
Discussion
Fifty percent of participants presented late to HIV services. High primary and secondary care use was found prior to HIV diagnosis representing missed opportunities for earlier HIV diagnosis. Primary care in particular was extremely well utilized by this high-risk population; however HIV testing was not broached by the GP for 82.4% (145/176) of Africans who subsequently tested HIV positive. Medical attention was sought for wide-ranging reasons, often not obviously connected to underlying HIV status. Despite the population predominantly coming from countries of high HIV prevalence personal appreciation of risk was comparatively low and knowledge lacking as to the benefits of HIV testing. Whereas people testing HIV positive after a previous negative test reflects failure in prevention messages, people who had previously tested for HIV (37.1%) were less likely to present to HIV services late. Confidentiality concerns meant trust and disclosure of HIV status to GPs was low.
 
Since 2000 there has been a 179% increase in heterosexual men and women seen for HIV care in the UK, the majority of whom are African [4]. High uptake of HIV testing [11,12] and primary care services [13] by African communities have been known for some time, and Sullivan et al. [8] reported that 17% of newly diagnosed HIV-positive patients had sought medical care with symptoms suggestive of HIV in the 12 months preceding diagnosis. There has, however, been no other studies that have specifically explored the missed opportunities for earlier HIV diagnosis among Africans within primary and secondary care settings.
 
Our study had some limitations. The study design meant only those people already accessing care were eligible. This could introduce selection bias, it is possible that this population may be more favourably disposed to and eligible for medical services than those not accessing services. The 17 people who were potentially eligible but died before being approached may have differed in their opportunities for earlier diagnosis in comparison with the sampled population. As all of these patients died of advanced HIV-related diseases, if any missed opportunity for earlier diagnosis did exist this reflects a real failing on the part of our health services. If no such opportunity had existed then we must ask ourselves why someone who was likely to have been unwell had not been or felt able to seek medical care earlier. Similarly of concern is the substantial proportion (15.4%) of potentially eligible patients who became lost to clinic follow up. These people may also differ in comparison with the sampled population. Although getting people into HIV services earlier is the first step to improving clinical outcomes, this will only be achieved if people find services acceptable and are able to continue to access them. The study was limited to London and so was unable to assess if people moving away from their communities, as in the asylum dispersal scheme [14], had any impact on opportunities for earlier diagnosis.
 
As data were collected retrospectively recall bias may have occurred, especially for those in whom prior accessing of health services was associated with their HIV diagnosis. Any effect of this is, however, likely to have been small given that participants were surveyed within 12 months of HIV diagnosis (the median time between diagnosis and questionnaire completion was only 3.5 months) and questions around healthcare were deliberately restricted to a relatively narrow time frame. Finally the term 'African' comprises an aggregation of heterogeneous population subgroups. Although data were collected to explore the ethnic, cultural and temporal diversities of this population the study may have lacked power to fully explore their influences on missed opportunities for earlier diagnosis of HIV infection.
 
Despite these limitations, our findings add substantially to our understanding of health-seeking behaviours of Africans living in the UK. Our data suggest that rather than having poor access to health services, as reported for many migrant groups, Africans report higher rates of primary and secondary care attendance and HIV testing than the general population (F. Burns and C. Mercer, pers. comm. 2007). That Africans continue to present to HIV services with advanced disease despite accessing health services prior to diagnosis suggests HIV is often missed as a differential diagnosis, or that clinicians are either reluctant to address HIV or are doing so ineffectively. Similarly, that many Africans test HIV positive after a previous negative test, suggests these HIV prevention opportunities are not being used effectively.
 
The age and country of origin of participants alone should guide health practitioners to the possibility of HIV infection irrespective of health status. Although some of the reasons for attending medical services may relate to HIV, many do not. Our findings suggest a proactive approach to HIV testing, as found in the antenatal setting, is required to minimize these missed opportunities for earlier diagnosis. A total of 37.1% of respondents reported a previous negative HIV test, and although the majority of these occurred in Africa, 32.5% had occurred in the UK. HIV infection risks are ongoing, with acquisition within the UK a real phenomenon for resident Africans. The continuing care relationship inherent in general practice provides an ideal context for ongoing HIV prevention messages. Similarly the majority of people came from countries with a high HIV prevalence but there was a comparatively low appreciation of personal risk, as reflected in the factors preventing earlier testing. Again primary care may be well placed to address these issues as it provides a setting for personalized and targeted health information. Advice from doctors, either primary or secondary care based, is influential with 40.2% primarily testing for HIV because of clinician recommendation.
 
Much of the failure to address the issue of HIV for this population may be the legacy of the HIV exceptionalism largely generated by HIV services over the past two decades. The whole process of HIV testing needs to be further normalized. Normalization refers to the process of treating HIV more like other infectious diseases for which early diagnosis is essential for appropriate therapeutic and preventive measures [15]. It encapsulates the notion that all doctors should be confident and competent at HIV testing and diagnosis. It also still incorporates the need for confidentiality and informed consent. The Centres for Disease Control and Prevention (CDC) now recommends that HIV screening be performed routinely in all health-care settings for 13-64 year olds [16]. GP's should be the first port of call for all health issues, including HIV. The ongoing care relationship provided by primary care services should lend itself to the provision of personalized ongoing HIV information and repeat screening opportunities. Work to address the concerns of service users around HIV and primary care is also required.
 
The National Strategy for Sexual Health and HIV [17] in 2001 set clear targets for HIV testing and reducing undiagnosed infection. In practice these recommendations have yet to be realized, probably because the low priority attributed to sexual health in most primary care trusts has resulted in lack of funds. Proposals to exclude overseas visitors from eligibility to free NHS primary medical service [18], designed to align primary care with hospital care, will further reduce opportunities for earlier diagnosis. A more positive approach would be to ensure that health services that are currently well utilized by this high-risk population have both the resources and incentives to effectively address HIV.
 
The key messages that are a result of the present study are listed here.
 
1. Late diagnosis of HIV increases HIV-associated morbidity and mortality and hinders prevention measures to limit onward transmission.
 
2. Africans in the UK access HIV services at a later stage of disease than non-Africans; missed opportunities for prevention messages and earlier HIV diagnosis within primary and secondary healthcare settings have not been fully identified for this population.
 
3. A total of 37.1% of newly diagnosed HIV-positive Africans had a previous negative HIV test, 32.5% of these within the UK.
 
4. Africans are accessing health services but clinicians are failing to use these opportunities effectively for preventive and diagnostic purposes with regard to HIV infection.
 
5. Primary care in particular is extremely well utilized by this high-risk population; however HIV testing was not broached for 82.4% of Africans who accessed GP services in the year prior to HIV diagnosis.
 
 
 
 
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